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Biomedical subjects

E A Rose

Publications and source records attributed to E A Rose.

At least 127 records · Page 7Linked to original sources
PubMed1995

Improved mortality and rehabilitation of transplant candidates treated with a long-term implantable left ventricular assist system.

OBJECTIVE: This nonrandomized study using concurrent controls was performed to determine whether the HeartMate implantable pneumatic (IP) left ventricular assist system (LVAS) could provide sufficient hemodynamic support to allow rehabilitation of severely debilitated transplant candidates and to evaluate whether such support reduced mortality before and after transplantation. METHODS: Outcomes of 75 LVAS patients were compared with outcomes of 33 control patients (not treated with an LVAS) at 17 centers in the United States. All patients were transplant candidates who met the following hemodynamic criteria: pulmonary capillary wedge pressure > or = 20 mm Hg with a systolic blood pressure < or = 80 mm Hg or a cardiac index < or = 2.0 L/minute/m2. In addition, none of the patients met predetermined exclusion criteria. RESULTS: More LVAS patients than control patients survived to transplantation: 53 (71%) versus 12 (36%) (p = 0.001); and more LVAS patients were alive at 1 year: 48 (91%) versus 8 (67%) (p = 0.0001). The time to transplantation was longer in the group supported with the LVAS (average, 76 days; range, < 1-344 days) than in the control group (average, 12 days; range, 1-72 days). In the LVAS group, the average pump index (2.77 L/minute/m2) throughout support was 50% greater than the corresponding cardiac index (1.86 L/minute/m2) at implantation (p = 0.0001). In addition, 58% of LVAS patients with renal dysfunction survived, compared with 16% of the control patients (p < 0.001). CONCLUSIONS: The LVAS provided adequate hemodynamic support and was effective in rehabilitating patients based on improved renal, hepatic, and physical capacity assessments over time. In the LVAS group, pretransplant mortality decreased by 55%, and the probability of surviving 1 year after transplant was significantly greater than in the control group (90% vs. 67%, p = 0.03). Thus, the HeartMate IP LVAS proved safe and effective as a bridge to transplant and decreased the risk of death for patients waiting for transplantation.

Adolescent↗
PubMed1995

Preperitoneal placement of ventricular assist devices: an illustrated stepwise approach.

Improvement in left ventricular assist device (LVAD) implantation techniques may favorably impact on the significant perioperative morbidity and mortality that follows placement of these devices. Based on the difficulties faced and complications encountered during our 45 case experience, we developed a quick-reference illustrated guide which outlines in detail the steps and considerations critical for successful LVAD implantation.

Anastomosis, Surgical↗
PubMed1994

Management of heart failure. III. The role of revascularization in the treatment of patients with moderate or severe left ventricular systolic dysfunction.

OBJECTIVE: This article reviews the benefits and risks of coronary artery bypass grafting and angioplasty for patients with moderate or severe left ventricular systolic dysfunction and summarizes the recommendations of the expert panel for the Agency for Health Care Policy and Research Heart Failure Guideline. DATA SOURCES: Data were obtained from studies published in English and referenced in MEDLINE or EMBASE between 1966 and 1993. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with the terms coronary artery bypass grafting and angioplasty. STUDY SELECTION: All cohort studies and case series that provided separate outcomes data on a subgroup of patients with a left ventricular ejection fraction less than 0.40 were reviewed. DATA EXTRACTION AND SYNTHESIS: Studies were reviewed for inclusion and exclusion criteria, survival, and functional status measures using a standardized form. Cohort studies were assessed on eight aspects of study quality using a defined list of study flaws. CONCLUSION: Coronary artery bypass grafting improves 3-year survival by approximately 30% to 50% and physical functioning by approximately one New York Heart Association class in patients with moderate to severe left ventricular dysfunction and limiting angina. However, the operative mortality ranges from 5% to 30% depending on patients' ejection fractions and comorbidity. It is not clear whether patients whose predominant symptom is heart failure rather than angina benefit from bypass surgery or how much ischemia is required to justify surgical intervention. Clinical outcomes after angioplasty have not been adequately studied to determine the relative risks and benefits compared with bypass grafting.

Aged↗
PubMed1994

Exposure of the intramyocardial left anterior descending artery.

A systematic approach incorporating several discrete technical maneuvers is described that facilitates localization of the intramyocardial left anterior descending coronary artery. These simple maneuvers reliably afford localization of the initially hidden intramyocardial vessel and are easily incorporated into one's technical armamentarium.

Coronary Artery Bypass↗
PubMed1994

Preservation of anterior leaflet chordae tendineae during mitral valve replacement.

Preservation of anterior mitral leaflet papillary muscle attachments during mitral valve replacement was achieved in 20 patients by excising the central portion of the anterior leaflet and suturing the rim of leaflet tissue containing marginal chordae to the remaining edge of leaflet attached to the left atrium. This closure tacks the chordae to the fibrous trigones, opens the subvalvular area, and avoids a potentially thrombogenic or obstructive redundant leaflet ridge along the rim of an inserted valve. The technique is simple, safe, reproducible, and teachable.

Cardiac Surgical Procedures↗
PubMed1994

Potential of left ventricular assist devices as outpatient therapy while awaiting transplantation.

Left ventricular assist devices (LVADs) increasingly are being used as a bridge to transplantation. We studied changes in New York Heart Association class, mean arterial pressure, resting cardiac output, end-organ function, exercise oxygen consumption, and exercise cardiac output in 12 LVAD recipients. In addition, resting levels of neurohormonal factors were evaluated 4 to 16 weeks after implantation. Two of the 12 patients died of right heart failure and 1 of aspiration; all deaths occurred in the first 2 weeks after LVAD implantation. Of the other 9 patients, 8 improved to New York Heart Association class I and 1 to class II, all of whom were in class IV preoperatively. The 4 patients who underwent exercise testing achieved an exercise oxygen consumption of 15.0 +/- 2.7 mL.kg-1.min-1, which was paralleled by an increase in resting cardiac output from 3.07 +/- 0.9 L.min-1 preoperatively to 5.66 +/- 1.1 L.min-1 at 2 months, and mean arterial pressure from 60 +/- 8 to 91 +/- 10 mm Hg at 2 months, a benefit that was maintained for up to 10 months. End-organ function revealed comparable improvement at 2 months for both creatinine (1.68 +/- 0.7 to 1.0 +/- 0.19 mg.dL-1) and total bilirubin (1.37 +/- 1.17 to 0.54 +/- 0.26 mg.dL-1) levels. Levels of neurohormones were within normal limits. Adverse clinical events after the perioperative period were minimal, and no thromboembolic complications occurred.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1994

1987: Adjustable annuloplasty for tricuspid insufficiency. Updated in 1994.

De Vega described a technique for tricuspid annuloplasty using synthetic suture to reduce the size of the dilated annulus. We present our experience with an adjustable modification of de Vega's suture annuloplasty technique. The records of 12 patients followed for 15 to 30 months were reviewed. All 10 survivors had a significant drop in right-sided filling pressure (average, 39% decrease) and an associated improvement in clinical status. The 2 deaths in the series were not related to persistent tricuspid insufficiency. This technique represents a reliable, rapid, and readily teachable method for the surgical management of tricuspid insufficiency.

Hemodynamics↗
PubMed1994

Malignant ventricular arrhythmias are well tolerated in patients receiving long-term left ventricular assist devices.

OBJECTIVES: We sought to quantitate the incidence of malignant ventricular arrhythmias and to identify subsequent hemodynamic changes and untoward events in patients who have received an implantable left ventricular circulatory assist device as an extended bridge to heart transplantation. BACKGROUND: Implantable long-term mechanical circulatory assist devices have been used clinically with increasing frequency and success for the past 4 years. Previous investigators have suggested that patients with malignant ventricular arrhythmias receiving a left ventricular assist device will require both left and right ventricular assistance to maintain vital organ perfusion. METHODS: We reviewed our 4-year experience with 21 patients who underwent implantation of a left ventricular assist device. Device flows and mean arterial pressure were used to assess systemic perfusion; central venous pressure provided a gauge of right ventricular function. Charts were screened for evidence of end-organ injury resulting from malignant ventricular arrhythmias. RESULTS: Malignant ventricular arrhythmias occurred in 4 patients (19%) before device placement and in 9 patients (43%) during device support. The latter nine patients formed the final study group; their arrhythmias occurred 0 to 186 days after device implantation and had a duration of 10 min to 12 days. The patients reported weakness or palpitation; however, none reported syncope or dyspnea. Mean arterial pressure and central venous pressure were insignificantly changed by the arrhythmias. Device flow decreased by 1.4 +/- 0.6 liters/min (p < 0.05) at the onset of the arrhythmias but returned to normal after cardioversion. No thromboembolic events or significant end-organ dysfunction occurred. CONCLUSION: Absence of right ventricular contraction during malignant ventricular arrhythmias is well tolerated in recipients of a left ventricular assist device. The diagnosis of malignant arrhythmia should be suspected if an unexplained decrease in left ventricular assist device flow occurs. Early electrical cardioversion is warranted to avoid both thrombus formation in the native heart and right ventricular myocardial injury from prolonged fibrillation.

Adolescent↗
PubMed1994

Single-stage management of 74 consecutive sternal wound complications with pectoralis major myocutaneous advancement flaps.

The optimal management of sternal wound complications remains controversial. Since 1985, we have utilized a combination of immediate, aggressive debridement with simultaneous repair using bilateral pectoralis major myocutaneous advancement flaps, regardless of the degree of infection. As compared with the use of distant pedicled muscle flaps or pectoralis major turnover flaps, the management of complicated sternal wounds with immediate pectoralis major myocutaneous advancement flaps provides an effective yet simpler, quicker method of management with improved aesthetic results. In addition, basing the pectoralis major myocutaneous flaps on the thoracoacromial arteries eliminates the need for intact internal mammary arteries, valuable since the latter are increasingly used for coronary grafts. Seventy-four consecutive patients, 17 (23 percent) of whom were immunosuppressed heart transplant recipients, have been managed with this procedure. There were no intraoperative deaths. The 30-day perioperative mortality rate was 9 percent (7 of 74), with only 1 death related to persistent sepsis. The morbidity rate was 39 percent, with the most common complication being seroma managed by needle aspiration (18 of 74, 24 percent). The aesthetic and functional results have been uniformly excellent.

Humans↗
PubMed1994

Artificial circulatory support with textured interior surfaces. A counterintuitive approach to minimizing thromboembolism.

BACKGROUND: Although numerous left ventricular assist devices (LVADs) have been used clinically, frequent thromboembolic complications have been reported despite the smooth interior LVAD surfaces and systemic anticoagulant medication. In contrast, the Thermo Cardiosystems HeartMate 1000 IP LVAD has textured interior surfaces that are promptly covered by a densely adherent neointima. We hypothesize that elimination of a direct interface between prosthetic material and blood elements reduces the risk of peripheral embolization and minimizes the necessity for systemic anticoagulant medication. This report defines the thromboembolic risk of this type of LVAD and characterizes the nature and effectiveness of the various anticoagulation regimens that were tested during the initial clinical trial with this device. METHODS AND RESULTS: All values are reported as mean +/- SD. Fifty-four males and three females with an average age of 47 +/- 11 years were supported with the HeartMate 1000 IP LVAD for an average of 62 +/- 76 days at 11 clinical centers in the United States. Patients were prospectively evaluated for thromboembolic complications. Five different anticoagulation regimens were used during the first 4 postoperative weeks: no anticoagulants, low-molecular-weight dextran, heparin, dipyridamole plus aspirin, or miscellaneous agents. After the first 4 weeks, the patients were treated with aspirin plus dipyridamole or miscellaneous agents. Prothrombin time (PT), partial thromboplastin time (PTT), and fibrinogen values for the patients were measured at 0.1, 1, 2, 4, 8, 12, 16, 20, 24, 32, and 46 weeks during support. Two patients (3.5%) suffered thromboembolic cerebrovascular complications, an incidence of 0.2 episodes per patient-year of observation. One episode was due to fungal vegetation developing on the device and the other was due to embolization from a previously placed native mechanical aortic valve prosthesis. In the absence of infection, there were no device-related thromboembolic complications. Mean prothrombin time for all groups was 13.3 +/- 0.5 seconds with no significant intergroup differences. Mean partial thromboplastin time during the first 4 weeks for the heparin-treated group was 53.3 +/- 6.6 seconds, which was significantly longer than for all other groups, but fell to control values after heparin was discontinued at 4 weeks. Mean fibrinogen level for all groups was 370 +/- 48 mg/dL, with no intergroup differences. CONCLUSIONS: The HeartMate 1000 IP LVAD provides adequate circulatory support with a low risk of thromboembolism despite minimal systemic anticoagulation. The use of textured surfaces may be an important factor contributing to the low observed risk of thromboembolic complications.

Anticoagulants↗
PubMed1994

Technique for removal of left ventricular assist devices.

As the use of long-term implantable left ventricular assist devices increases, more surgeons will be required to remove the devices for transplantation or in the event of infection. We outline several maneuvers that facilitate device removal and several pitfalls that complicate the procedure. Important considerations include preventive measures at the time of device implantation and prevention of air embolism.

Embolism, Air↗