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Biomedical subjects

Edward L Bove

Publications and source records attributed to Edward L Bove.

At least 19 recordsLinked to original sources
PubMed2005

Risk factors for cerebrovascular events following fontan palliation in patients with a functional single ventricle.

The risk for cerebrovascular events (CVEs) is increased in children with functional single ventricles (FSVs). However, there are limited data indicating the prevalence of CVEs or the role of preventative therapy. To measure the prevalence of clinically evident CVEs in patients with FSVs, identify risk factors, and analyze the effect of aspirin on the risk for CVEs, a retrospective chart review was performed on all patients who underwent Fontan palliation at the University of Michigan from January 1, 1975, to June 30, 1998 (n = 402). Data collected included original anatomy, Fontan type, date of CVE, medications at the time of CVE, intraoperative placement of fenestration, and date of last follow-up. The overall mortality rate was 12%. There were 38 CVEs (9%), of which only 11 (3%, or 0.0036/patient-year) could not be attributed to a defined event (catheterization, extracorporeal membrane oxygenation, or cardiac arrest). Anticoagulation with aspirin was associated with a statistically significantly decreased risk for CVEs. Fontan type was not associated with the risk for CVEs. Thus, patients with FSVs are at increased risk for CVEs, although the de novo risk was low. Aspirin use is associated with a decreased risk for CVEs.

Aspirin↗
PubMed2005

Extended resection and end-to-end anastomosis for aortic coarctation in infants: results of a tailored surgical approach.

BACKGROUND: The surgical repair of aortic coarctation in infants has evolved over time. This study evaluates our current approach utilizing extended end-to-end anastomosis without prosthetic material to enlarge all areas of aortic arch hypoplasia. METHODS: The Michigan Congenital Heart Center database was reviewed for infants who underwent repair of isolated aortic coarctation from January 1, 1990, to January 1, 2000. RESULTS: Eighty-three infants underwent surgical repair of isolated coarctation during this decade. Median age at repair was 21 days (range, 2 to 365). Repair was performed through thoracotomy in 72 patients. Because of severe transverse arch hypoplasia, the remaining 11 infants underwent median sternotomy with circulatory arrest. There were 2 deaths: 1 due to pulmonary hypertension in a patient with alveolar capillary dysplasia and 1 late death due to pneumonia in a patient with noncardiac anomalies. Neither patient had residual coarctation. Technique-related complications of bronchial compression, chylothorax, and vocal cord paralysis were noted in 4 patients. Follow-up data were available for 66 patients (80%) with mean follow-up duration of 4.5 years (SD +/- 3.1). Reintervention was required in 4 patients (6%). One underwent reoperation after 1 month, and 3 underwent balloon angioplasty within 7 months of initial repair. The remaining 61 patients are asymptomatic, on no antihypertensive medications, and have aortic arch gradients less than 15 mm Hg. One developed subaortic stenosis necessitating resection. CONCLUSIONS: Tailored surgical repair for aortic coarctation has a low rate (6%) of residual and recurrent coarctation even when performed in infants. Mortality and morbidity are low.

Anastomosis, Surgical↗
PubMed2005

Multiscale modeling of the cardiovascular system: application to the study of pulmonary and coronary perfusions in the univentricular circulation.

The objective of this study is to compare the coronary and pulmonary blood flow dynamics resulting from two configurations of systemic-to-pulmonary artery shunts currently utilized during the Norwood procedure: the central (CS) and modified Blalock Taussig (MBTS) shunts. A lumped parameter model of the neonatal cardiovascular circulation and detailed 3-D models of the shunt based on the finite volume method were constructed. Shunt sizes of 3, 3.5 and 4 mm were considered. A multiscale approach was adopted to prescribe appropriate and realistic boundary conditions for the 3-D models of the Norwood circulation. Results showed that the average shunt flow rate is higher for the CS option than for the MBTS and that pulmonary flow increases with shunt size for both options. Cardiac output is higher for the CS option for all shunt sizes. Flow distribution between the left and the right pulmonary arteries is not completely balanced, although for the CS option the discrepancy is low (50-51% of the pulmonary flow to the right lung) while for the MBTS it is more pronounced with larger shunt sizes (51-54% to the left lung). The CS option favors perfusion to the right lung while the MBTS favors the left. In the CS option, a smaller percentage of aortic flow is distributed to the coronary circulation, while that percentage rises for the MBTS. These findings may have important implications for coronary blood flow and ventricular function.

Blood Flow Velocity↗
PubMed2004

Tricuspid valve repair in hypoplastic left heart syndrome.

OBJECTIVES: Currently, the survival for the Norwood procedure for hypoplastic left heart syndrome is approximately 90% in selected centers. However, the development of tricuspid regurgitation remains a significant obstacle to successful staged repair in a subset of these patients. The results of tricuspid valve repair in this challenging patient population remain largely unknown. METHODS: Twenty-eight patients with significant (3-4+) tricuspid regurgitation after the Norwood procedure required tricuspid valve repair from August 1995 through December 2002. The clinical and Doppler-echocardiographic data were reviewed to determine the efficacy of repair and patient outcome. RESULTS: Follow-up was 96% complete (27/28). Patients were divided into 2 groups on the basis of tricuspid regurgitation at late follow-up: those with a successful late outcome (0-2+) and those with a poor outcome (3-4+). There were 17 (63%) patients with a successful result and 10 (37%) with an adverse outcome. Age, weight, follow-up duration, valve anatomy, and stage of palliation were not significantly different between groups. Early postoperative 0 to 2+ regurgitation was associated with a durable result (P =.012) and preserved ventricular function (P =.04). Need for repair other than a partial annuloplasty was predictive of a poor outcome (P =.04). Overall survival was 67% (18/27). Survival was 94% (16/17) for patients with a successful late result versus 20% (2/10) for those with a poor outcome (P =.0002). CONCLUSIONS: Tricuspid valve repair can be accomplished in this challenging patient population with excellent results. Successful tricuspid valve repair is predictive of continued good valve function and preserved right ventricular function. Successful valve repair at late follow-up predicts excellent late survival.

Child↗
PubMed2004

Primary closure for postoperative mediastinitis in children.

OBJECTIVES: Mediastinitis affects approximately 1% of children undergoing median sternotomy. Conventional therapy involves debridement followed by open wound care with delayed closure, days to weeks of closed suction or antimicrobial irrigation, and vacuum-assisted closure or muscle flap closure. We hypothesized that primary closure without prolonged suction or irrigation is an effective, less traumatic treatment for mediastinitis in children. METHODS: From January 1986 to July 2002, 6705 procedures involving median sternotomy were performed at the C. S. Mott Children's Hospital, resulting in 57 cases of mediastinitis (0.85%). Cases were divided into 2 groups, with 42 cases treated with primary closure and 15 cases treated with delayed or muscle flap closure. The 42 cases of primary closure comprised the primary study group of this institutional review board-approved, retrospective analysis. Patient demographics, surgical variables, mediastinitis-related parameters, and outcomes were evaluated. RESULTS: One patient had recurrent mediastinitis for an overall infection eradication rate of 97% (40/41). Three patients (7%) required re-exploration for suspected ongoing infection. Of these re-explorations, 1 patient had evidence of continued mediastinitis. The remaining 2 patients with sepsis of unclear cause had no clinical or culture evidence of recurrent infection. One of these patients ultimately died of sepsis without active mediastinitis for a hospital survival of 97% (41/42). No significant differences could be detected between the treatment successes and failures in this small cohort of patients. CONCLUSIONS: Simple primary closure is an effective means to treat selected cases of postoperative mediastinitis in children. The results compare favorably with other more lengthy or debilitating treatments.

Child↗
PubMed2004

High systemic vascular resistance and sudden cardiovascular collapse in recovering Norwood patients.

BACKGROUND: Sudden death, remote from surgery, in patients with hypoplastic left heart syndrome (HLHS) after Norwood palliation is an important problem. The episodic nature of this syndrome has made its cause(s) difficult to ascertain. Observations made in hospitalized Norwood patients may afford insight into the pathophysiology of sudden death among these patients. METHODS: We conducted a retrospective chart review. RESULTS: Five patients with HLHS experiencing unremarkable recoveries from Norwood palliation, still hospitalized but extubated (only 1 in intensive care), had unexpected, acute decompensation 8 to 15 days postoperatively. All had acutely decreased peripheral perfusion; severe metabolic acidosis (mean HCO(3) = 9 mEq/L, range 6 to 11 mEq/L; mean arterial lactate = 16 mmol/L, range 10 to 20 mmol/L, normal less than 2 mmol/L); relatively high arterial pO(2), especially considering their low systemic perfusion (mean = 57 mm Hg, range 50 to 66 mm Hg on fraction of inspired oxygen (FiO(2)) less than 0.3 in 4 of 5 patients); and relatively high systolic blood pressure (mean systolic blood pressure = 91 mm Hg, range 78 to 116 mm Hg). During the preceding 24 hours, all had had systolic blood pressures of more than 85 mm Hg at multiple times. All were resuscitated with mechanical ventilation and administration of HCO(3) and intravenous inotropic agents or vasodilators (1 also required extracorporeal membrane oxygenation), with rapid resolution of their acidosis. After decompensating, all were treated with oral antihypertensive agents; 1 had an early hemi-Fontan. All survived to discharge. CONCLUSIONS: Increased systemic vascular resistance may be especially pernicious in Norwood patients-even remote from operation-as the condition increases myocardial work and O(2) consumption while diminishing systemic perfusion. Chronic and acutely increased systemic vascular resistance may account for some cases of sudden unexpected death in Norwood patients.

Cardiac Surgical Procedures↗
PubMed2004

Single-stage repair of tetralogy of Fallot with pseudoaneurysm: a unique approach.

Pseudoaneurysm is a potentially lethal complication after modified Blalock-Taussig shunt. This report describes a frequently misdiagnosed clinical presentation along with noninvasive diagnosis of pseudoaneurysm after a modified Blalock-Taussig shunt. We report a novel single-stage surgical management of the pseudoaneurysm with concomitant complete repair of tetralogy of Fallot.

Anastomosis, Surgical↗
PubMed2004

Comparison of right ventricle to pulmonary artery conduit and modified Blalock-Taussig shunt hemodynamics after the Norwood operation.

The Norwood procedure remains one of the highest-risk operations in congenital heart surgery. A significant contributor to this risk is thought to be the diastolic run-off into the modified Blalock-Taussig shunt (MBTS). In an effort to eliminate this risk, several groups have begun to utilize a right ventricle to pulmonary artery conduit (RVPAC), which decreases this diastolic "steal" of coronary blood flow. Whereas initial results with the RVPAC are encouraging, the postulated hemodynamic advantages are unproven. This case illustrates the positive hemodynamic changes by echocardiography after the replacement of a MBTS with a RVPAC in a patient after a Norwood procedure.

Anastomosis, Surgical↗
PubMed2004

Double intramural coronary arteries in D-transposition of the great arteries.

We report a rare case of D-transposition of the great arteries with intramural origin of both the left and right coronary arteries. The patient underwent a successful arterial switch operation at 7 days of life with an uneventful postoperative course. Regardless of challenging coronary anatomy, the arterial switch operation remains the optimal approach for repair of the transposition of the great arteries in the neonate.

Abnormalities, Multiple↗
PubMed2004

Hypoplastic left heart syndrome: conventional surgical management.

Surgical palliation for hypoplastic left heart syndrome has become standard therapy in many centers throughout the world. Significant improvements in management, from preoperative diagnosis and intraoperative technique to postoperative care, have resulted in a dramatic increase in survival. With this improved survival, however, come new challenges and unforeseen problems. The first stage of the reconstructive surgery remains the highest risk procedure for the reason that establishing a stable circulation that is dependent on a single, volume-overloaded right ventricle with the potential for jeopardized coronary blood flow remains a surgical challenge. In this review, current management strategies for the conventional reconstructive surgical approach are examined.

Cardiac Surgical Procedures↗
PubMed2003

Valve sparing aortic root replacement for dilatation of the pulmonary autograft and aortic regurgitation after the Ross procedure.

BACKGROUND: Aortic insufficiency secondary to progressive dilatation of the pulmonary autograft is being recognized with increasing frequency after the Ross procedure. We reviewed our experience with valve-sparing aortic root replacement concomitant with aortic annuloplasty to assess the effectiveness of this approach. METHODS: Four patients, aged 8 to 27 years, presented with moderate to severe aortic insufficiency associated with progressive root dilatation from 1 to 8 years after a Ross procedure. All patients had 0 to 1+ aortic insufficiency early after the Ross procedure, with a mean maximal sinus diameter of 37 mm (range 30 to 45 mm). At reoperation the maximum diameter of the root ranged from 45 to 55 mm (mean 50 +/- 4 mm). A valve-sparing aortic root replacement with annular reduction was performed. The annulus was decreased from a mean of 27 mm to 23 mm. For the root replacement, 1 patient underwent a standard root remodeling procedure; in the others, a separate piece of scalloped Dacron (C.R. Bard, Haverhill, PA) graft material was used for each sinus to facilitate optimal exposure. RESULTS: All 4 patients are in New York Heart Association functional class I at a mean follow-up of 6 months. The most recent echocardiography demonstrated 0 to 1+ aortic insufficiency with good left ventricular function. Histology of the excised pulmonary autograft walls demonstrated severe elastin fragmentation. CONCLUSIONS: Aortic root remodeling with annular reduction is an effective treatment for aortic root dilatation and aortic insufficiency after the Ross operation. This procedure allows correction of aortic insufficiency and avoids the need for a prosthetic valve and anticoagulation.

Adolescent↗
PubMed2003

Outcome of pediatric patients treated with extracorporeal life support after cardiac surgery.

BACKGROUND: Extracorporeal life support (ECLS) has been used for over two decades in select patients after cardiac surgery. We previously described factors associated with death in this population. We now review our recent experience to reassess factors related to mortality. METHODS: All pediatric patients who received ECLS support within 7 days after surgery between July 1995 and June 2001 were examined to describe clinical features associated with survival. We compared the results with our prior report to assess changes in practice and outcome. RESULTS: Seventy-four patients were followed. Fifty percent survived to discharge. Hospital survival was not significantly related to patient age, cannulation site, or indication. Thirty-five percent of patients required hemofiltration while on ECLS and were significantly less likely to survive (23% vs 65%). A multivariate analysis combining all children from our prior report with the present cohort revealed that patients who received hemofiltration were five times more likely to die (odds ratio 5.01, 95% confidence interval 2.11-11.88). Children with an adequate two-ventricular repair had lower risk of death (odds ratio 0.42, 95% confidence interval 0.19-0.91) after adjusting for patient age, study period, and hours elapsed before initiation of ECLS after surgery. CONCLUSIONS: Patients with an adequate two-ventricle repair have significantly higher hospital survival, whereas those with single ventricle physiology or need for dialysis have decreased survival.

Cardiac Surgical Procedures↗
PubMed2003

Computational fluid dynamics in the evaluation of hemodynamic performance of cavopulmonary connections after the Norwood procedure for hypoplastic left heart syndrome.

OBJECTIVE: Computational fluid dynamics have been used to study the hemodynamic performance of surgical operations, resulting in improved design. Efficient designs with minimal energy losses are especially important for cavopulmonary connections. The purpose of this study was to compare hydraulic performance between the hemi-Fontan and bidirectional Glenn procedures, as well as the various types of completion Fontan operations. METHODS: Three-dimensional models were constructed of typical hemi-Fontan and bidirectional Glenn operations according to anatomic data derived from magnetic resonance scans, angiocardiograms, and echocardiograms. Boundary conditions were imposed, and fluid dynamics were calculated from a mathematic code. Power losses, flow distribution to each lung, and pressures were measured at three predetermined levels of pulmonary arteriolar resistance. Models of the lateral tunnel, total cavopulmonary connection, and extracardiac conduit completion Fontan operations were constructed, and power losses, total flow distribution, vena caval and pulmonary arterial pressures, and flow distribution of inferior vena caval return were calculated. RESULTS: The hemi-Fontan and bidirectional Glenn procedures performed nearly identically, with similar power losses and nearly equal flow distributions to each lung at all levels of pulmonary arteriolar resistance. However, the lateral tunnel Fontan procedure as performed after the hemi-Fontan operation had lower power losses (6.9 mW, pulmonary arteriolar resistance 3 units) than the total cavopulmonary connection (40.5 mW) or the extracardiac conduit (42.9 mW), although the inclusion of an enlargement patch toward the right in the total cavopulmonary connection was effective in reducing the difference (10.0 mW). Inferior vena caval flow to the right lung was 52% for the lateral tunnel, compared with 19%, 30%, 19%, and 15% for the total cavopulmonary connection, total cavopulmonary connection with right-sided enlargement patch, extracardiac conduit, and extracardiac conduit with a bevel to the left lung, respectively. CONCLUSIONS: According to these methods, the hemi-Fontan and bidirectional Glenn procedures performed equally well, but important differences in energy losses and flow distribution were found after the completion Fontan procedures. The superior hydraulic performance of the lateral tunnel Fontan operation after the hemi-Fontan procedure relative to any other method may be due to closer to optimal caval offset achieved in the surgical reconstruction.

Cardiac Surgical Procedures↗