Thrombosis of a Starr-Edwards tricuspid prosthesis: diagnosis by Doppler echocardiography and treatment with thrombolysis.
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Adult↗
Biomedical subjects
A C Galloway
Publications and source records attributed to A C Galloway.
Severe calcification does not affect long-term outcome of mitral valve repair.
Some surgeons have suggested that the presence of severe calcification in the mitral valve annulus or leaflets precludes successful repair. Our institution has attempted to repair these calcified valves when good annular and leaflet mobility could be achieved by annular debridement and leaflet resection. From June 1979 through June 1993 558 mitral valve repairs were performed using Carpentier's techniques. When calcified valves were encountered, these techniques were modified to include annular debridement and mechanical leaflet decalcification. Calcification was identified preoperatively in 49 patients (8.8%) by either left ventricular fluoroscopy or echocardiography and was debrided in 64 patients (11.5%). This included 24 annular debridements, 28 leaflet debridements, and 12 annular and leaflet debridements. Patient ages ranged from 13 to 83 years (mean age, 62.3 years), and 25 patients (39.1%, 25/64) had concomitant cardiac procedures. Operative mortality was 6.2% (4/64) overall and 2.6% (1/39) for isolated mitral valve repairs. Calcium debridement was performed in 19.3% (23/119) of patients with a rheumatic cause compared with 9.3% (41/439) of the nonrheumatic patients (p < 0.01). Long-term follow-up revealed the necessity for reoperation in 7.8% (5/64) in patients with calcium debridement as compared with 7.7% (38/494) with no debridement (p = not significant). Cumulative freedom from reoperation at 10 years was 83.3% for all patients, 88.1% for debrided patients, and 82.6% for nondebrided patients (p = not significant). Cox proportional hazards analysis revealed that the presence of rheumatic disease significantly increased the risk of reoperation (odds ratio = 3.28; p < 0.001), whereas calcium debridement had no significant effect. These results demonstrate that when good annulus and leaflet motion can be achieved in calcified mitral valves, calcium debridement allows durable repairs.
Adolescent↗
Mammary artery versus saphenous vein grafts: assessment of basic fibroblast growth factor receptors.
Neointimal hyperplasia limits the long-term patency of saphenous vein grafts (SVGs), but is notably absent from most internal mammary artery (IMA) grafts. Basic fibroblast growth factor (bFGF) is a local endothelial and vascular smooth muscle mitogen known to be involved in the pathogenesis of neointimal hyperplasia. This study used an animal model to compare the number of available high-affinity (HAR) and low-affinity (LAR) bFGF receptors in SVGs and IMA grafts and to determine whether distention injury causes an increase in receptor availability. The IMA and SVG specimens were harvested from 12 dogs and distended at 25 or 200 mm Hg for 15 minutes, and then the bFGF receptor uptake was measured in them using iodine 125-labeled bFGF. In the IMA conduits distended at low pressure, there were 2.54 +/- 0.10 (mean +/- standard error of the mean) HARs per mm2 of intimal surface area available and 5.19 +/- 0.40 LARs per mm2. High-pressure distention significantly (p < 0.001) increased the number of available HARs to 5.06 +/- 0.27 per mm2 and of LARs to 7.27 +/- 0.042 per mm2. At low pressure, the SVGs had significantly (p < 0.001) more HARs (9.14 +/- 0.84 per mm2) and LARs (18.2 +/- 0.57 per mm2) available than did the IMA conduits, and high pressure significantly (p < 0.001) increased the number of HARs available in SVGs to 24.1 +/- 2.43 per mm2 and the number of LARs to 44.7 +/- 2.34 per mm2.(ABSTRACT TRUNCATED AT 250 WORDS)
Animals↗
Decreasing incidence of systolic anterior motion after mitral valve reconstruction.
BACKGROUND: With the widespread application of mitral valve reconstructive techniques, systolic anterior motion (SAM) of the anterior mitral leaflet causing left ventricular outflow tract obstruction has been recognized by several groups. SAM occurred in 9.1% of the first 441 patients operated on for mitral valve reconstruction at our institution. Fortunately, SAM subsided with medical therapy within 1 year for a majority of patients as reported in May 1993. Some surgeons, however, have considered abandoning repair for prosthetic replacement after SAM was detected on intraoperative echocardiogram. METHODS AND RESULTS: Since June 1991, a triangular anterior leaflet resection has been cautiously evaluated in patients with extensive anterior leaflet tissue. This has been performed in 23 of 119 patients. CONCLUSIONS: The frequency of SAM in the 119 study patients has decreased from 9.1% to 3.4%.
Female↗
Effect of retrograde warm continuous cardioplegia on right ventricular function.
BACKGROUND: Although retrograde warm continuous cardioplegia (RWCC) has been recently advocated as a method of myocardial preservation during cardiac surgery, scant data exist on the effects of RWCC on right ventricular function. However, previous data have clearly shown that retrograde cardioplegia is poorly distributed to the right ventricle and interventricular septum. This experiment was performed to analyze functional preservation of the right ventricle after RWCC. METHODS AND RESULTS: Fourteen mongrel dogs were instrumented with sonomicrometers and pressure transducers to determine left and right ventricular (LV, RV) pressure-volume relationships and placed on cardiopulmonary bypass. All dogs underwent 90 minutes of aortic cross-clamping with either (1) RWCC (n = 7) after antegrade warm arrest or (2) retrograde cold multidose cardioplegia (RCMC) (n = 7) with topical hypothermia after antegrade cold arrest. All dogs received identical blood cardioplegia solutions. Ventricular function was measured before arrest and 30 and 60 minutes after unclamping. The end-diastolic-work area relationship was calculated, and the slope is presented as percent of baseline (mean +/- SEM; repeated measures ANOVA). At 30 minutes after unclamping, RWCC provided 68.77 +/- 9.09 for the left ventricle and 41.03 +/- 7.49 (P < .05 for RWCC versus RCMC for RV function at 30 minutes) for the right ventricle, and RCMC provided 62.80 +/- 7.23 for the left ventricle and 79.40 +/- 13.82 for the right ventricle. At 60 minutes after unclamping, RWCC provided 58.24 +/- 12.35 for the left ventricle and 48.05 +/- 9.72 for the right ventricle, and RCMC provided 65.38 +/- 6.76 for the left ventricle and 61.95 +/- 8.70 for the right ventricle. (P = NS for RWCC versus RCMC for LV function at either 30 or 60 minutes). These results demonstrate depressed recovery of RV function after 90 minutes of RWCC (P < .05 at 30 minutes after reperfusion) compared with RCMC. No difference in recovery of LV function was detected. CONCLUSION: RWCC may be harmful to the right ventricle and should be used with caution, particularly in patients with preexisting RV hypertrophy.
Animals↗
Suppression of neointimal lesions after vascular injury: a role for polyclonal anti-basic fibroblast growth factor antibody.
BACKGROUND: Basic fibroblast growth factor (bFGF) is a potent local promoter of vascular smooth muscle cell migration and proliferation and may play a major role in the pathogenesis of intimal fibromuscular lesions. Preliminary studies have shown that exogenous bFGF localizes to injured rabbit aorta and suggest that this interaction might be inhibited by anti-bFGF immunoglobulin (Ig) G. This study was designed to evaluate the possible role of polyclonal anti-bFGF IgG in reducing intimal fibromuscular lesion formation in the injured rabbit aorta. METHODS: The abdominal aortic endothelium was subjected to balloon injury in 13 rabbits. Six rabbits received intravenous rabbit anti-bFGF IgG, and seven received irrelevant rabbit IgG (16 micrograms/kg) 30 minutes before injury and daily for 5 days after injury. At 14 days after injury the aorta was fixed and sectioned, and the intimal and medial areas were measured by computerized digital morphometry with the intimal/medial ratio as an index of neointimal lesion formation. RESULTS: In the control group the intimal/medial ratio was 0.538 +/- 0.046 (mean +/- SEM), which was significantly greater than the anti-bFGF-treated group value of 0.148 +/- 0.021 (p < 0.001). CONCLUSIONS: These results show that daily doses of intravenous polyclonal anti-bFGF IgG for 5 days after balloon aortic injury significantly inhibit intimal fibromuscular lesion formation at 14 days. The results suggest that the process of intimal fibromuscular lesion formation may be susceptible to modification by antagonists to bFGF.
Animals↗
Sterol 27-hydroxylase: high levels of activity in vascular endothelium.
Sterol 27-hydroxylase activity in bovine aortic endothelial (BAE) cells in culture has been compared with that in HepG2 cells and in Chinese hamster ovary (CHO) cells using identical culture conditions. The total enzyme activity of BAE cells (3.0 nmol/72 h per mg cell protein) was comparable with that of HepG2 cells (4.0 nmol/72 h per mg protein) and both values were significantly greater than that in CHO cells (0.002 nmol/72 h per mg protein). The enzyme was identified in the mitochondria extracted from BAE cells by Western blotting using an antibody of proven specificity, and its metabolites 27-hydroxycholesterol and 3 beta-hydroxy-5-cholestenoic acid were identified by mass spectrum analysis. The presence of the enzyme in endothelium provides a mechanism for preventing accumulation of intracellular cholesterol by initiating a pathway of bile acid synthesis different from that initiated by 7 alpha-hydroxylation of cholesterol in the liver.
Animals↗
Direct-current injury from external pacemaker results in tissue electrolysis.
In two patients undergoing open heart operations, electrochemical burns developed at the sites of connection to an external pacing system. Investigation revealed that failure of the pacing generator caused a small, continuous, direct current to pass through the patients, resulting in electrolysis at the sites of contact with the pacing and grounding wires. This electrolytic reaction was recreated in a mock pacing system and resulted in tissue injury and disintegration of the pacing wire. Guidelines to help recognize and prevent this complication are presented.
Aged↗
Aortic aneurysm and dissection: normal MR imaging and CT findings after surgical repair with the continuous-suture graft-inclusion technique.
The normal range of postoperative imaging findings are described in 34 asymptomatic patients studied 5-66 months (mean, 28 months) after undergoing the continuous-suture graft-inclusion technique for repair of aortic aneurysms (n = 20) and dissections (n = 14) involving the ascending aorta. All 34 patients underwent magnetic resonance (MR) imaging, and 24 patients also underwent computed tomography (CT). Perigraft thickening was seen in 19 patients (56%) with MR imaging and in eight patients (33%) with CT. Flow outside the graft but contained within the native wrap was noted in five patients (15%) with MR imaging and in four patients (17%) with contrast material-enhanced CT. Thrombus was identified outside the graft and within the wrap in seven patients (21%) with MR imaging and in six patients (25%) with CT. Mass effect on the graft was depicted in four patients (12%) with MR imaging and in three patients (13%) with CT. Of the 14 patients who underwent repair of aortic dissections, an intimal flap was seen distal to the graft in seven of the 14 (50%) evaluated with MR imaging and in four of the 10 (40%) evaluated with contrast-enhanced CT. An accurate postoperative imaging evaluation requires precise knowledge of the surgical technique performed and its anatomic consequences.
Adolescent↗
Role of amino acids and enhancement cardioplegia in routine myocardial protection. Experimental results.
The purpose of this study was to determine the effects of the addition of amino acids to blood cardioplegic solution and the value of terminal cardioplegia enhancement techniques in routine myocardial protection. Forty-five open-chest adult dogs were instrumented with sonomicrometry crystals to measure left ventricular long axis, midequatorial short axis, and wall thickness. The aorta was clamped for 120 minutes of cardiopulmonary bypass. Animals were randomly separated into four myocardial protection groups: (1) blood cardioplegic solution with amino acids and no terminal cardioplegia (n = 12); (2) blood cardioplegic solution with amino acids and warm amino acid terminal cardioplegia (n = 11); (3) blood cardioplegic solution with amino acids and cold amino acid terminal cardioplegia (n = 12); and (4) blood cardioplegic solution plus cold terminal cardioplegia (no amino acids, n = 10). Data for preload recruitable stroke work were obtained by inflow occlusion before bypass (baseline) and at 30 and 60 minutes after reperfusion and analyzed for changes in x-intercept and slope. A significant rightward shift in x-intercept did not occur in any group. When cardiac function was expressed as a percentage of baseline preload recruitable stroke work slope, improved functional recovery was seen at both 30 and 60 minutes in groups 2 (88.6% and 91.8%), 3 (85.8% and 86.9%), and 4 (88.6% and 92.6%) compared with group 1 (77.3% and 79.2%, p < 0.05). No significant difference was found in the degree of functional recovery among groups 2, 3, and 4. These results suggest that for myocardial protection of 2 hours in nonischemic hearts, a terminal dose of blood cardioplegic solution before unclamping is beneficial, but this positive effect is independent of amino acid supplementation and temperature.
Amino Acids↗
Surgical repair of type A aortic dissection by the circulatory arrest-graft inclusion technique in sixty-six patients.
During an 8-year period (1984 to 1991) 66 patients (mean age 59 years, range 26 to 84 years) with type A aortic dissection (60 ascending aorta tears, 6 arch tears; 35 acute, 31 chronic) had surgical repair by a continuous suture-graft inclusion technique. Hypothermic circulatory arrest (16 degrees C) was used in 58 patients (35/35 acute, 23/31 chronic; mean arrest time 26 minutes, range 10 to 55 minutes). Fifty-two patients had hemiarch repair and 6 had total arch replacement. Aortic valve disease necessitated treatment in 38 patients (1 valved conduit, 20 valve replacements, 17 valve repairs). Recently 11 patients had valve repair by reconstruction of the native aortic root, by means of techniques similar to those used for homograft valve insertion. Operative mortality was 9% (14% acute, 3% chronic). Stroke occurred in 2 patients (3%) and was fatal in both. Variables suggestive of increased operative risk by univariate analysis were acuteness (p = 0.12), visceral ischemia (p = 0.12), and preoperative shock (p = 0.13). No variable was significant by multivariate analysis. Overall actuarial survival at 48 months was 77%, with 3 late deaths from a ruptured distal aneurysm. Late computed tomography or magnetic resonance imaging scan was done in 28 patients at a mean interval of 33 months. These studies identified 1 patient with a pseudoaneurysm requiring reoperation and 3 patients with contained flow between the graft and the wrap. Three patients required late operation: 1 for pseudoaneurysm, 1 for arch dissection, and 1 for repair of a distal aneurysm.
Actuarial Analysis↗
Multiple valve operation for advanced valvular heart disease: results and risk factors in 513 patients.
To assess the results and incremental risk factors affecting outcome after multiple-valve operation in the early blood cardioplegia era of cardiac surgery, follow-up data (mean +/- SD 3.1 +/- 2 years) were obtained on 97% of 513 patients (mean age +/- SD 58.8 +/- 10.5 years) who underwent a multiple-valve procedure between June 1976 and August 1985. Preoperatively 41% of patients were in New York Heart Association functional class III and 54% in class IV. Three groups accounted for 98.6% of the patients: 57.7% had an aortic and mitral valve procedure, 29% had a mitral and tricuspid valve procedure and 11.9% had a triple-valve procedure. The overall hospital mortality rate was 12.5% and overall 5-year survival rate was 67.1%. Hazard function analysis for all deaths revealed systolic pulmonary artery pressure (p less than 0.0001), age (p = 0.005), triple valve procedure (p less than 0.005), concomitant coronary bypass operation (p less than 0.005) and prior cardiac surgery (p less than 0.002) as the significant incremental risk factors predicting decreased survival in the early hazard phase; diabetes (p less than 0.005) predicted decreased survival in the late hazard phase. Postoperatively the condition of 80% of the patients improved to functional class I or II; only 0.6% remained in functional class IV. The 5-year rate of freedom from late combined valve-related morbidity was 81.7% and that of freedom from late combined valve-related morbidity and mortality was 71.7%. These results demonstrate excellent clinical improvement and late survival after multiple valve operation in patients with advanced valvular heart disease, justifying aggressive surgical therapy in these patients.(ABSTRACT TRUNCATED AT 250 WORDS)
Bioprosthesis↗
Treatment of AIDS-related bronchopleural fistula by pleurectomy.
Spontaneous pneumothorax in patients with acquired immunodeficiency syndrome (AIDS) may require prolonged therapy for treatment of a persistent bronchopleural fistula, and treatment by standard methods often fails. This pilot study was done to test the effectiveness of aggressive surgical therapy for definitive treatment of persistent bronchopleural fistula in patients with AIDS. Between March 1989 and September 1991, 44 patients with AIDS were treated for spontaneous pneumothorax with closed tube thoracostomy; 14 of these patients had development of persistent bronchopleural fistula for more than 10 days, and 2 patients had subsequent bronchopleural fistula on the opposite side. Operative therapy in 14 patients included 15 thoracotomies and one sternotomy. The bronchopleural fistula was closed directly with suture or staples in 15 procedures and resected by lobectomy in 1 patient. All 14 patients received adjuvant parietal pleurectomy. Operative mortality was 7% (1 of 14 patients). The fistula was closed in all survivors and 13 patients were discharged between 7 and 28 days postoperatively. Pathologic examination confirmed Pneumocystis carinii in 13 patients with a high incidence of diffuse involvement and subpleural necrosis, further demonstrating the need for pleurectomy. These data suggest that in selected patients bronchopleural fistulas associated with AIDS can be effectively controlled by surgical closure combined with pleurectomy.
Acquired Immunodeficiency Syndrome↗
Surgical implications of transesophageal echocardiography to grade the atheromatous aortic arch.
Stroke is an especially serious complication of cardiopulmonary bypass with an incidence of 2% to 5%. This prospective study used transesophageal echocardiography (TEE) in 97 patients more than 65 years of age (mean age, 73 years) to identify those at high risk for aortic atheroemboli. The atheromatous disease of the aorta was graded by TEE: grade I = minimal intimal thickening (n = 29); II = extensive intimal thickening (n = 33); III = sessile atheroma (n = 15); IV = protruding atheroma (n = 10); V = mobile atheroma (n = 10). Clinical evaluation was also performed by intraoperative aortic palpation. Four patients who were graded as having normal aortas by palpation had intraoperative strokes. In contrast, 3 of these 4 patients were in grade V on TEE. The relationship of TEE to incidence of stroke was statistically significant (p less than 0.006), whereas there was no significant correlation between clinical grade and stroke incidence. Four of 10 TEE grade V patients were treated with hypothermic circulatory arrest and aortic arch debridement, and none suffered strokes. The other 6 patients were treated with standard techniques, and 3 had strokes. These results suggest that patients with mobile atheromatous disease are at high risk for embolic strokes that are not predicted by routine clinical evaluation. Selective use of circulatory arrest in the presence of TEE-detected mobile arch atheromas may reduce the risk of intraoperative stroke.
Aged↗
The effects of different techniques of internal mammary artery harvesting on sternal blood flow.
We investigated chest wall blood flow in a canine model to determine if the technique used to harvest the mammary artery has a differential effect on residual chest wall blood flow. Eight dogs underwent bilateral internal mammary artery mobilization; one artery was harvested as a pedicle and the other was harvested as a skeletonized vessel. Residual blood flow to the chest wall distribution of each artery was measured with radioactive microspheres. Chest wall blood flow was significantly decreased from preharvest levels after internal mammary artery mobilization regardless of the technique used. Tissue blood flows decreased to 46.9%, 22.1%, and 41.2% of baseline values for the manubrium (p < 0.01), sternum (p < 0.001), and ribs (p < 0.05), respectively. Residual sternal blood flow on the side of the skeletonized vessel was significantly greater than on the side of the pedicle graft (2.60 +/- 0.68 versus 1.27 +/- 0.27 cm3/min/100 gm, p < 0.001). We conclude that minimization of tissue mobilization during internal mammary artery harvesting may reduce sternal devascularization. This finding may have clinical significance with respect to lowering the incidence of sternal wound complications in coronary bypass surgery using the internal mammary artery as a bypass conduit.
Animals↗
Experience with twenty-eight cases of systolic anterior motion after mitral valve reconstruction by the Carpentier technique.
Systolic anterior motion of the mitral valve with left ventricular outflow tract obstruction after Carpentier-type mitral reconstruction with ring annuloplasty has led some surgeons to abandon an otherwise successful repair or to avoid use of a rigid ring. To assess the long-term significance of such motion, we studied 439 patients undergoing Carpenter mitral reconstruction at our institution between March 1981 and June 1990. The hospital mortality rate was 4.8% (21/439) overall and 3.7% (9/243) for isolated mitral reconstruction. Systolic anterior motion was found in 6.4% (28/438) after the operation, and 2.3% (10/438) had a coexisting left ventricular outflow tract gradient (mean 53 mm Hg). Of the 28 patients with systolic anterior motion, 27 (96.4%) had leaflet prolapse, 17 (60.7%) had undergone more than a 3 cm resection of the posterior leaflet, and two (7.1%) had preexisting idiopathic hypertrophic subaortic stenosis. All patients were treated medically, 14 with negative inotropic agents. Follow-up echocardiograms at a mean of 32 months demonstrated the disappearance of systolic anterior motion in 13 of 28 patients (46.4%) and resolution of the outflow tract gradient in 10 of 10 (100%). At follow-up only one patient was in New York Heart Association class III or IV and required reoperation for rheumatic mitral insufficiency. These data demonstrate that systolic anterior motion after Carpentier mitral reconstruction with ring annuloplasty is not prevalent and should be managed medically in most cases. Associated left ventricular outflow tract obstruction resolves with medical treatment.
Cardiac Surgical Procedures↗
Aortic valve replacement for aortic stenosis in persons aged 80 years and over.
Seventy-one patients aged greater than or equal to 80 years (mean +/- standard deviation 82 +/- 2) with aortic stenosis or mixed stenosis and regurgitation underwent aortic valve replacement alone (n = 35, group 1) or in combination with a coronary artery bypass procedure without any other valve procedure (n = 36, group 2). Preoperatively, 91% had severe cardiac limitations (New York Heart Association class III or IV). Hospital mortality was 12.7% overall (9 of 71), 5.7% (2 of 35) for group 1 and 19.4% (7 of 36) for group 2. Perioperatively, 1 patient (1.4%) had a stroke. Survival from late cardiac death at 1 and 3 years was 98.2 and 95.5%, respectively, for all patients, 100% for patients who underwent isolated aortic valve replacement, and 96.3 and 91.2%, respectively, for patients who underwent aortic valve replacement plus coronary artery bypass. Eighty-three percent of surviving patients had marked symptomatic improvement. Freedom from all valve-related complications (thromboembolism, anticoagulant, endocarditis, reoperation or prosthetic failure) was 93.3 and 80.4% at 1 and 3 years, respectively. Thus, short- and long-term morbidity and mortality after aortic valve replacement for aortic stenosis in patients aged greater than or equal to 80 years are encouragingly low, although the addition of coronary artery bypass grafting increases short- and long-term mortality.
Aged↗
Repair of posterior left ventricular aneurysm in a six-year-old boy.
Left ventricular aneurysms and diverticula are rarely encountered in the pediatric age group. This paper reports a case of congestive heart failure and mitral regurgitation in a 6-year-old boy with a large posterolateral left ventricular aneurysm. Complete repair was successfully performed by excision of the aneurysm and Dacron patch reconstruction of the left ventricular free wall. The patch extended onto the posterior annulus of the mitral valve, thus restoring the mitral valve to normal geometry and correcting the mitral insufficiency. The surgical literature on congenital cardiac diverticula and acquired aneurysms in children is reviewed and summarized.
Child↗