Biomedical subjects
Publications and source records attributed to D A Ott.
A rare case of an intracardiac undifferentiated sarcoma in a 3 month old infant is described together with the clinical, angiographic, echocardiographic, surgical and histopathologic findings. The tumor was successfully removed surgically, and monthly echocardiographic follow-up is being performed.
Explore the source record for details and available documents.
Between 1956 and June 1984, 201 patients with uncomplicated total anomalous pulmonary venous return (TAPVR) were operated on at the Texas Heart Institute and Texas Children's Hospital. Two groups were previously reported that included periods from 1955 to 1964 and from 1964 to 1972. From 1972 until 1984, 76 patients were operated on for uncomplicated TAPVR. The mortality was 11/19 (57%) for patients less than 1 month old, 2/27 (7%) for patients 1 month to 1 year old, and 0/21 (0%) for patients older than 1 year. Forty-five percent (5/11) of the infants who died in the less than 1-month-old category were operated on when they were less than 24 hours old and in extremis when presented for correction.
Early reports on the excellent hemodynamic function and low thromboembolic rates of the Ionescu-Shiley bovine pericardial bioprosthetic valve (BPV) encouraged us to use it as our choice for valve replacement in 2680 patients from 1978 through 1983. Analysis of these patients at 5-year follow-up (mean 21.6 months) demonstrated the following important trends. Despite anticoagulation therapy in 48%, thromboembolism occurred in 88 patients for a linearized rate of 1.87% emboli per patient-year and was not time-related. The highest incidence of thromboembolism was in mitral valve replacement (MVR) (2.76% per patient-year). The actuarial freedom from reoperation resulting from valve failure at 5 years was 82% in aortic valve replacement (AVR), 87.1% in MVR, and 92.6% in AVR/MVR. The most distressing causes for reoperation were valve calcification (33 patients, 0.68% per patient-year) and leaflet disruption (11 patients, 0.23% per patient-year). Valve calcification was related to age, small valve size, and AVR position and increased with time, especially at the 4- to 5-year intervals. In patients under 30 years of age, calcification occurred in 18.7% at a mean time of 40.8 months in AVR and in 8.2% at 44 months in MVR, for an overall rate of 11.6%. Over the age of 30 years, it occurred in 14 patients (0.6%) at a mean time of 44 months. Leaflet disruption was not related to age and occurred later in AVR (50 to 58 months) than MVR (1.5 to 61 months). Events increased with time (mean range 37 to 58 months). Because of calcification and leaflet disruption, valve failure causing reoperation has increased significantly at the 4- to 5-year intervals even when valve replacement in patients under 30 years of age is excluded. If this trend continues, the valve failure rate will be exceedingly high on further follow-up. Thus we have limited the use of the BPV to a selected group of patients in whom valve longevity is less important than effective orifice size, thromboembolic rate, and freedom from anticoagulation.
The choice between bioprosthetic or mechanical prosthetic valve replacement for active valvular endocarditis has been controversial. To establish the role of each, we reviewed the case histories of 185 patients who underwent valve replacement for active valvular endocarditis during the past 5 years. All patients had life-threatening, active bacterial endocarditis of a native or prosthetic valve. Group I (88 patients) had replacement with the Ionescu-Shiley pericardial valve and Group II (97 patients) with the St. Jude Medical valve. The male/female distribution, age range, and functional classification were the same in the two groups. Mean follow-up was approximately 20 months for both groups. Valve replacement was done because of native valve endocarditis in 76 patients in Group I and 49 patients in Group II. Of the remainder of the Group I patients, six had endocarditis of a bioprosthesis and six of a mechanical valve; of the remainder of Group II patients, 30 had endocarditis of a bioprosthesis and 18 of a mechanical valve. Early mortality was not significantly different between the two groups (14 deaths in each group). Of the 74 survivors in Group I, 15 underwent valve reoperation, 10 because of recurrent endocarditis and five because of sterile perivalvular leakage. The frequency of reoperation was significantly different (p less than 0.01) from that in Group II, in which only five patients underwent valve reoperation, four for recurrent endocarditis and one for sterile perivalvular leakage. The actuarial rate for freedom from reoperation was also significantly higher in Group II patients; 94.6% were free from reoperation at 4 years compared to 75% at 4 years in Group I patients (p less than 0.01). The actuarial survival rate, which also differed significantly between groups, was 78.7% at 4 years in Group I and 87.4% at 4 years in Group II (p less than 0.05). Patients receiving a bioprosthesis for active endocarditis had a significantly higher reoperation rate and a significantly greater incidence of recurrent endocarditis (p less than 0.01). Therefore, we prefer to use a mechanical valve for valve replacement in most patients who have active endocarditis.
A total of 114 children (age range 4 months to 18 years) underwent definitive operation for life-threatening or incessant tachydysrhythmias resulting from accessory conduction pathways (Kent bundle) (79), atrial ectopic foci (18), or ventricular ectopic foci (17). Of the patients with the accessory pathway type of supraventricular tachycardia, 63.3% (50/79) had classical Wolff-Parkinson-White syndrome whereas 36.7% (29/79) had retrograde conduction only across the pathway. Locations of the pathways were as follows: left posterior 48.1% (38/79), right anterior or lateral 27.8% (22/79), posterior septal 16.5% (13/79), anterior septal 3.8% (3/79), and both right and left 3.8% (3/79). With increasing experience, the success rate (cure of tachycardia) improved from 85% in the first 40 patients to 95% in the last 40 patients. One surgical death (1.3%) occurred secondary to a paradoxical air embolus. Atrial ectopic tachycardia was treated by cryoablation (nine), excision (one), combined excision and cryoablation (six), and atrial disconnection (two). The ectopic focus was located on the right atrial wall in 13 patients (72.2%) and cardiopulmonary bypass was required in eight (44.4%). The operation was successful in 89%; two patients with multiple ectopic foci continued to have uncontrolled tachycardia after the operation. Ventricular tachycardia presenting in the first 2 years of life was due to gross tumor in three cases (rhabdomyoma two, fibroma one) or microscopic hamartomatous change (Purkinje tumor) in five cases and was treated by excision alone or with adjuvant cryoablation. In four cases no tumor was found but the area of ectopic focus was successfully cryoablated. One child with diffuse endocardial tumor died of low cardiac output after the operation. Ventricular tachycardia in older children was localized to outflow patch aneurysms or other areas in the right ventricle following tetralogy of Fallot repair (three patients, treated by excision or cryoablation) and arrhythmogenic right ventricular dysplasia (two patients, treated by right ventricular disconnection). We conclude that mapping and operation for supraventricular tachycardia resulting from accessory pathways are predictable and curative in a high percentage of patients. Atrial ectopic tachycardias are more difficult to precisely localize but can be cured by a combination of excisional and cryoablative techniques. Ventricular tachycardia in infants is lethal and is commonly due to ectopic foci or microscopic tumors that may not be apparent on preoperative angiography or echocardiography. Electrophysiologically directed operations in these patients can be lifesaving.
Utilizing two-dimensional echocardiography, the diagnosis of anomalous origin of the right pulmonary artery from the aorta was made prospectively in a neonate who presented with signs of congestive heart failure. A complete echocardiographic evaluation, including both right parasternal short-axis and suprasternal long-axis scans, permitted differentiation from other defects in aortopulmonary septation.
A new operation is described for the definitive treatment of acutely occluded axillary femoral bypass grafts in patients who have previously had an infected aortofemoral prosthesis removed. An aortofemoral or aortopopliteal artery bypass is constructed by using the supraceliac aorta for the proximal anastomosis and avoiding the infrarenal retroperitoneal area. The disadvantages of other extra-anatomic bypasses are thus corrected and long-term patency enhanced.
We describe a simplified surgical procedure whereby pulmonary or other intrathoracic operations can be safely and easily performed in conjunction with cardiopulmonary bypass for indicated cardiac procedures. Transsternal bilateral anterior thoracotomy can provide excellent exposure in cases requiring concomitant attention to cardiac and pulmonary pathology.
At the Texas Heart Institute between October 1969 and August 1983, there were 191 single bypass procedures performed without pump oxygenator support. These cases have been divided into two groups: Group I (160 patients) represents the time period from October 1969 through December 1981 and includes our experience with single vessel left anterior descending (LAD) coronary artery bypass without pump oxygenator support; Group II (31 patients) represents the period between January 1982 and August 1983 and includes our initial operative experience in patients with failed percutaneous transluminal coronary angioplasty (PTCA). Of 145 primary operations in Group I patients, 113 were single bypasses to the right coronary artery with a postoperative infarction rate of 3.5% (4/113). Single bypass to the left anterior descending (LAD) coronary artery in 32 patients who underwent operation early in the series was associated with a postoperative infarction rate of 18.7% (6/32) and is no longer performed without pump oxygenator support. Fifteen patients had previous coronary bypass operations and underwent single bypass without pump as a second procedure. Postoperative infarction rate in this redo group was 6.6% (1/15). Long-term follow-up data was obtained on all patients from 1 to 11 years after surgery (mean follow-up, 4 years). Four late cardiac deaths occurred at 2,3,4 and 7 years in the primary operation group (3.5%) 4/113. One late death occurred at 7 years in the redo group (6.6%) 1/15. In Group II, failed PTCA accounted for 39% of the 31 patients who underwent single right bypass without pump support; there were no perioperative infarctions and one death. Coronary bypass can be safely and effectively employed without pump oxygenator support if performed expeditiously and limited to right coronary lesions which have an adequate distal vessel. This technique has become more useful with the advent of attempted PTCA for single coronary lesions.
Of 518 consecutive patients undergoing percutaneous transluminal coronary angioplasty for 571 coronary lesions, 184 eventually underwent coronary artery bypass because of angioplasty failure. Delayed coronary bypass (1 week to 19 months) was done in 27 patients with no deaths. Immediate bypass was done in 87 patients with two deaths, both of which were caused by further dissection of the artery after angioplasty. Urgent bypass was required in 63 patients who were in unstable condition because of ischemia on the electrocardiogram (52 patients), unrelieved angina (57 patients), or hypotension (13 patients). There was one death in this group. In the remaining seven patients, urgent coronary bypass was done because of cardiac arrest (three deaths). Myocardial complications occurred in 23 of the 70 unstable patients, including the seven patients with cardiac arrest. There were only eight completed myocardial infarctions in the 70 unstable patients and a completed myocardial infarction rate of 11 of 184 (6.0%) overall. In the 10 patients in whom extracorporeal circulation was established within 25 minutes of myocardial insult, mortality and myocardial complications were completely avoided. The remaining patients in the urgent group were placed on cardiopulmonary bypass within 26 to 300 minutes (mean 82 minutes). Operative mortality (3.3%), completed myocardial infarction (6.0%), myocardial infarction in unstable patients (32.9%), postoperative hemorrhage (5.0%), and sternal problems (2.8%) were all significantly different from those in 3,500 consecutive coronary bypasses not following angioplasty, that were done in 1982.
Arteriosclerotic occlusive disease of the vertebral arteries is common; however, vertebral artery operations are performed infrequently. From 1971 through 1983 more than 3000 cerebrovascular operations were performed; only 40 of these were direct vertebral artery operations. There were 22 women and 18 men, varying in age from 44 to 80 years (mean 61.6 years). Symptoms included dizziness or vertigo in 29 patients (73%), transient ischemic attacks in 17 (43%), syncope in eight (20%), and previous stroke in 14 (35%). Operative procedures were directed toward establishing normal antegrade vertebral flow by reimplantation (21 patients), patch graft (15 patients), or grafts (three patients). Two patients underwent bilateral procedures. There were no operative deaths. All except two patients (95%) were available for follow-up at 1 to 12 years (mean follow-up 7.75 years). There were eight late deaths from 1 to 9 years, with a 12-year actuarial survival rate of 75.8%. The eight patients who died were known to be without symptoms before death. Of the 30 survivors available for follow-up, 21 remained without symptoms, seven patients showed no improvement, two patients who had no symptoms had recurrence at 4 and 5 years, and one patient without symptoms had a stroke at 7 years. In this select group of patients with severe disease, direct vertebral artery operations have resulted in significant long-term relief of symptoms and prevention of transient ischemic attacks and strokes.
Hypothermic circulatory arrest has been used to facilitate resection of aneurysms of the aortic arch. During a five-year period, two methods of hypothermic arrest were compared in 60 patients. In Group 1, 20 patients underwent deep hypothermia (14 degrees to 18 degrees C) and circulatory arrest to allow repair of the transverse arch under optimal conditions. A hospital mortality of 50% occurred and was attributed to uncontrolled hemorrhage and cerebral or cardiac complications. In Group 2, modified techniques were employed in 40 patients and included moderate levels of hypothermia (22 degrees to 26 degrees C) and simplified operative methods, which reduced the duration of circulatory arrest and shortened the length of perfusion. Pretreatment of plasma-soaked Dacron grafts by autoclaving eliminated serious bleeding problems. A marked improvement in patient survival (90%) and reduction in postoperative complications were observed after adoption of these modifications. The improved results in the present series have reconfirmed our belief that this type of intervention is the preferred approach to aneurysms of the aortic arch.
Over a 25-year period, 58 patients underwent evaluation or surgical treatment of coronary artery fistulas, or both, at our institution. Twenty-one patients had major associated cardiac defects, either congenital or acquired, and 9 had multiple fistulas. Fistulas to the left heart were unusual. Exertional angina and dyspnea were the most common presenting symptoms, but most young patients were asymptomatic. Seventy percent had audible heart murmurs. No operative deaths occurred in patients with isolated fistulas. Coronary artery fistulas cause symptoms due to "coronary steal" with resulting myocardial ischemia and, more rarely, marked left-to-right or left-to-left shunting. Definitive surgical correction is safe and effective, with good long-term results.
During a 31-year period, 54 patients were treated for Kawasaki's disease at the Texas Heart Institute and Texas Children's Hospital. Classically, the illness is characterized by prolonged fever, conjunctivitis, oral mucosal inflammation, exanthema, and later skin desquamation and cervical lymphoadenopathy. Seventy percent of patients have electrocardiographic abnormalities consisting of prolongation of the PR and QT intervals and ST-T wave changes. Most deaths occur within 1 to 2 months after onset of the disease. The risk of coronary abnormalities and cardiac death appear to be higher in those patients under 1 year of age with prolonged fever, elevated white blood count, and erythrocyte sedimentation rate.
During a 17-year period, femorofemoral bypass grafting was performed on 85 patients as the primary operation for unilateral iliac artery disease. Of these patients, 53 (62%) were operated on for claudication and 32 (38%) for limb salvage. There were two operative deaths (2.4%). The 5-year cumulative graft patency rate was 63.2%, and the limb salvage rate was 70%. Prognostic factors included poor runoff and distal disease, donor iliac artery stenosis prior to femorofemoral bypass grafting, and progression of disease in the donor vessel following surgery. Definitive surgical correction is safe and effective with good long-term results.
This is an unusual case report of a patient in whom extensive atherosclerosis of the abdominal and pelvic arterial tree apparently contributed to long-standing infertility. Conception occurred after revascularization. Guidelines are presented for the treatment of infertility with associated vascular disease and for the handling of pregnancy and delivery in the rare patient who has abdominal or pelvic vascular grafts.
The St. Jude Medical cardiac valve is a low-profile, bileaflet, central-flow prosthesis made entirely of pyrolytic carbon. A total of 261 St. Jude valves were implanted in 253 patients during a 25-month period. Perioperative mortality for the entire series was 9.1%, including patients undergoing reoperation for valve disease and those having associated cardiac procedures. There were four nonfatal thromboembolic episodes during the follow-up period, resulting in a risk of thromboembolism for aortic and mitral valves of 2.1% and 2.1% per patient year, respectively. There were no instances of structural failure of the valve, and no valve-related hemolysis occurred. Two-year actuarial survival was 95%. Hemodynamic studies indicate that the valve has the lowest transvalvular pressure gradient of any prosthetic mechanical valve available, and we believe it is the valve of choice for patients in whom a prosthetic mechanical valve is indicated.