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Biomedical subjects

D M Cosgrove

Publications and source records attributed to D M Cosgrove.

At least 235 records · Page 13Linked to original sources
PubMed1983

Multivessel coronary revascularization without saphenous vein: long-term results of bilateral internal mammary artery grafting.

When the saphenous vein is absent or inadequate, options for multivessel coronary revascularization include bilateral mammary artery grafting and the use of conduits of unproven durability (arm vein, homologous umbilical vein, prosthetic graft). To evaluate the long-term effectiveness of bilateral mammary artery grafting, we reviewed the cases of 76 consecutive patients with multivessel disease (33 with two-vessel disease, 43 with three-vessel disease) who underwent revascularization with bilateral mammary artery grafts only during the period from 1971 to 1980. No hospital deaths occurred. Thirty-three free and 119 in situ grafts were used. Late follow-up was complete, ranging from 12 to 132 months (mean interval, 67 months) and revealed improvement by at least one New York Heart Association functional class in 59 of 71 survivors. Postoperative arteriograms (mean interval, 26 months) of 55 grafts in 28 patients showed that 49 grafts were patent (89%). Five late deaths (2 noncardiac) occurred. Actuarial survival was 97.2% to seven years and 90.2% at nine years after operation. Bilateral mammary artery grafting yielded excellent graft patency, relief of symptoms, and long-term survival. When saphenous vein is unsuitable for grafting, bilateral mammary artery grafts should be utilized before other conduits are considered.

Actuarial Analysis↗
PubMed1983

Coronary artery surgery in women compared with men: analyses of risks and long-term results.

A surgical experience with 2,445 consecutive women who underwent isolated bypass grafting was analyzed for comparison with 18,079 consecutive men. Severe or unstable angina occurred preoperatively in 60% of women and 45% of men (p less than 0.001). Despite less three vessel disease (44 versus 56%, p less than 0.001) and better left ventricular contraction (normal in 60% of women and 53% of men [p less than 0.001]), women had a higher operative mortality rate (2.9 versus 1.3%). When matched for age, severity of angina and extent of coronary atherosclerosis, women still had twice the operative mortality of men. In matched patients, body surface area was the strongest predictor of operative risk, even when the model was adjusted for gender. When the model was adjusted for body surface area, gender was not an important predictor of operative death. The smaller size of women, rather than their sex, appears to explain the difference in operative mortality. After a mean interval of 2 years, women had a lower overall graft patency rate (76.4%) than men (82.1%) (p less than 0.001). At 5 and 10 years postoperatively, a higher percent of men were angina-free. Yet, survival for women (90.6%) and for men (93.0%) at 5 years, and at 10 years (78.6 and 78.2%, respectively) was not dissimilar.

Adolescent↗
PubMed1983

Replacement of aortic valve combined with myocardial revascularization: determinants of early and late risk for 500 patients, 1967-1981.

Five hundred consecutive patients underwent aortic valve replacement and coronary revascularization in the years from 1967 to 1981, with 29 (5.9%) in-hospital deaths. Current operative mortality (1978-1981) is 3.4%. Univariate and multivariate analyses were used to identify determinants of early and late risk. Female sex, aortic insufficiency, and advanced age increased in-hospital mortality, whereas use of cardioplegia decreased it. At follow-up of 471 patients who survived hospitalization for 1 to 135 months (mean 41) after surgery, 96 late deaths were documented. Survival rates were 87%, 80%, and 55%, and event-free survival rates were 80%, 65%, and 39% at 2, 5, and 10 years after surgery, respectively. The late survival rate was unfavorably influenced by the presence of moderately or severely impaired left ventricular function and double-vessel coronary disease; the rate was enhanced for patients in age group from 50 to 59 years old and was not influenced by the method of myocardial protection. The event-free survival rate decreased with the presence of moderately or severely impaired left ventricular function and was enhanced for patients with New York Heart Association class I or II symptoms before surgery. Patients with bioprostheses who did not receive anticoagulants had higher survival and event-free survival rates than did either patients with bioprostheses who received anticoagulants or patients with mechanical valves, whether they received anticoagulants or not.

Age Factors↗
PubMed1982

Peripheral nervous system complications of coronary artery bypass graft surgery.

Among 421 patients undergoing coronary artery bypass graft surgery, 55 (13%) developed 63 new peripheral nervous system (PNS) complications postoperatively. Most common was a brachial radiculoplexopathy, which occurred in 23 patients. Of these, 21 involved lower trunk or medial cord fibers. In 17 there was a correlation between the site of jugular vein cannulation and the side affected, suggesting that needle trauma played a role. Stretching from chest wall retraction may have caused some cases. Other deficits included 13 saphenous, 8 common peroneal, and 5 ulnar mononeuropathies. Six patients had persistent singultus, suggesting phrenic nerve involvement. Unilateral vocal cord paralysis was found in 5. An isolated partial Horner syndrome and a facial neuropathy were also identified. Males were more likely to develop PNS complications. Hypothermia during surgery was associated with increased risk. Most PNS deficits were transient, and lasting disability was rare.

Adult↗
PubMed1982

Failure of positive end-expiratory pressure to decrease postoperative bleeding after cardiac surgery.

To determine whether the application of positive end-expiratory pressure (PEEP) in the postoperative period after cardiac operation would reduce postoperative blood loss, the number of transfusions required, or the rate of reoperation for bleeding, we conducted a prospective study of 83 patients who underwent elective coronary revascularization. These patients were randomly assigned to receive either PEEP (10 cm H2O) or no PEEP (zero end-expiratory pressure). All other aspects of their care were identical. There was no statistically significant reduction in the amount of bleeding in patients treated with PEEP at 8 or 24 hours postoperatively. There was no significant difference in hematocrit between the groups preoperatively or postoperatively. There was no statistically significant difference in the number of reexplorations for bleeding. Finally, there was no significant difference between the groups in the amount of blood administered. On the basis of our results, we conclude that the application of PEEP in the postoperative period of cardiac operation did not reduce the amount of blood loss, the need for reexploration for bleeding, or the blood requirements in this group of patients.

Cardiac Surgical Procedures↗
PubMed1982

Clinical comparison of hetastarch and albumin in postoperative cardiac patients.

Hetastarch, 6% hydroxyethyl starch solution, is an artificial colloid proposed for use as a volume expander. There is concern that hetastarch, like dextran, may adversely affect coagulation. To compare the effects of hetastarch with 5% albumin in postoperative patients, 60 consecutive patients who underwent coronary artery bypass were prospectively randomized into two study groups. Both groups were comparable in all respects preoperatively. Group 1 (27 patients) received a mean of 1,241 ml of 5% albumin and Group 2 (33 patients) a mean of 1,210 ml of hetastarch as volume replacement within the first 24 postoperative hours. Indices of postoperative hepatic, renal, and pulmonary function did not differ significantly between the groups immediately postoperatively, at 24 hours postoperatively, or at 7 days postoperatively. Hematocrits, platelet counts, prothrombin times, partial thromboplastin times, and serum fibrinogen levels were comparable between the two groups at all times. The mean volume of chest tube drainage did not differ between the groups (Group 1, 495 +/- 216 ml; Group 2, 637 +/- 402 ml; not significant), and no patient required reexploration for bleeding. Eighteen percent of Group 1 and 15% of Group 2 patients received banded blood during their hospitalization and required similar amounts (Group 1, 0.37 unit per patient; Group 2, 0.36 unit per patient; not significant). The use of hetastarch as a postoperative volume expander after myocardial revascularization is safe and effective, and results in substantial financial savings.

Albumins↗
PubMed1982

Extravascular lung water values in patients undergoing coronary artery bypass surgery.

Using a commercially produced lung water computer, we measured extravascular thermal volume (ETVL) to study changes in extravascular lung water (EVLW) caused by coronary artery bypass surgery. The normal baseline ETVL before anesthesia was 5.47 +/- 1.67 (SD) ml/kg. ETVL was not significantly changed 2 h after surgery but was significantly lower (P less than 0.05) 24 h later in 9 patients. There was no relationship between P(A-a)O2/FIO2 ratios and values of ETV1.

Body Water↗
PubMed1982

Results of myocardial revascularization: a 12-year experience.

All 740 patients who underwent isolated myocardial revascularization procedures from 1967 to 1970 at our institution were compared with the first 1000 patients who underwent similar elective operations each from 1971 to 1979. Data from these 9 years were processed through a computerized cardiovascular information registry. In the 1971-1979 period, the patients were older (median age 57 years, compared with 50 years in the 1967-1970 period), more had multivessel disease (90% vs 44%) and more had ventricular asynergy (54% vs 41%). The number of grafts per patient increased from 1.5 to 2.7, and yet morbidity declined in every category except neurologic deficit. The operative mortality rate was 1.1% from 1967 to 1979 and 1.0% from 1971 to 1979. Graft patency was determined in 475 patients from 1967 to 1970, in 533 patients from 1971, in 519 from 1972, in 540 from 1973 and in 408 from 1974. Patency rates after a mean catheterization interval of 21 months were 77%, 77%, 84%, 87% and 87%, respectively. Five- and 10-year follow-ups were completed for the 1967-1970 series and a 5-year follow-up was completed for 1971, 1972, 1973 and 1974 cohorts. The 5- and 10-year actuarial survival rates for the 1967-1970 series were 89.4% and 77.3%, respectively. The 5-year survival rates for the 1971-1974 series were 91.9%, 93.4%, 92.1% and 91.7%. Abnormal ventricular function and incomplete revascularization adversely influenced the mortality rate (p less than 0.05) in all years. The percentage of asymptomatic patients at 5 years was 66%, 65%, 69%, 67% and 74% for the five patient cohorts. Lower risk and a higher 5-year survival rate are attributable to greater technical experience, changing technology and improved management rather than to selection of lower-risk cases. These 5- and 10-year survival rates compare favorably with the reported results of medical therapy.

Actuarial Analysis↗
PubMed1982

Early clinical evaluation after aortic valve replacement with the St. Jude Medical valve in patients with a small aortic root.

Forty-three patients, nine men and 34 women, mean age 60 years (range 23-81 years), who had small aortic roots underwent aortic valve replacement with a St. Jude Medical valve. Preoperatively, five patients were in New York Heart Association (NYHA) class I, 19 were in class II, 15 were in class III and four were in class IV. In 30 of 36 patients with aortic stenosis, the mean gradient was 102 mm Hg (range 52-175 mm Hg; in six patients with aortic stenosis, the gradient was not measured. Seven patients underwent surgery for aortic regurgitation. Ten patients received a 19-mm valve, 29 a 21-mm valve and nine a 23-mm valve. Two patients (4.6%) died in the hospital, one immediately postoperatively and the other from low cardiac output 9 days postoperatively. There are 670 patient-months of follow-up (mean 17 months). Thirty-six patients are NYHA class I and two patients are in class II. There have been no thromboembolic episodes in 605 months of follow-up for patients maintained on warfarin. There was one partial valve thrombosis among eight patients being managed without warfarin. No mechanical valve failures have occurred. The St. Jude Medical valve provides a satisfactory early result when used to replace the aortic valve of patients who have a small aortic root.

Adult↗
PubMed1981

Late clinical and arteriographic results in 500 coronary artery reoperations.

The incidence of coronary artery reoperations averaged 2.7% from 1967 through 1979. In a mean interval of 51 months between operations, three-vessel disease increased from 24% to 63%, and 31% of these 500 consecutive patients lost previously normal left ventricular function. Three angiographic indication groups were identified: (1) progressive coronary atherosclerosis, 247 (51%); (2) graft failure, 147 (29%); and (3) a combination of progressive coronary atherosclerosis and graft failure, 96 (19%). Angina recurred earlier in patient with graft failure, mean 17 months compared with a mean of 37 months for the other groups. Twenty (4%) operative deaths occurred. The series is divided into 387 patients operated upon under normothermic anoxic arrest and 113 with systemic hypothermia and cold cardioplegia. In the cardioplegia group, perioperative myocardial infarction was 2.7% in comparison with 7.8% for patients with anoxic arrest (p = 0.055). The number of grafts per patient increased from 1.0 to 1.9 and blood usage decreased from 11 units to 2.7 units. After a mean follow-up of 42 months, angina was relieved or improved in 86%. Recatheterization of 104 patients after a mean interval of 19 months showed a 79% vein graft patency rate and a 97% mammary artery graft patency rate. Grafting performed for graft failure (47) yielded an 85% patency rate. Actuarial 5 year survival was 87.4% for those with progressive atherosclerosis, 89.4% for patients with graft failure, and 91.5% for the combined indication group. Clinical improvement, graft patency, and long-term survival are nearly equal among the indication groups. Palliation derived from these reoperations approaches that achieved after primary revascularization.

Adult↗