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1.
J Thorac Cardiovasc Surg ; 129(5): 1024-31, 2005 May.
Article in English | MEDLINE | ID: mdl-15867776

ABSTRACT

OBJECTIVES: Freedom from anticoagulation is the principal advantage of bioprosthesis; however, the American Heart Association/American College of Cardiology and the American College of Chest Physicians guidelines recommend early anticoagulation with heparin, followed by warfarin for 3 months after bioprosthetic aortic valve replacement. We examined neurologic events within 90 days of bioprosthetic aortic valve replacement at our institution. METHODS: Between 1993 and 2000, 1151 patients underwent bioprosthetic aortic valve replacement with (641) or without (510) associated coronary artery bypass. By surgeon preference, 624 had early postoperative anticoagulation (AC+) and 527 did not (AC-). In the AC- group, 410 patients (78%) received antiplatelet therapy. Groups were similar with respect to gender (female, 36% AC+ vs 40% AC-, P = .21), hypertension (64% AC+ vs 61%, P = .27), and prior stroke (7.6% AC+ vs 8.5% AC-, P = .54). The AC+ group was slightly younger than the AC- group (median, 76 years vs 78 years, P = .006). RESULTS: Operative mortality was 4.1% with 43 (3.7%) cerebrovascular events within 90 days. Excluding 18 deficits apparent upon emergence from anesthesia, we found that postoperative cerebrovascular accident occurred in 2.4% of AC+ and 1.9% AC- patients. By multivariable analysis, the only predictor of operative mortality was hypertension ( P < .0001). Postoperative cerebrovascular accident was unrelated to warfarin use ( P = .32). The incidence of mediastinal bleeding requiring reexploration was similar (5.0% vs 7.4%), as were other bleeding complications in the first 90 days (1.1% vs 0.8%). No variables were predictive of bleeding by multivariate analysis. CONCLUSIONS: Although these data do not address the role of antiplatelet agents, early anticoagulation with warfarin after bioprosthetic aortic valve replacement did not appear to protect against neurologic events.


Subject(s)
Anticoagulants/therapeutic use , Aortic Valve/surgery , Bioprosthesis/adverse effects , Heart Valve Prosthesis Implantation/adverse effects , Heart Valve Prosthesis/adverse effects , Postoperative Care/methods , Warfarin/therapeutic use , Aged , Anticoagulants/adverse effects , Coronary Artery Bypass , Female , Heart Valve Prosthesis Implantation/mortality , Hemorrhage/chemically induced , Hemorrhage/epidemiology , Hemorrhage/surgery , Humans , Incidence , Length of Stay , Logistic Models , Male , Multivariate Analysis , Patient Selection , Proportional Hazards Models , Prosthesis Failure , Reoperation , Retrospective Studies , Risk Factors , Stroke/epidemiology , Stroke/etiology , Stroke/prevention & control , Time Factors , Treatment Outcome , Warfarin/adverse effects
2.
Anesth Analg ; 93(6): 1410-6, table of contents, 2001 Dec.
Article in English | MEDLINE | ID: mdl-11726415

ABSTRACT

UNLABELLED: Visual loss (acuity or field) secondary to ischemic optic neuropathy (ION) is a rare but devastating complication of cardiac surgery involving cardiopulmonary bypass (CPB). We determined clinical features and risk factors for ION by a retrospective time-matched, case-control study. ION was identified in 17 (0.06%) patients out of 27,915 patients who underwent CPB between January 1, 1976, and December 31, 1994. For each ION patient, two patients who underwent CPB exactly 2 wk before the ION patient were selected as controls. Data were analyzed by using conditional logistic regression with the 1:2 matched-set feature of 17 cases and 34 controls. Two-tailed P values < or =0.05 were considered significant. From bivariate analysis, smaller minimum postoperative hemoglobin concentration (odds ratio [OR] = 1.9, P = 0.047) and the presence of atherosclerotic vascular disease (OR = 7.0, P = 0.026) were found to be independently associated with ION after CPB, as were smaller minimum postoperative hemoglobin concentration (OR = 2.2, P = 0.027) and preoperative angiogram within 48 h of surgery (OR = 7.2, P = 0.042). In ION patients, 13 (76.5%) of 17 experienced a minimum postoperative hemoglobin value of < 8.5 g/dL, whereas only 14 (41.2%) of 34 control patients experienced values < 8.5 g/dL. IMPLICATIONS: Patients with clinically significant vascular disease history or preoperative angiogram may be at increased risk for ischemic optic neuropathy after cardiac surgery, especially if the hemoglobin remains low in the postoperative period.


Subject(s)
Cardiopulmonary Bypass/adverse effects , Optic Neuropathy, Ischemic/etiology , Adult , Aged , Arteriosclerosis/complications , Cardiac Surgical Procedures , Case-Control Studies , Female , Hemoglobins/analysis , Humans , Male , Middle Aged , Odds Ratio , Postoperative Complications , Retrospective Studies , Risk Factors
4.
Circulation ; 104(12 Suppl 1): I36-40, 2001 Sep 18.
Article in English | MEDLINE | ID: mdl-11568027

ABSTRACT

BACKGROUND: Carcinoid involvement of left-sided heart valves has been reported in patients with a patent foramen ovale, carcinoid tumor of the lung, and active carcinoid syndrome with high levels of serotonin. The present study details the clinical features and surgical management of patients with carcinoid heart disease affecting both left- and right-sided valves. METHODS AND RESULTS: Eleven patients (7 men, 4 women) with symptomatic carcinoid heart disease underwent surgery for left- and right-sided valve disease between 1989 and 1999. Mean age was 57+/-9 years, and median preoperative NYHA class was 3. All patients had metastatic carcinoid tumors and were on somatostatin analog. Of 11 patients, 5 (45%) had a patent foramen ovale; 1 of these also had a primary lung carcinoid tumor. Surgery included tricuspid valve replacement in all patients, pulmonary valve replacement in 3 and valvectomy in 7, mitral valve replacement in 6 and repair in 1, aortic valve replacement in 4 and repair in 2, CABG in 2, and patent foramen ovale closure in 5. One myocardial metastatic carcinoid tumor was removed. There were 2 perioperative deaths. At a mean follow-up of 41 months, 4 additional patients were dead. All but 1 surgical survivor initially improved >/=1 functional class. No patient required reoperation. CONCLUSIONS: Carcinoid heart disease may affect left- and right-sided valves and occurred without intracardiac shunting in 55% of this surgical series. Despite metastatic disease that limits longevity, operative survivors had improvement in functional capacity. Cardiac surgery should be considered for select patients with carcinoid heart disease affecting left- and right-sided valves.


Subject(s)
Carcinoid Heart Disease/surgery , Cardiac Surgical Procedures , Heart Valve Diseases/surgery , Adult , Aged , Carcinoid Heart Disease/diagnosis , Carcinoid Heart Disease/etiology , Disease Progression , Echocardiography , Female , Follow-Up Studies , Heart Septal Defects, Atrial/complications , Heart Septal Defects, Atrial/surgery , Heart Valve Diseases/diagnosis , Heart Valve Diseases/etiology , Heart Valves/pathology , Heart Valves/surgery , Humans , Male , Middle Aged , Severity of Illness Index , Somatostatin/therapeutic use , Survival Rate , Treatment Outcome
5.
Mayo Clin Proc ; 76(8): 784-8, 2001 Aug.
Article in English | MEDLINE | ID: mdl-11499816

ABSTRACT

OBJECTIVE: To evaluate the outcome of coronary artery bypass grafting (CABG) for failed percutaneous coronary intervention (PCI) in patients who had received abciximab. PATIENTS AND METHODS: In this retrospective study, we analyzed the records of patients who had PCI at our institution between January 1994 and December 1998 and identified those who had urgent or emergency CABG within 48 hours after PCI. CABG was performed for failed PCI in patients who had ongoing ischemia, hemodynamic compromise, or both. These patients were categorized into 2 groups depending on whether they had been given abciximab during PCI. We compared blood product transfusion requirements, bleeding complications, and frequency of in-hospital adverse events of the 2 groups. RESULTS: Of 5636 patients who had PCI, 77 (1.4%) had urgent or emergency CABG within 48 hours, including 11 who were given abciximab (abciximab group) during PCI and 66 who were not given abciximab (no abciximab group). The 2 groups had similar baseline characteristics. The mean +/- SD time to surgery was 8.4 +/-8.0 hours (median, 6 hours) for the abciximab group vs 12.1 +/- 12.5 hours (median, 4 hours) for the no abciximab group. Major bleeding (Thrombolysis in Myocardial Infarction criteria) occurred in 9 (90%) of 10 patients in the abciximab group vs 48 (77%) of 62 patients in the no abciximab group. The total volumes of intraoperative autotransfusion and transfusion of red blood cells and fresh frozen plasma tended to be higher for the abciximab group. Also, this group received a mean of 13.9 U of platelets vs 3.2 U for the no abciximab group (P<.001). However, no in-hospital deaths occurred among patients in the abciximab group, and adverse events were infrequent and comparable between the 2 groups. No difference was noted between the 2 groups in the frequency of surgical reexploration for bleeding. CONCLUSION: Transfusion requirements are higher for patients who undergo emergency or urgent CABG after having received abciximab during PCI. However, in-hospital adverse events are infrequent and comparable to those for patients who do not receive abciximab.


Subject(s)
Angioplasty, Balloon, Coronary , Antibodies, Monoclonal/therapeutic use , Coronary Artery Bypass , Immunoglobulin Fab Fragments/therapeutic use , Platelet Glycoprotein GPIIb-IIIa Complex/therapeutic use , Abciximab , Aged , Blood Component Transfusion , Emergency Treatment , Female , Humans , Male , Middle Aged , Retrospective Studies , Treatment Failure , Treatment Outcome
6.
Ann Thorac Surg ; 71(6): 1880-4, 2001 Jun.
Article in English | MEDLINE | ID: mdl-11426762

ABSTRACT

BACKGROUND: The outcome of valvular heart operations in patients with previous mediastinal radiation therapy was studied. METHODS: This is a single center retrospective study of 60 patients (37 females, 23 males) with a mean age of 62 +/- 15 years (28 to 88 years old) operated on from January 1976 to December 1998. Valvular heart operations performed included aortic valve replacements (n = 26), mitral valve procedures (n = 16), tricuspid valve procedures (n = 6), and multiple valve procedures (n = 12). A total of 264 clinical, hemodynamic, electrocardiographic and echocardiographic variables were analyzed. RESULTS: Total follow-up was 199 patient-years with a mean of 3.3 +/- 3.1 years and a range of 0 to 12.4 years old. Early mortality was 7 patients (12%). Early mortality in patients with constrictive pericarditis was 40% (4 of 10) compared with 6% (3 of 50) in patients without constrictive pericarditis. By univariate analysis, early mortality was associated with constrictive pericarditis (p = 0.011), reduced preoperative ejection fraction (p = 0.015), and longer cardiopulmonary bypass times (p = 0.037). A total of 14 patients (23%) required permanent pacemaker placement before (n = 7), during (n = 1), or early (n = 6) after valvular heart operations. There were 19 late deaths (malignancies, 7; heart failures, 5; other cardiac, 4; and other noncardiac, 3). Overall survival and freedom from late cardiac death and cardiac reoperation at 5 years for hospital survivors were 66% +/- 8%, 82% +/- 7%, and 93% +/- 4%, respectively. By univariate analysis, late cardiac death was associated with low ejection fraction (p = 0.002), New York Heart Association (NYHA) functional class IV (p = 0.004), preoperative congestive heart failure (p = 0.02), and preoperative atrial fibrillation (p = 0.038). Eighty-five percent of the discharged patients were in NYHA functional class I or II at follow-up. CONCLUSIONS: Early results of valve replacement after mediastinal radiation therapy were good except in the presence of constrictive pericarditis. Long-term outcome was limited by malignancy and heart failure. Early surgical intervention is recommended before the development of risk factors for late death, namely, severe symptoms, left ventricular dysfunction, and atrial fibrillation.


Subject(s)
Heart Valve Diseases/surgery , Heart Valves/radiation effects , Mediastinal Neoplasms/radiotherapy , Radiation Injuries/surgery , Adult , Aged , Aged, 80 and over , Cause of Death , Female , Follow-Up Studies , Heart Valve Diseases/mortality , Heart Valves/surgery , Humans , Male , Middle Aged , Radiation Injuries/mortality , Reoperation , Retrospective Studies , Survival Rate
7.
J Am Coll Cardiol ; 37(2): 579-84, 2001 Feb.
Article in English | MEDLINE | ID: mdl-11216982

ABSTRACT

OBJECTIVES: We sought to: 1) identify trends in the diagnostic testing of patients with prosthetic aortic valve (AVR) obstruction who undergo reoperation and 2) compare diagnostic test results with pathologic findings at surgery. BACKGROUND: It is unclear whether Doppler transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) have reduced hemodynamic catheterization rates. METHODS: We reviewed 92 consecutive cases ofAVR reoperation at a single center from 1989 to 1998, comparing 49 cases of mechanical AVR obstruction (group A) to 43 cases of bioprosthetic obstruction (group B). Preoperative Doppler TTE was performed in all cases. RESULTS: In group A cases, there was a marginally significant trend towards lower catheterization rates for the Gorlin AVR area, from 36% in 1989 to 1990 to 10% in 1997 to 1998 (p = 0.07), but diagnostic TEE utilization (47% of cases) did not vary. The cause of mechanical AVR obstruction was pannus in 26 cases (53%), mismatch (P-PM) in 19 (39%) and thrombosis in 4 (8%). The mechanism (pannus/thrombus vs. mismatch) was identified in 10% by TTE and 49% by TEE (p < 0.001). In group B cases, hemodynamic catheterization rates (21%) and diagnostic TEE utilization (21%) did not vary with time. Obstruction was caused by structural degeneration in 37 cases (86%), thrombosis in 3 (7%), mismatch in 2 (5%) and pannus in 1 (2%). The mechanism was correctly identified in 63% by TTE and in 81% by TEE (p = 0.18). CONCLUSIONS: Doppler TTE is the primary means to diagnose AVR obstruction; hemodynamic catheterization is not routinely needed. In unselected patients with mechanical AVR obstruction, TEE differentiation of pannus or thrombus from mismatch is challenging.


Subject(s)
Aortic Valve/diagnostic imaging , Echocardiography, Doppler , Echocardiography, Transesophageal , Heart Valve Prosthesis , Postoperative Complications/diagnostic imaging , Prosthesis Failure , Adult , Aged , Aortic Valve/surgery , Female , Hemodynamics/physiology , Humans , Male , Middle Aged , Postoperative Complications/surgery , Predictive Value of Tests , Reoperation
8.
Ann Thorac Surg ; 70(1): 31-7, 2000 Jul.
Article in English | MEDLINE | ID: mdl-10921678

ABSTRACT

BACKGROUND: Bypass grafting for repeat operation or complex forms of descending aortic disease is an alternative approach to decrease potential complications of anatomic repair. METHODS: Between December 1985 and February 1998, 17 patients (13 men, 4 women; mean age, 47.6 +/- 18.5 years) underwent ascending aorta-to-descending aorta bypass through a median sternotomy and posterior pericardial approach. Indications for operation were coarctation or recoarctation of aorta in 8 patients, Takayasu's aortitis in 2, prosthetic aortic valve stenosis associated with coarctation of aorta, complex descending aortic arch aneurysm, reoperation for chronic descending aortic dissection, long-segment stenosis of descending aorta, acquired coarctation after repair of traumatic transection of descending aorta, severe aortic atherosclerosis, and false aneurysm of descending aorta after repair of coarctation in 1 patient each. Concomitant procedures were performed in 12 patients. RESULTS: No early or late mortality has occurred. Follow-up was 100% complete and extended to 12 years (mean, 2.7 +/- 3.3 years). No late graft-related complications have occurred; 1 patient had successful repair of perivalvular leak after mitral valve replacement, and 1 patient had replacement of lower descending and abdominal aorta. CONCLUSIONS: Exposure of the descending aorta through the posterior pericardium for ascending aorta-descending aorta bypass is a safe alternative and particularly useful when simultaneous intracardiac repair is necessary.


Subject(s)
Aorta, Thoracic/surgery , Aortic Diseases/surgery , Thoracic Surgical Procedures/methods , Adolescent , Adult , Aged , Anastomosis, Surgical , Aorta/surgery , Female , Humans , Male , Middle Aged , Pericardium , Sternum/surgery
9.
Mayo Clin Proc ; 75(6): 631-5, 2000 Jun.
Article in English | MEDLINE | ID: mdl-10852425

ABSTRACT

A 34-year-old woman with asthma had increasing dyspnea on exertion for 9 months and new-onset mononeuritis multiplex. An examination demonstrated sinus tachycardia, elevated jugular venous pressure, and a tender nonpulsatile liver. The leukocyte count was 15.8 x 10(9)/L, with 23% eosinophils. Echocardiography revealed a laminated thrombus obliterating much of the right ventricular cavity, with encasement of the tricuspid valve. Ultrafast computed tomography showed no evidence of pulmonary emboli. Biopsy specimens of skin nodules revealed extravascular palisading granulomas. The thrombus was refractory to corticosteroids, and right ventricular thrombectomy was performed. To our knowledge, this is the third reported case of Churg-Strauss syndrome with thrombotic complications from coexistent eosinophilic endomyocarditis. In an asthmatic patient with chronic dyspnea, eosinophilic tissue infiltration, and neuropathy, Churg-Strauss syndrome should be considered; evaluation for cardiac involvement may be warranted.


Subject(s)
Asthma/complications , Churg-Strauss Syndrome/complications , Churg-Strauss Syndrome/diagnosis , Endocarditis/complications , Eosinophilia/complications , Adult , Churg-Strauss Syndrome/surgery , Diagnosis, Differential , Echocardiography , Endocarditis/pathology , Endocarditis/surgery , Eosinophilia/pathology , Eosinophilia/surgery , Female , Humans , Tomography, X-Ray Computed
10.
Semin Thorac Cardiovasc Surg ; 12(2): 77-88, 2000 Apr.
Article in English | MEDLINE | ID: mdl-10807430

ABSTRACT

Myxomas, particularly left-atrial myxomas, are the most common primary tumors of the heart that cardiac surgeons will be called upon to remove. Although some tumors are discovered incidentally during echocardiographic examination, many produce symptoms caused by the release of inflammatory cytokines, obstruction to intracardiac blood flow, and/or embolization. With rare exception, cardiac myxomas are benign, and excision is safe and curative in most patients. In a 38-year experience at the Mayo Clinic, 100 patients have had 106 operations for myxoma, and there has been only 1 perioperative death. During follow-up extending to 25 years, postoperative survival is similar to that of an age- and sex-matched population, and at 20 years postoperatively, 94% of patients were free of recurrent myxomas. Recognition of familial and syndrome myxomas (eg, Carney's complex) is important in guiding surgical approach, planning follow-up, and predicting recurrence of these unusual neoplasms.


Subject(s)
Heart Neoplasms/surgery , Myxoma/surgery , Heart Atria , Heart Neoplasms/diagnosis , Heart Neoplasms/mortality , Heart Neoplasms/pathology , Humans , Myxoma/diagnosis , Myxoma/mortality , Myxoma/pathology , Neoplastic Cells, Circulating , Survival Analysis
11.
Chest ; 117(4): 1094-9, 2000 Apr.
Article in English | MEDLINE | ID: mdl-10767246

ABSTRACT

OBJECTIVE: This study of surgical aortic stenosis characterized sex differences in left ventricular (LV) geometry and outcome. MATERIALS AND METHODS: We examined 92 women and 82 men who underwent echocardiography before valve replacement for aortic stenosis. RESULTS: Women had a smaller cavity size (LV end-diastolic diameter 48.2 +/- 7 mm in women vs 53.6 +/- 7.6 mm in men; p = 0.0001) and higher ejection fraction (59% in women vs 54% in men; p = 0.02). LV mass was greater in men than women (300.4 +/- 88 g in men vs 250.6 +/- 85.8 g in women; p = 0.0055) but when corrected for body surface area, the difference was not significant. The prevalence of LV hypertrophy was similar in both sexes (51% in women vs 49% in men; p = 0.62). The 5-year survival was 82% in women and 79% in men (p = 0. 9). CONCLUSION: Several descriptors of LV geometry differed between men and women. These differences were largely eliminated after normalizing for body surface area. No differences in surgical mortality or long-term outcome were noted.


Subject(s)
Aortic Valve Stenosis/diagnostic imaging , Heart Valve Prosthesis Implantation , Heart Ventricles/diagnostic imaging , Sex Characteristics , Aged , Aortic Valve Stenosis/complications , Aortic Valve Stenosis/surgery , Echocardiography, Doppler , Female , Heart Ventricles/physiopathology , Humans , Hypertrophy, Left Ventricular/diagnostic imaging , Hypertrophy, Left Ventricular/epidemiology , Hypertrophy, Left Ventricular/etiology , Male , Middle Aged , Myocardial Contraction , Prevalence , Retrospective Studies , Survival Rate , Treatment Outcome , Ventricular Function, Left
12.
Anesth Analg ; 90(4): 801-7, 2000 Apr.
Article in English | MEDLINE | ID: mdl-10735779

ABSTRACT

UNLABELLED: Hetastarch is used for intravascular volume expansion in cardiac surgery. Studies show conflicting effects of intraoperative hetastarch administration on postoperative bleeding. Hetastarch was routinely used for volume expansion during cardiovascular surgeries at our institution until its use was discontinued intraoperatively. We performed a retrospective chart review on patients undergoing primary coronary artery bypass grafting, valve repair or replacement requiring cardiopulmonary bypass (n = 444), 234 of which received intraoperative hetastarch and 210 did not. There was no difference in demographics, cardiac surgery, or cardiopulmonary bypass duration between the two groups. Blood loss for 0-4 h postoperatively was 377 +/- 244 mL in the group not receiving hetastarch compared with 515 +/- 336 mL in the group that received hetastarch (P < 0.001). For 0-24 h postoperatively, blood loss was 923 +/- 473 mL versus 1,283 +/- 686 mL in the absence and presence of hetastarch, respectively (P < 0.001). Allogeneic transfusion requirements (cryoprecipitate, fresh frozen plasma, and platelets) were larger in the hetastarch group (all P < 0.001). Nearly all (99%) patients in the hetastarch group received less than the manufacturer's recommended dose (20 mL/kg) of hetastarch. IMPLICATIONS: Our large retrospective study suggests that intraoperative use of hetastarch in primary cardiac surgery with cardiopulmonary bypass may increase bleeding and transfusion requirements. A large prospective study is needed to determine if intraoperative administration of hetastarch should be avoided during cardiovascular surgery.


Subject(s)
Blood Transfusion , Cardiopulmonary Bypass , Hydroxyethyl Starch Derivatives/adverse effects , Plasma Substitutes/adverse effects , Postoperative Hemorrhage/chemically induced , Aged , Female , Humans , Male , Middle Aged , Multivariate Analysis , Retrospective Studies
13.
Nucl Med Commun ; 21(1): 55-63, 2000 Jan.
Article in English | MEDLINE | ID: mdl-10717903

ABSTRACT

Left ventricular function is modified by respiration and pericardial constraint. The aim of this study was to compare left ventricular systolic and diastolic function during inspiration and expiration in four patient groups: patients (1) without cardiac disease, (2) with severe pulmonary disease, (3) with cardiac amyloid and (4) with pericardial constriction (before and after pericardiectomy). Using blood-pool left ventriculography with modified gating, we obtained time-activity curves at the onset of inspiration and expiration. On inspiration and expiration, patients with pericardial constriction and patients with cardiac amyloid were significantly different from those without cardiac disease and those with severe pulmonary disease, in that left ventricular ejection fraction (LVEF) was less, peak filling rate was greater, time to peak filling rate was shorter, and rapid filling fraction was increased. When inspiration and expiration were compared, time to left ventricular peak filling rate was shorter (P = 0.05) on inspiration (118 +/- 48 ms) than on expiration (168 +/- 35 ms) in patients with pericardial constriction. No other measures differed between inspiration and expiration in pericardial constriction, and left ventricular function was unaffected by respiration in the other groups. Time to left ventricular peak filling rate was 49 +/- 69 ms less on inspiration than on expiration in pericardial constriction and this difference was significantly different (P = 0.04) from that in patients with cardiac amyloid (34 +/- 58 ms greater), patients without cardiac disease (2 +/- 69 ms greater) and patients with severe pulmonary disease (19 +/- 63 ms less). In pericardial constriction, pericardial resection caused an increase in LVEF without a change in left ventricular diastolic filling but abolished the differences present between inspiration and expiration in time to left ventricular peak filling rate. This respiratory response in time to left ventricular peak filling rate may be valuable in the diagnosis of pericardial constriction.


Subject(s)
Heart/diagnostic imaging , Respiratory Mechanics/physiology , Ventricular Function, Left/physiology , Aged , Amyloidosis/diagnostic imaging , Amyloidosis/physiopathology , Female , Heart Diseases/diagnostic imaging , Heart Diseases/physiopathology , Heart Ventricles/diagnostic imaging , Humans , Lung Diseases/diagnostic imaging , Lung Diseases/physiopathology , Male , Middle Aged , Pericardium/physiology , Radionuclide Ventriculography , Stroke Volume/physiology
14.
Ann Thorac Surg ; 69(1): 25-9, 2000 Jan.
Article in English | MEDLINE | ID: mdl-10654480

ABSTRACT

BACKGROUND: To determine the optimal method of repair for severe, segmental anterior leaflet prolapse, we analyzed outcome of 121 patients who underwent chordal shortening (n = 46) and chordal replacement (n = 75) from 1988 to 1996. METHODS: Chordae were replaced with expanded polytetrafluoroethylene sutures. Patients had an annuloplasty with either chordal replacement or shortening. Follow-up was 100% complete (mean, 3.7 years). RESULTS: Mean age was 62.1 years, 86 were men, and 60 patients had isolated valve repair. There was one hospital death and 14 late deaths for a 5-year actuarial survival of 86.4%+/-4.5%. Sixteen patients underwent reoperation, 5 in the replacement group and 11 in the shortening group. Mechanism of valve failure in the replacement group was native chordae rupture (n = 4) and neochordae dehiscence (n = 1). With chordal shortening, repair failure was attributed to rupture of shortened chordae (n = 8), leaflet prolapse with and without annuloplasty ring dehiscence (n = 2), and native chordae elongation (n = 1). Risk of reoperation because of repair failure at 3.5 years was 1.4% in the chordal replacement group and 14.8% in the chordal shortening group (p = 0.02). CONCLUSIONS: Chordal replacement is superior to chordal shortening, providing a predictable method for correction of mitral regurgitation with a low incidence of reoperation.


Subject(s)
Chordae Tendineae/surgery , Mitral Valve Prolapse/surgery , Mitral Valve/surgery , Actuarial Analysis , Analysis of Variance , Cause of Death , Female , Follow-Up Studies , Humans , Incidence , Linear Models , Male , Middle Aged , Papillary Muscles/surgery , Polytetrafluoroethylene , Proportional Hazards Models , Reoperation , Risk Factors , Rupture, Spontaneous , Surgical Wound Dehiscence/etiology , Survival Rate , Suture Techniques/adverse effects , Suture Techniques/instrumentation , Sutures , Treatment Outcome
15.
Cardiol Rev ; 8(6): 333-9, 2000.
Article in English | MEDLINE | ID: mdl-11208253

ABSTRACT

As the population ages, aortic valve replacement, particularly for aortic stenosis, has become more common. Although many patients have considerable coexisting morbidity, almost all symptomatic patients are candidates for surgery. Once symptoms develop, surgery should not be unduly delayed, because the operative mortality clearly increases in the presence of poor left ventricular function, heart failure, and New York Heart Association Class III or IV symptoms. Operative difficulties often are related to fragile tissues, a small aortic annulus, and extensive calcification of the aortic annulus and root. In the author's experience, approximately 10% of these patients undergo aortic annulus and root enlargement using pericardium. A tissue valve is the preferred prosthesis. Operative mortality for elective surgery in patients older than 80 years of age is 4-10%, depending on whether associated procedures are required (eg, coronary artery bypass grafting) or whether the patient has had previous surgery. Postoperative neurologic events are important complications that are more common in the elderly. Outcome after successful surgery is excellent, with a 5-year survival of approximately 60%. The vast majority of patients have an improved symptomatic status.


Subject(s)
Aortic Valve Stenosis/mortality , Aortic Valve Stenosis/surgery , Heart Valve Prosthesis Implantation/mortality , Heart Valve Prosthesis Implantation/methods , Quality of Life , Age Factors , Aged , Aged, 80 and over , Aortic Valve Stenosis/diagnosis , Female , Humans , Male , Patient Selection , Postoperative Complications/mortality , Prognosis , Risk Assessment , Risk Factors , Survival Rate
16.
Circulation ; 100(19 Suppl): II84-9, 1999 Nov 09.
Article in English | MEDLINE | ID: mdl-10567283

ABSTRACT

BACKGROUND: Patients who have had previous CABG may subsequently develop significant mitral valve (MV) dysfunction that requires surgical intervention. METHODS AND RESULTS: We reviewed 80 consecutive patients who had had previous CABG and who underwent MV surgery between January 1972 and March 1997. Forty-seven (59%) had initial CABG elsewhere, and 5 had had previous CABG twice. The mean interval between the previous CABG and the MV surgery was 6.3 years (range, 4.4 months to -17 years). At least 15 patients had grade 1/4 to 2/4 mitral regurgitation at initial CABG. The study group included 59 men and 21 women, with a mean study group age of 65.5 years. Ninety-four percent had symptoms of congestive heart failure, 60% had angina, 96% were in NYHA class III to IV, and 37% had an ejection fraction (EF) <50%. Origin of the MV disease was ischemic in 33 patients, myxomatous in 19, combined ischemic and myxomatous in 16, rheumatic in 5, infective in 3, and unknown in 4. MV repair was performed in 46 patients (58%) and MV replacement (MVR) in 34. Concomitant repeat CABG was performed in 38 (48%) patients. In-hospital mortality was 7 of 80 (8.8%); no early death occurred among patients with myxomatous disease. EF <50% was the only significant predictor of early mortality. Overall 1-, 5-, and 10-year survival was 83.8%, 55.6%, and 34.4% respectively. Predictors of late cardiac death were preoperative NYHA class IV (P=0.0006), urgent or emergency operation (P<0.0001), use of intra-aortic balloon pump (P=0.002), and EF <50% (P=0.01). Seven patients had an additional reoperation: 4 received CABG, 2 MVR, and 2 MV repair. CONCLUSIONS: Ischemic, myxomatous, rheumatic, or infective MV dysfunction may develop subsequently after CABG. MVR or MV repair after previous CABG is associated with an acceptably low operative risk and good relief of symptoms. Left ventricular function is strongly correlated with both hospital and late mortality. Surgery should be done before LV dysfunction develops.


Subject(s)
Bioprosthesis , Coronary Artery Bypass , Heart Valve Prosthesis Implantation , Heart Valve Prosthesis , Mitral Valve/surgery , Aged , Female , Graft Survival , Humans , Male , Middle Aged , Retrospective Studies
17.
Circulation ; 100(19 Suppl): II171-5, 1999 Nov 09.
Article in English | MEDLINE | ID: mdl-10567299

ABSTRACT

BACKGROUND: The role of surgical closure of patent foramen ovale (PFO) for cerebral infarction (CI) or transient ischemic attack (TIA) resulting from paradoxical embolism is unclear, and its effect on recurrence is unknown. Our objective was to determine the outcome of surgical closure of PFO in patients with a prior ischemic neurological event, define the rate of CI or TIA recurrence after PFO closure, and identify risk factors for these recurrences. METHODS AND RESULTS: We retrospectively analyzed 91 patients (58 men, 33 women) with >/=1 previous cerebrovascular ischemic events who underwent surgical PFO closure between April 1982 and March 1998. The presence of a PFO with a right-to-left shunt was confirmed with transesophageal echocardiography. Mean age was 44.2+/-12.2 years. The index event was a CI in 59 and a TIA in 32; a Valsalva-like episode preceded the event in 15 patients. Deep venous thrombosis was documented in 9 patients, and a hypercoagulable state was identified in 10. Surgical closure was performed with extracorporeal circulation by either direct suture (n=82) or patch closure (n=9). Limited incisions were used in 18.7% of patients. There was no operative mortality. Morbidity included transient atrial fibrillation (n=11), pericardial drainage for effusion (n=4), exploration for bleeding (n=3), and superficial wound infection (n=1). Follow-up totaled 176.3 patient-years, and mean follow-up was 2.0 years. No one had a CI, and 8 had a TIA during follow-up, with 1 caused by temporal arteritis. Transesophageal echocardiography demonstrated all closures to be intact in these patients. The overall freedom from TIA recurrence during follow-up was 92.5+/-3.2% at 1 year and 83.4+/-6.0% at 4 years. Having multiple neurological events before PFO closure was the only significant risk factor for TIA or CI recurrence after closure by univariate analysis (P=0.05); the small number of post-PFO closure cerebral ischemic events precluded multivariate analysis. CONCLUSIONS: Surgical closure of PFO can be performed with minimal morbidity and mortality. PFO closure may decrease the risk of recurrent stroke or TIA and may avoid lifelong anticoagulation in the young adult if there is no other indication. Recurrent cerebrovascular ischemic events after surgery should prompt further evaluation to identify causes other than paradoxical embolism.


Subject(s)
Brain Ischemia/prevention & control , Cardiac Surgical Procedures , Embolism, Paradoxical/complications , Heart Septal Defects, Atrial/surgery , Adult , Brain Ischemia/etiology , Brain Ischemia/surgery , Female , Heart Septal Defects, Atrial/complications , Humans , Male , Middle Aged , Retrospective Studies , Treatment Outcome
18.
Circulation ; 100(19 Suppl): II392-6, 1999 Nov 09.
Article in English | MEDLINE | ID: mdl-10567335

ABSTRACT

BACKGROUND: Proliferation of the intima is an early lesion of saphenous vein graft disease. Early patency rates of radial artery grafts are acceptable, but little is known about their risk of intimal hyperplasia. METHODS AND RESULTS: To develop a model of intimal hyperplasia, we incubated human saphenous veins, internal mammary arteries, and radial arteries (n=6, 8, and 10, respectively) in an organ culture with Roswell Park Memorial Institute 1640 (30% serum) for 0, 4, 7, 10, and 14 days. Quantitative histological studies were performed, and the average intimal-to-medial (I/M) ratio was calculated for each incubation interval. After 10 and 14 days of culture, the I/M ratio increased in the saphenous veins (P=0. 03, P=0.04 versus 0 day, respectively). No significant increase occurred in the I/M ratio in either the internal mammary or radial arteries. Next, the ability of adenoviral gene transfers to inhibit intimal hyperplasia in the saphenous veins was evaluated. Adenoviral-mediated gene transfer of nitric oxide synthase significantly reduced the I/M ratio at 14 days compared with vehicle (P=0.001) and virus (P=0.004) controls. CONCLUSIONS: The human saphenous vein has a greater propensity for intimal hyperplasia than arterial grafts; the human radial artery behaves similarly to the internal mammary artery. In the future, gene therapy may augment nitric oxide synthase, limiting vein graft disease.


Subject(s)
Cardiopulmonary Bypass , Genetic Therapy , Nitric Oxide/physiology , Tunica Media/pathology , Adenoviridae , Gene Transfer Techniques , Genetic Vectors , Humans , Hyperplasia/genetics , Hyperplasia/therapy , Mammary Arteries/pathology , Organ Culture Techniques , Radial Artery/pathology , Saphenous Vein/pathology
19.
Anesth Analg ; 89(5): 1078-83, 1999 Nov.
Article in English | MEDLINE | ID: mdl-10553815

ABSTRACT

UNLABELLED: We examined the cerebral response to changing hematocrit during hypothermic cardiopulmonary bypass (CPB) in 18 adults. Cerebral blood flow (CBF), cerebral metabolic rate for oxygen (CMRO2), and cerebral oxygen delivery (CDO2) were determined using the nitrous oxide saturation technique. Measurements were obtained before CPB at 36 degrees C, and twice during 27 degrees C CPB: first with a hemoglobin (Hgb) of 6.2 +/- 1.2 g/dL and then with a Hgb of 8.5 +/- 1.2 g/dL. During hypothermia, appropriate reductions in CMRO2 were demonstrated, but hemodilution-associated increases in CBF offset the reduction in CBF seen with hypothermia. At 27 degrees C CPB, as the Hgb concentration was increased from 6.2 to 8.5 g/ dL, CBF decreased. CDO2 and CMRO2 were no different whether the Hgb was 6.2 or 8.5 g/dL. In eight patients in whom the Hgb was less than 6 g/dL, CDO2 remained more than twice CMRO2. IMPLICATIONS: This study suggests that cerebral oxygen balance during cardiopulmonary bypass is well maintained at more pronounced levels of hemodilution than are typically practiced, because changes in cerebral blood flow compensate for changes in hemoglobin concentration.


Subject(s)
Brain/metabolism , Cardiopulmonary Bypass , Cerebrovascular Circulation , Hemodilution , Hypothermia, Induced , Oxygen Consumption , Aged , Cardiac Surgical Procedures , Hemoglobins/analysis , Humans , Oxygen/blood
20.
Mayo Clin Proc ; 74(9): 897-9, 1999 Sep.
Article in English | MEDLINE | ID: mdl-10488792

ABSTRACT

Cardiac valvular involvement associated with Wegener granulomatosis is uncommon. We describe a 17-year-old male adolescent who sought medical attention because of a sore throat, arthralgias, low-grade fever, and fatigue of 3 weeks' duration. A rash was noted on his elbows, hands, and ankles; subsequently, a crusting lesion was noted in his internal nares, and infiltrates were detected on chest radiography. Blood cultures were negative for pathogens. An echocardiogram disclosed mild left ventricular enlargement with grade 2 aortic insufficiency, and Wegener granulomatosis was diagnosed based on an antineutrophil cytoplasmic antibody titer of 1:512. When blood cultures are negative for aortic valve endocarditis, a high index of clinical suspicion and antineutrophil cytoplasmic antibody testing may lead to the diagnosis of acute aortic insufficiency associated with Wegener granulomatosis.


Subject(s)
Antibodies, Antineutrophil Cytoplasmic/blood , Aortic Valve Insufficiency/etiology , Granulomatosis with Polyangiitis/complications , Granulomatosis with Polyangiitis/diagnosis , Acute Disease , Adolescent , Aortic Valve Insufficiency/immunology , Diagnosis, Differential , Granulomatosis with Polyangiitis/immunology , Humans , Male
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