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Biomedical subjects

D M Cosgrove

Publications and source records attributed to D M Cosgrove.

At least 199 records · Page 11Linked to original sources
PubMed1987

Intraoperative Doppler echocardiography in hypertrophic cardiomyopathy: correlations with the obstructive gradient.

Although significant pressure gradients can be recorded across the left ventricular outflow tract in patients with hypertrophic cardiomyopathy, controversy exists regarding the presence or absence of true obstruction. Ten patients with hypertrophic cardiomyopathy were studied at the time of septal myectomy. A sterile continuous wave Doppler transducer was placed on the ascending aorta and directed toward the left ventricular outflow tract to measure velocity simultaneously with invasive gradient measured using solid-state hub transducers by direct puncture of the left ventricle and aorta. Simultaneous Doppler velocity and invasive gradient measurements (n = 33) were made at rest, before and after myectomy and during interventions with isoproterenol, volume loading and phenylephrine. High velocity flow with a characteristic contour was recorded in patients with a significant gradient. Using the modified Bernoulli equation (gradient = 4 X velocity), a good correlation was found between the Doppler-derived gradient and the peak instantaneous gradient measured invasively (r = 0.93, y = 0.89X + 12, p = 0.0001). Changes in gradient and velocity due to interventions also correlated well (r = 0.96, y = 0.91X - 3, p = 0.0001). Continuous wave Doppler echocardiography can accurately estimate the outflow tract gradient. The magnitude, timing and contour of these high velocity flow signals support the hypothesis that true obstruction is present in patients with hypertrophic cardiomyopathy who have a significant gradient.

Adolescent↗
PubMed1987

Reoperation in patients with patent coronary bypass grafts.

As the population of patients having undergone myocardial revascularization increases, the number of reoperations will escalate and reoperations of patients with patent grafts will become increasingly frequent. Successful management of this new surgical entity requires a clear understanding of the probability of atherosclerotic involvement of patent vein grafts and careful attention to technical detail. Patent vein grafts more than five years old should be replaced to avoid the potential for embolization of atheromatous material and late vein graft closure.

Arteriosclerosis↗
PubMed1987

Fifteen hundred coronary reoperations. Results and determinants of early and late survival.

Fifteen hundred consecutive patients undergoing a first reoperation for coronary revascularization were reviewed to determine early and late results and predictors of survival. Patients were subdivided into cohorts on the basis of the year of reoperation: Group A (1967 to 1978, 436 patients); Group B (1979 to 1981, 439 patients); and Group C (1982 to 1984, 625 patients). Overall operative mortality was 3.4% (51 deaths): 4.6%, 2.3%, and 3.4% for Groups A, B, and C, respectively. Group C had significantly more women (p = 0.01) and patients with triple-vessel disease, left main coronary artery stenosis (greater than or equal to 50%), abnormal left ventricular function, age greater than or equal to 70 years, and graft failure as a surgical indication (all p less than 0.001). The mean interval between operations increased from 50 months for Group A to 84 months for Group C. At reoperation, Group C patients received more grafts, more internal mammary artery grafts, and had a higher prevalence of complete revascularization (all p less than 0.001). Univariate and multivariate analyses identified left main stenosis (p less than 0.0001), Class III or IV symptoms (p = 0.0002), advanced age (p = 0.0006), Group A (p = 0.02), and incomplete revascularization (p = 0.004) as predictors of increased in-hospital mortality. Follow-up of in-hospital survivors (mean interval 54 months, range 13 to 171 months) documented a 5 year survival rate of 90% and a 10 year survival rate of 75%. Multivariate testing identified advanced age (p less than 0.0001), hypertension (p less than 0.0001), and abnormal left ventricular function (p less than 0.0001) as predictors of decreased late survival.

Aged↗
PubMed1987

Repeat mitral commissurotomy: long-term results.

Fifty-three patients underwent reoperation for open mitral commissurotomy (OMC) with one (1.9%) in-hospital death. The previous mitral operation was an OMC in 14 patients and a closed commissurotomy in 39. Mean age at the time of repeat OMC was 46 years (range 27 to 64), and NYHA functional class was II in 19 patients, III in 31, and IV in three. Follow-up of the 52 in-hospital survivors at a postoperative interval of 1 to 23 years (mean 10) documented 13 late deaths (mean interval 117 months, range 17 to 209) and survival of 96%, 83%, and 63% at 5, 10, and 15 postoperative years, respectively. Sixteen patients underwent subsequent mitral valve surgery (one OMC and 15 mitral valve replacements) 1 to 223 months after repeat OMC (mean 99), three patients within 5 years of repeat OMC. Reoperation-free survival was 94%, 74%, and 52% at 5, 10, and 15 postoperative years, respectively. Univariate testing did not document any correlation between age, functional class, rhythm, and either survival or reoperation-free survival. When feasible, repeat OMC can afford patients excellent long-term survival and relative freedom from prosthetic valve replacement.

Adult↗
PubMed1986

Influence of the internal-mammary-artery graft on 10-year survival and other cardiac events.

We compared patients who received an internal-mammary-artery graft to the anterior descending coronary artery alone or combined with one or more saphenous-vein grafts (n = 2306) with patients who had only saphenous-vein bypass grafts (n = 3625). The 10-year actuarial survival rate among the group receiving the internal-mammary-artery graft, as compared with the group who received the vein grafts (exclusive of hospital deaths), was 93.4 percent versus 88.0 percent (P = 0.05) for those with one-vessel disease; 90.0 percent versus 79.5 percent (P less than 0.0001) for those with two-vessel disease; and 82.6 percent versus 71.0 percent (P less than 0.0001) for those with three-vessel disease. After an adjustment for demographic and clinical differences by Cox multivariate analysis, we found that patients who had only vein grafts had a 1.61 times greater risk of death throughout the 10 years, as compared with those who received an internal-mammary-artery graft. In addition, patients who received only vein grafts had 1.41 times the risk of late myocardial infarction (P less than 0.0001), 1.25 times the risk of hospitalization for cardiac events (P less than 0.0001), 2.00 times the risk of cardiac reoperation (P less than 0.0001), and 1.27 times the risk of all late cardiac events (P less than 0.0001), as compared with patients who received internal-mammary-artery grafts. Internal-mammary-artery grafting for lesions of the anterior descending coronary artery is preferable whenever indicated and technically feasible.

Coronary Artery Bypass↗
PubMed1986

Reoperations for valve surgery: perioperative mortality and determinants of risk for 1,000 patients, 1958-1984.

One thousand consecutive cardiac reoperations for valve surgery in 897 patients were reviewed to determine in-hospital mortality and indicators of risk. Subgroups based on the number of previous cardiac procedures and the valve or valves replaced or repaired at reoperation (aortic valve, mitral valve, tricuspid valve, or multiple valves and mortality [deaths/number of procedures (% mortality)]) for those subgroups are as follows: (Table: see text) Predictors of increased risk for a first aortic valve reoperation were advanced age (p = .0002), endocarditis (p = .0018), female sex (p = .014), impaired left ventricular function (p = .039), and number of coronary vessels obstructed by 70% or more (p = .055). For a first mitral valve reoperation, the predictors were advanced age (p less than .0001), preoperative shock or cardiac arrest (p = .01), previous aortic or tricuspid valve operations (p = .02), type of mitral valve procedure (risk for repair of periprosthetic leak was greater than mitral valve replacement which was greater than mitral valve-conserving operation [p = .05]), and impaired left ventricular function (p = .059). For a first multiple valve reoperation, the predictors were diabetes (p = .04) and ascites (p = .02), whereas patients undergoing mitral valve replacement and tricuspid valve operations were at decreased risk (p = .01). Comparison of second reoperations with first reoperations indicates risk increases for multiple operations (p = .01) but not for aortic or mitral valve procedures. Rereplacement of a prosthesis (p = .007), coronary bypass grafting at reoperation (p = .006), and advanced age (p = .06) increased the risk for second reoperations. Age is the most consistent predictor of risk for patients undergoing valve reoperations.

Aortic Valve↗
PubMed1986

Cancer of the esophagus. The Cleveland Clinic experience.

The therapy and survival rates of patients with esophageal carcinoma at the Cleveland Clinic over the 12-year period 1969-1980 are reviewed. Data on 238 patients were analyzed. Seventy-one per cent of the patients underwent surgery, with esophagogastrectomy being performed in half of these. One or more early postoperative complications occurred in 72.6% of these patients. Most of these complications were pulmonary and related to the patients' chronic obstructive pulmonary disease. The mortality rate for esophagogastrectomy at the Cleveland Clinic has decreased over the past 15 years to 7.1%. The 5-year survival rate after "curative" esophagogastrectomy was 15.4% with a mean survival time of 34.4 months. Invasion of the tumor through or beyond the serosa in this group of patients was associated with an increased relative risk of death of 3.3 compared to those with lesser degrees of invasion. The cell type, degree of differentiation, stage of disease, and presence of tumor at the lines of resection were all prognostically significant for all patients.

Adenocarcinoma↗
PubMed1986

Free (aorta-coronary) internal mammary artery graft. Late results.

Free internal mammary artery grafts were placed in 156 patients (1971 to 1985). Preoperative clinical and angiographic variables were similar to those of other series of isolated coronary bypass grafts. Of 244 total internal mammary artery grafts, 166 were in the aorta-coronary position and were performed mainly because of unsuitable saphenous veins or to gain additional graft length. One patient (0.6%) died during hospitalization. Perioperative complications included respiratory dysfunction in 16 (10.3%), reoperation for bleeding in 13 (8.0%), stroke in four (2.6%), myocardial infarction in three (1.9%), and wound complications in two (1.3%). Morbidity occurred significantly more often in the 1971 to 1975 period. Subsequently, eight (7%) had reoperation (6 to 158 months; mean 99 months). After a 98 month mean follow-up, the 10 year actuarial survival rate (including all causes of death) was 73.3%. Of 40 free grafts restudied within 18 months of operation, 31 (77%) were patent. The higher rate of early closure is attributed to technical problems early in our experience, especially construction of the aortic anastomosis. However, 32 of 35 (91%) free grafts studied after more than 18 months (mean 94 months) were open. Fifty of 58 (86%) free internal mammary artery grafts placed to the anterior descending coronary artery, seven of nine (78%) to the circumflex, and six of eight (75.0%) to the right coronary artery were patent. Sequential catheterization showed that of 24 free grafts open at 9 months, 24 remained patent at 80 months; when six of these were restudied at 93 months (third catheterization) and two (fourth catheterization) at 125 months, all were patent. These late studies of free internal mammary artery grafts showed no evidence of graft atherosclerosis. Free internal mammary artery grafts, like in situ internal mammary artery grafts, appear to have relative immunity from atherosclerosis. These findings expand the versatility of internal mammary artery grafting and justify wider use of free internal mammary artery grafts.

Adult↗
PubMed1986

Perioperative risk of bilateral internal mammary artery grafting: analysis of 500 cases from 1971 to 1984.

The records of the first 500 patients (420 men, 80 women, mean age 55 years, range 24 to 78) undergoing bilateral internal mammary artery (IMA) grafting were reviewed to determine in-hospital morbidity and mortality. Sixty patients (12%) had had previous cardiac operations and 130 (26%) previous saphenous vein removal. From two to seven total grafts (mean 3.2) were performed, including 595 IMA grafts to the anterior descending or diagonal artery, 355 to the circumflex, and 105 to the right coronary system. To assess changing risks, the first 125 patients (group A, 1971 to 1982) were compared with the next 375 (group B, 1982 to 1984). Major complications in groups A and B included stroke, four (3.2%) vs ine (2.4%); wound complications requiring reoperation, three (2.4%) vs five (1.3%); prolonged (greater than 48 hr) respiratory care, seven (5.6%) vs 19 (5.1%); and death, two (1.6%) vs five (1.3%) (no p value less than .05). Complications significantly less frequent in group B were new Q waves in nine (7.2%) vs 10 (2.7%) in group A (p = .02) and reoperation for bleeding in 17 (13.6%) vs 16 (4.3%) in group A (p = .0003). Logistic regression analysis showed that major complications did not correlate with gender, diabetes, number of grafts, or preoperative left ventricular function but were associated with increasing age (p = .0001) and previous cardiac surgery (p = .009) and were decreased by the use of cardioplegia (p = .002). The excellent long-term patency of IMA grafts, combined with low and decreasing perioperative risk, supports the continued use of bilateral IMA grafting.

Adult↗
PubMed1986

A self-retaining retractor for mitral valve operations.

A new self-retaining retractor for mitral valve operations is described. It is universally adjustable, may be affixed to any sternal retractor, and is completely removable when not required for the intracardiac portion of the procedure.

Mitral Valve↗
PubMed1986

Results of mitral valve reconstruction.

To evaluate the early results of mitral valve reconstruction for mitral insufficiency, 117 consecutive cases were analyzed. Sixty-four (57.7%) of the patients were men, and the mean age was 60 +/- 13 years (range 18 to 85). Eighty-nine (76%) of the patients were in NYHA functional class III or IV preoperatively. The cause of the mitral disease was degenerative in 94 (80%) and rheumatic in 13 (11%) patients. Isolated mitral valve repair was performed in 56 patients (47.9%); the remainder underwent associated procedures that included myocardial revascularization in 38 (32.5%). Ninety-nine (85%) underwent a ring annuloplasty but in only seven (6%) was this the only repair technique. Resection of the posterior leaflet was performed in 41 (35%). There were five operative deaths (4.3%); one (1.8%) occurred after isolated repair and four (6.5%) after repair with associated procedures. All deaths occurred in patients greater than 65 years of age who were in NYHA functional class III or IV. Mean follow-up was 13.5 months (range 1 to 62). Two year actuarial survival was 90.6%. Three patients required reoperation (incidence of 2.5% per patient-year). Two patients sustained embolic events (incidence of 1.6% per patient-year). There were no anticoagulant-related complications. After surgery, 100 survivors (96.2%) were in NYHA functional class I or II.

Adolescent↗
PubMed1986

Predictors of reoperation after myocardial revascularization.

The first 1,000 patients undergoing primary isolated myocardial revascularization each year from 1971 to 1978 were analyzed to define the incidence of reoperation and to elucidate the determinants of reoperation and reoperation-free survival. Six hundred sixty-six patients (9.7%) underwent reoperation in a mean of 6.9 +/- 3.2 years. Cumulative percent reoperation was 2.7% at 5 years, 11.4% at 10 years, and 17.3% at 12 years. The annual incidence of reoperation was 1.1% at 5 years and increased to 3.9% at 12 years. Twenty-five patient descriptors were analyzed for predictors of reoperation. Young age was found to be the most important predictor of potential for reoperation. Other risk factors in descending order of significance were absence of an internal mammary artery graft, incomplete revascularization, New York Heart Association Functional Class III/IV, and single or double vessel disease. Absence of an internal mammary artery graft was an important predictor for all age groups. In the multivariate analyses for risk factors for reoperation-free survival, absence of an internal mammary artery graft was the most important predictor. Other factors of major significance were smoking, incomplete revascularization, and moderate/severe left ventricular impairment. Internal mammary artery grafting neutralizes hypertension, serum cholesterol level higher than 300 mg/dl, and smoking as risk factors for reoperation-free survival.

Adult↗
PubMed1986

Surgical management of synchronous carotid and coronary artery disease.

To determine the safest method of treating simultaneously occurring coronary artery disease and asymptomatic carotid stenosis, patients were randomly assigned to either combined operation or a staged procedure with coronary artery surgery done first, followed by carotid endarterectomy. In the initial 70 patients, there were two strokes (5.9%) and two deaths (5.9%) in the combined group and four strokes (11%) and one death (2.8%) in the group with coronary artery surgery performed first.

Carotid Artery Diseases↗
PubMed1985

Reoperation after previous grafting with the internal mammary artery: technique and early results.

Among 1,006 patients undergoing coronary bypass reoperation from 1968 through 1982, 100 had a patent internal mammary artery graft. There were 88 men and 12 women with a mean age of 53.4 years and a mean interval between first and second operations of 56.6 months. Reasons for reoperation were vein graft closure in 26% of the patients, progressive disease in previously ungrafted arteries in 48%, and combined indications in 26%. One operative death occurred. There was no significant difference in morbidity when compared with a reference group of 906 reoperations in patients without IMA grafting. Complete revascularization was achieved in 64% of the patients; the mean number of grafts per patient was 1.6. Seven patients had a perioperative myocardial infarction, and eight mammary artery pedicles were damaged during reoperation.

Coronary Disease↗
PubMed1985

Determinants of blood utilization during myocardial revascularization.

Blood transfusion during cardiac surgical procedures has steadily decreased, but little information is available regarding the factors that determine its necessity or amount. To determine the predictors of blood utilization during myocardial revascularization, 441 consecutive patients undergoing primary myocardial revascularization were studied. Forty-four patients (10%) received blood during hospitalization with a mean transfusion of 0.3 +/- 1.4 units per patient. Age, sex, weight, body surface area, preoperative hematocrit, blood volume, and red blood cell volume were examined univariately for trends. All demonstrated a statistically significant trend for both need and amount of transfusion (p less than 0.001). Neither number of grafts nor duration of cardiopulmonary bypass demonstrated statistically significant trends. All univariately significant factors were evaluated by multivariate logistic regression analysis. Red cell volume was the best predictor of the need for transfusion (p less than 0.001), followed by age. No other factors improved predictive capabilities. We conclude that preoperative red cell mass and age are the principal determinants of the need for and quantity of blood transfused during myocardial revascularization. Use of this information may greatly improve the efficiency of ordering blood before operation.

Adult↗
PubMed1985

Techniques to maximize mammary artery length.

The available length of the internal mammary artery has limited its versatility as a bypass conduit. Several techniques for increasing usable internal mammary artery length are described.

Fasciotomy↗