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Biomedical subjects

A Chaux

Publications and source records attributed to A Chaux.

At least 37 records · Page 2Linked to original sources
PubMed1994

The St. Jude Medical valve. Experience with 1,000 cases.

We analyzed the long-term results of valve replacement with the St. Jude Medical bileaflet valve (St. Jude Medical, Inc., St. Paul, Minn.) in our first 1000 implantations between 1978 and 1992. A total of 399 patients had mitral valve replacement, 471 aortic valve, and 130 double (mitral and aortic) valve replacement. The average patient age was 64 +/- 15 years and the majority of patients (52%) had concomitant coronary disease. With 4328 patient-years of follow-up, 83% of the mitral group, 76% of the aortic group, and 77% of the double valve group were free of thromboembolism at 10 years after operation, and 87% of the mitral group, 82% of the aortic group, and 85% of the double valve group were free of valve-related hemorrhage. At 10 years, 91% of the mitral group, 84% of the aortic group, and 84% of the double valve group were free of valve-related death. However, overall survival at 10 years was only 42% +/- 4% for the mitral group, 43% +/- 4% for the aortic group, and 43% +/- 6% for the double valve group. For all three groups, age was a highly significant factor stratifying survival (p < 0.001), as was the presence of coronary disease (all p < 0.001). The excellent freedom from valve-related death at 10 years of 84% to 91% is in striking contrast to the overall survivals of 42% to 43% at 10 years. This difference suggests that the primary factors limiting long-term survival after valve replacement with the St. Jude Medical valve are not valve-related factors, but other patient factors such as age and concomitant coronary disease.

Aged↗
PubMed1993

The St. Jude valve. Thrombolysis as the first line of therapy for cardiac valve thrombosis.

BACKGROUND: Thrombolytic therapy is a promising alternative to valve replacement in the management of prosthetic valve thrombosis. We sought to determine the short- and long-term results of treating thrombosed St. Jude heart valves with thrombolytic therapy as the primary treatment modality. METHODS AND RESULTS: Between March 1978 and December 1991, 988 patients underwent implantation of St. Jude prosthetic valves at our medical center, and all patients with thrombosed valves were identified prospectively. During this period, 17 patients (13 women; mean age, 66.8 +/- 19.0 years) developed prosthetic valve thrombosis (11 aortic, six mitral). In six patients, Coumadin was stopped in preparation for elective surgery. The clinical presentation was congestive heart failure in 13, syncope and fatigue in two, and a cerebrovascular accident in one; one patient was asymptomatic. The average duration of symptoms was 11.7 +/- 12.0 days (range, 1-45 days). Anticoagulation was subtherapeutic in all but one patient at the time of presentation. Cinefluoroscopy was the primary method used for diagnosis and was also used to follow the response to therapy. Twelve patients were treated medically (10 with thrombolytic therapy and two with heparin), three were treated surgically, and two were diagnosed at autopsy. Of the 12 medically treated patients, 10 had marked improvement in leaflet movement and symptoms within 12 hours. Thus, 10 of 12 patients (83%) had a satisfactory response to medical therapy alone. No medically treated patient died or had a major complication resulting in permanent damage. However, four of the 12 medically treated patients had minor complications, including a transient episode of facial weakness in one patient, hematomas in two, and epistaxis in one. Late rethrombosis recurred in two patients in the medically treated group and was successfully retreated with thrombolytic therapy. At 3 months, all patients were alive and well. CONCLUSIONS: Thrombolytic therapy can be used as the first line of therapy for thrombosed St. Jude valves with a low risk of permanent side effects and excellent chances of success. In most cases, surgery can be reserved for patients who do not respond to thrombolytic therapy.

Adolescent↗
PubMed1992

Results of early repair of ventricular septal defect after an acute myocardial infarction.

A 10-year experience with early operation for postinfarction ventricular septal defect is reviewed. Twenty-two patients underwent surgical repair; operative mortality was 36% (< 30 days). The actuarial survival was 64% at 1 month, 59% at 1 year, and 47% at 5 years. Risk factors predictive of operative mortality were diabetes (p = 0.001), elevated preoperative right atrial pressure (p = 0.02), the absence of a preoperative intraaortic balloon pump (p = 0.006), and a short time interval between infarct and operation (p = 0.018). Long-term survival was adversely related to diabetes (p = 0.030), elevated preoperative right atrial pressure (p = 0.005), and, surprisingly, survival was better in patients with a greater extent of coronary artery disease (p = 0.023). There were 14 operative survivors (64%) and 11 long-term survivors (3 months to 10 years, mean 6.0 +/- 3.5 years). Six of eleven survivors were in functional New York Heart Association class I, one was in class II, and four were in class III.

Aged↗
PubMed1992

Comparative efficacy of ring and suture annuloplasty for ischemic mitral regurgitation.

BACKGROUND: Patients with ischemic mitral regurgitation (MR) represent a therapeutic challenge, and results after combined valve replacement and revascularization have been poor. Valve repair is a promising approach, but the optimal method of repair is not known. METHODS AND RESULTS: In 60 patients with coronary artery disease and 3+ or 4+ MR, we used intraoperative Doppler echocardiography to study the efficacy of Carpentier-Edwards ring (n = 27) and commissural suture (n = 33) annuloplasty. Patients with ruptured papillary muscles, torn chordae, and ballooning or scalloping of the leaflets were excluded. Ring and suture groups were similar in preoperative ejection fraction (35 +/- 14% and 34 +/- 17%), MR grade (3.5 +/- 0.5 and 3.4 +/- 0.6), and acuity of MR (41% and 33% acute) (p = NS). Postoperatively, the ring group achieved a lower residual MR grade than the suture group (0.5 +/- 0.5 versus 1.5 +/- 1.1; p < 0.001), and the mitral annular diameter was reduced to a greater extent in the ring group (by 1.5 +/- 0.5 cm versus 0.5 +/- 0.4 cm; p < 0.001). Success (> or = 2 grade MR reduction) was more frequent in the ring than in the suture group (96% versus 67%, p < 0.01). One-year survival was similar (74 +/- 9% ring, 71 +/- 8% suture). Follow-up Doppler studies showed a higher mean gradient (4.0 +/- 1.2 mm Hg) and smaller valve area (2.1 +/- 0.5 cm2) in the ring group, but the postoperative New York Heart Association class was similar in both groups (83% versus 74% class I-II). CONCLUSIONS: Ring annuloplasty provides a more effective reduction of ischemic MR and a higher success rate than the suture technique. This may be related to uniform rather than localized shortening of the annulus and a greater reduction in annulus diameter.

Aged↗
PubMed1991

Morbidity and mortality after coronary artery bypass in octogenarians.

One hundred fifty seven consecutive octogenarians (mean age +/- standard deviation, 82.4 +/- 1.9 years) underwent coronary artery bypass grafting with hypothermia (mean temperature, 21.8 degrees +/- 1.8 degrees C), hyperkalemic cardioplegia, and cardiopulmonary bypass in a 9-year period. Sixty-six percent were male. Preoperatively, 115 patients (73%) were in New York Heart Association functional class IV, with the remainder being in either class III (23%) or class II (4%). Twenty percent of the patients had major complications including postoperative hemorrhage (15), sepsis (9), cerebrovascular accident (6), third-degree heart block (5), renal failure requiring dialysis (1), and pulmonary embolism (1). The 30-day or in-hospital mortality rate was 7.0%. Mean total hospital stay was 26.1 +/- 17.9 days. One-year and 5-year actuarial survival rates were 85% and 62%, respectively. Higher mortality was seen to be associated with New York Heart Association class IV, left ventricular ejection fraction less than 0.40, and lesser values for cardiac output and cardiac index. At the 6-month postoperative follow-up, 73% of the survivors reported that their general health had improved as compared with before operation. This experience demonstrates that for select octogenarians with unmanageable angina pectoris, coronary artery bypass grafting is an effective therapeutic option.

Aged↗
PubMed1990

Increased mortality of women in coronary artery bypass surgery: evidence for referral bias.

STUDY OBJECTIVE: To determine whether differences in referral reasons explain the higher operative mortality of women in coronary artery bypass surgery. DESIGN: Case series. SETTING: A tertiary care, private teaching hospital. PATIENTS: Consecutive patients who had isolated coronary artery bypass surgery between 1982 and 1987 (total, 2297; 79% male and 21% female). MEASUREMENTS AND MAIN RESULTS: The inhospital mortality rate was significantly higher for women than for men (4.6% compared with 2.6%; P = 0.036; 95% CI for difference in mortality, 0% to 4.0%). Women were older than men (mean, 68.2 and 64.0 years, respectively; P less than 0.001), and a higher percentage of women were referred with unstable angina (P = 0.007), postmyocardial infarction angina (P = 0.029), congestive heart failure (P less than 0.001), and New York Heart Association class IV symptoms (66% compared with 45%, P less than 0.001). More men were referred with a history of an abnormal exercise test (P less than 0.001), and patients referred because of a positive exercise test had a lower mortality (P less than 0.001). Using multivariate analysis, adjustment for the higher preoperative functional class of women and for age accounted for all of the difference in mortality between men and women (odds ratio, 1.04; CI, 0.60 to 1.79; P = 0.89). After correction for functional class alone, there continued to be no significant difference in mortality between men and women (P = 0.40). CONCLUSIONS: Differences in functional class and age account for the higher operative mortality of women in coronary bypass surgery. Women are referred for coronary bypass surgery later in the course of their disease than men, and later referral may increase their changes of operative death.

Adult↗
PubMed1990

Ten-year experience with the St. Jude Medical valve for primary valve replacement.

The St. Jude Medical valve is a bileaflet prosthesis with excellent hemodynamic characteristics, but the long-term surgical experience with this valve, its durability, and its biocompatibility are unknown. During a 10-year period from March 1978 to 1988, 690 prostheses (290 aortic, 252 mitral, and 74 double aortic-mitral) were inserted as the initial valve replacement substitute in 616 patients (mean age 63 years). Coronary atherosclerosis was present in 58%. Follow-up totaled 2031 patient-years (mean 3.3 years) and was 95% complete (32 lost). Early (30-day) mortality rates were 5.2%, 11.9%, and 8.1% after aortic, mitral, and double valve replacement; 5- and 9-year actuarial survival rates were 71% +/- 3% and 51% +/- 8%, 59% +/- 4% and 41% +/- 6%, and 69% +/- 6% and 47% +/- 15%, respectively. Deaths were associated with extensive coronary atherosclerosis (p less than 0.001), older age (p less than 0.001), advanced preoperative New York Heart Association functional class (p less than 0.05), and malignant ventricular arrhythmias (p less than 0.05). No structural failures have been observed. Embolism (40 events) occurred at a rate of 2.0%/pt-yr (2.3% aortic, 1.6% mitral, 2.0% double). There were six cases of valve thrombosis (0.3%/pt-yr; one fatal). Hemorrhage was the most frequent complication (2.6%/pt-yr); 13 (25%) of 52 events were fatal, accounting for 62% of all valve-related deaths. After the target prothrombin time ratio was lowered, the rate of hemorrhage decreased by 44% (2.7% to 1.5%/pt-yr), while the combined rate of embolism and valve thrombosis increased slightly (2.2% to 2.5%/pt-yr, a 14% change). In summary, the St. Jude Medical valve remains a durable valve substitute. Survival was strongly related to the presence of associated coronary atherosclerosis. The most common complication has been hemorrhage; a less intensive warfarin regimen may reduce hemorrhagic risk while maintaining thromboembolic protection.

Adolescent↗
PubMed1989

A quantitative comparison of transesophageal and epicardial color Doppler echocardiography in the intraoperative assessment of mitral regurgitation.

Epicardial and transesophageal color Doppler echocardiography are both widely used for the intraoperative assessment of mitral regurgitation (MR); however, it has not been established whether grading of regurgitation is comparable when evaluated by these 2 techniques. MR jet size was quantitatively compared in 29 hemodynamically and temporally matched open-chest epicardial and transesophageal color Doppler echocardiography studies from 22 patients (18 with native and 4 with porcine mitral valves) scheduled to undergo mitral valve repair or replacement. Jet area, jet length and left atrial area were analyzed. Comparison of jet area measurements as assessed by epicardial and transesophageal color flow mapping revealed an excellent correlation between the techniques (r = 0.95, p less than 0.001). Epicardial and transesophageal jet length measurements were also similar (r = 0.77, p less than 0.001). Left atrial area could not be measured in 18 transesophageal studies (62%) due to foreshortening, and in 5 epicardial studies (17%) due to poor image resolution. Acoustic interference with left atrial and color flow mapping signals was noted in all patients with mitral valve prostheses when imaged by epicardial echocardiography, but this did not occur with transesophageal imaging. Thus, in patients undergoing valve repair or replacement, transesophageal and epicardial color flow mapping provide similar quantitative assessment of MR jet size. Jet area to left atrial area ratios have limited applicability in transesophageal color flow mapping, due to foreshortening of the left atrial borders in transesophageal views. Transesophageal color flow mapping may be especially useful in assessing dysfunctional mitral prostheses due to the lack of left atrial acoustic interference.

Adult↗
PubMed1989

Thermal coronary angiography: a method for assessing graft patency and coronary anatomy in coronary bypass surgery.

Thermal coronary angiography was evaluated in 50 patients undergoing 137 saphenous vein and 48 internal mammary artery bypass grafts. A total of 177 thermal coronary angiograms were performed after completion of the distal anastomoses by injection of cold cardioplegia into the vein or by reperfusion with warmer blood in the internal mammary artery grafts. These angiograms provided details of graft and anastomosis patency, flow directions, and presence of native coronary stenoses. Temperature differences between the injectant and the epimyocardium of greater than 4 degrees C resulted in high-contrast images. Thermal coronary angiograms were obtained in 173 of the 177 studied bypass grafts; 172 grafts were patent, and 1 internal mammary artery graft was occluded. Unsuspected stenoses were detected at the site of four distal anastomoses. Subsequently, two anastomoses were successfully revised and three additional grafts performed. Ninety-six native coronary stenoses were located in the recipient coronary arteries. In ten instances, the thermal coronary angiograms were obscured by excess fat or myocardium, thereby impeding correct image analysis. We conclude that thermal coronary angiography can be clinically relevant and helps improve decision making during coronary artery bypass operations.

Adult↗
PubMed1989

Tricuspid valve repair. Operative and follow-up evaluation by Doppler color flow mapping.

Severe tricuspid regurgitation may produce significant morbidity and mortality if not corrected, but commonly used methods of intraoperative assessment may be unreliable. Tricuspid regurgitation was evaluated by a new intraoperative technique, Doppler color flow mapping, in 85 patients before and after cardiopulmonary bypass. Regurgitation grade by intraoperative color Doppler mapping correlated well with right ventricular angiography (kappa value = 0.92, p less than 0.01; n = 8) and with preoperative color Doppler studies (kappa = 0.71, p less than 0.05; n = 51). The right atrial V wave correlated poorly with the severity of tricuspid regurgitation intraoperatively, both before (r = 0.30) and after (r = -0.05, p = no significant difference) cardiopulmonary bypass. Advanced (3+ or 4+) tricuspid regurgitation was found in 40% (21) of 52 patients requiring mitral valve repair or replacement. Tricuspid annuloplasty with a prosthetic ring provided a significant (greater than or equal to 2 grade) reduction in regurgitation severity in 94% (17/18; p less than 0.05). Without repair, tricuspid regurgitation decreased to a similar degree after mitral valve operations in 14% (5/36); only one of the five patients had advanced tricuspid regurgitation prepump. Fluid filling of the arrested right ventricle after the surgical procedure did not predict regurgitation severity (false negative rate 50%, 2/4; false positive rate 22%, 2/9). Regurgitation grade remained unchanged after the initial postpump study, up to 60 weeks postoperatively. In conclusion, color Doppler flow mapping provides more accurate intraoperative assessment of tricuspid regurgitation than the right atrial V wave or fluid filling of the right ventricle. This semiquantitative technique aids in the selection of patients appropriate for surgical repair of the tricuspid valve and is useful in judging the adequacy of tricuspid valve repair before chest closure. Advanced (3+ or 4+) tricuspid regurgitation is a common occurrence in patients undergoing mitral valve repair or replacement and rarely responds to conservative (nonoperative) management. Ring annuloplasty provides a highly effective and durable reduction in tricuspid regurgitation.

Adult↗
PubMed1988

Reduction in sudden late death by concomitant revascularization with aortic valve replacement.

To determine the impact of coronary atherosclerosis and myocardial revascularization on survival after aortic valve replacement, we reviewed our experience with single aortic valve replacement between 1969 and 1984. Of 474 patients (mean age 62 +/- 13 years), 185 (39%) had no associated coronary artery disease, 233 (49%) had coronary artery bypass grafting, and 56 (12%) had unbypassed coronary artery disease. Early (30-day) mortality rates were 2.2%, 8.2%, and 7.1%, respectively (p less than 0.01, coronary disease absent versus present). Actuarial survival rates at 10 years were 77% +/- 4%, 41% +/- 6%, and 26% +/- 11% (p less than 0.001, coronary disease absent versus present), with 1 to 177 months of follow-up (mean 56 +/- 40). Preoperative angina (39%) did not predict the presence of coronary artery disease (61%). Multivariate logistic regression analysis showed that early deaths were associated with advanced preoperative New York Heart Association functional class (p less than 0.001), advanced age (p less than 0.05), more extensive coronary artery disease (p less than 0.05), and lack of cardioplegic myocardial protection (p less than 0.05). Complete revascularization did not increase operative risk when coronary artery disease was present (early mortality 6.8%, p = not significant). Late deaths were strongly associated with the presence of coronary artery disease (p less than 0.001) and reduced left ventricular ejection fraction (less than or equal to 55%, p less than 0.01). Late cardiac mortality was most commonly attributable to sudden death (30/71, 42%), especially in the unbypassed coronary disease cohort (9/14, 64%). The actuarial rate of freedom from sudden death at 10 years was 52% +/- 17% in the unbypassed coronary artery disease group (p = 0.009), compared with 90% +/- 3% and 91% +/- 3% in the revascularized and no coronary disease patients, respectively. Thus, coexistent coronary atherosclerosis has a detrimental impact on early and late survival after aortic valve replacement. Revascularization does not increase operative risk when associated coronary artery disease is present and significantly reduces the occurrence of late sudden death. Strategies that minimize operative risk when associated coronary artery disease is present include use of cardioplegia and complete revascularization.

Adolescent↗
PubMed1987

Intraoperative Doppler color flow mapping for assessment of valve repair for mitral regurgitation.

The ability of color Doppler flow mapping to provide intraoperative information about mitral regurgitation (MR) severity and to evaluate adequacy of mitral valve repair was assessed by performing color Doppler echocardiography immediately before and after cardiopulmonary bypass, with the transducer placed directly on the epicardium. In 56 patients, the degree of MR by intraoperative color Doppler correlated well with left ventricular angiography (kappa = 0.80) and with closed-chest preoperative color Doppler (kappa = 0.84) and had good interobserver reproducibility (kappa = 0.88). Good correlation was also seen between closed-chest color Doppler and angiography (kappa = 0.75). After mitral valve repair in 18 patients (15 ischemic MR, 3 cleft valves), color Doppler was used to assess severity of residual MR intraoperatively and postoperatively. Intraoperative color Doppler identified satisfactory repair (MR less than or equal to 2+) in 15 patients and failure (MR greater than or equal to 3+) in 3, whereas conventional surgical assessment of MR by fluid filling of the arrested ventricle failed to provide reliable differentiation. MR severity on subsequent closed-chest color Doppler follow-up did not change significantly compared with intraoperative evaluation after repair. Intraoperative color Doppler provides accurate grading of MR severity, offers instantaneous evaluation of the adequacy of mitral valve repair before chest closure, and appears to predict the degree of postoperative MR seen on subsequent closed-chest follow-up studies.

Blood Flow Velocity↗
PubMed1987

The St. Jude valve: analysis of thromboembolism, warfarin-related hemorrhage, and survival.

From March 1978-86, 590 St. Jude prostheses (232 aortic, 232 mitral, and 63 double aortic-mitral) were implanted in 527 patients (mean age 63 years) and followed for up to 8 years (mean 33 months; three lost; 99% complete). The early (30-day) mortality rate was 8.9% and was strongly associated with preoperatively depressed left ventricular function (ejection fraction less than 0.55), ischemic mitral regurgitation, and advanced functional class (IV) (p less than 0.05). Actuarial survival rates at 5 years were 72% +/- 4%, 72% +/- 8%, and 63 +/- 4% after aortic, double, and mitral valve replacement (p less than 0.01). There have been no structural failures. Embolism (28 events, 2.1%/patient-year) was less common with warfarin treatment (1.5%/patient-year; n = 492) than with antiplatelet (3.2%/patient-year; n = 19) or no drug therapy (18.9%/patient-year; n = 16) (p less than 0.01). One embolic event was fatal (3.6%). Warfarin-treated patients remained 91% +/- 1% free of emboli after 8 years. Valve thrombosis (six events; 0.4%/patient-year) occurred exclusively in patients not treated with effective warfarin therapy; one (17%) died. The most common complication was hemorrhage (39 events; 2.9%/patient-year); nine (23%) were fatal, and these constituted 82% of 11 valve-related late deaths. In warfarin-treated patients (target prothrombin time ratio 1.5 to 2.5), hemorrhage was twice as frequent (2.9%/patient-year) as embolism (1.5%/patient-year).(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗