Biomedical subjects
Publications and source records attributed to F C Wells.
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BACKGROUND AND AIMS OF THE STUDY: Previous studies have shown that outcome from mitral valve surgery is poorer in the elderly. However, such studies did not distinguish between age itself, age-associated factors and interactions between age and other factors. We aimed to examine the relative influences of age and these other factors on outcome. METHODS: We compared outcomes from mitral valve repair or replacement in 190 elderly (> or = 70 years) and 424 younger (< 70 years) consecutive adult patients. RESULTS: At baseline, the elderly had more (p > 0.05) degenerative mitral regurgitation, coronary artery disease, left ventricular impairment, New York Heart Association (NYHA) class III or IV symptoms, bioprosthetic replacement and mitral valve repair. Operative mortality rate was low both in elderly (7/190 patients, 3.7%) and younger patients (15/424 patients, 3.5%, NS). Seven-year survival was poorer in the elderly with respect to overall survival, (49 +/- 6% vs. 72 +/- 3%, p = 0.0001), freedom from complications-related death (57 +/- 7% vs. 79 +/- 3%, p = 0.001), from death due to myocardial failure (66 +/- 6% vs. 86 +/- 3%, p < 0.0001) and from overt myocardial failure (44 +/- 7% vs. 74 +/- 3%, p = 0.0001). Multivariate analysis showed better survival with younger age, mitral valve repair, better preoperative NYHA class and better left ventricular function. However, 7-year freedom from complications-related death was excellent and similar in both elderly (90 +/- 7%) and younger (93 +/- 3%, NS) patients who underwent surgery early while in NYHA class I or II with left ventricular ejection fraction > 40%. CONCLUSIONS: Late surgery contributes far more than age itself to poor outcome from mitral valve surgery in the elderly. If surgery is performed early and repair preferred to replacement whenever feasible, medium-term results are excellent in both young and old.
Mitral valve repair has become the operation of choice for mitral regurgitation. It is often technically more demanding than valve replacement. The role of echocardiography has now extended beyond the identification of severe mitral regurgitation that would benefit from surgical correction. It helps the surgeon to assess valve reparability preoperatively, to assess the need for valve surgery in equivocal cases of ischemic mitral regurgitation, to plan the operation, and to assess valve function after repair. This article aims to discuss the role of echocardiography in providing the information needed by the surgeon for successful mitral valve repair. The echocardiographer must understand the surgeon's needs, while surgeons should understand both the benefits and limitations of echocardiography.
BACKGROUND: Mitral valve replacement (MVR) has a high mortality and morbidity. It has been suggested that preservation of the subvalvular apparatus and more optimal timing of surgery might improve outcome. METHODS AND RESULTS: We performed a retrospective study of 612 consecutive patients who underwent mitral valve repair or replacement: 226 patients had repair, 68 had replacement with subvalvular preservation (MVR/SVP), and 318 had replacement without subvalvular preservation (MVR/NoSVP). Baseline characteristics were most unfavorable in the repair group with respect to age (P = .002) and in the repair and MVR/SVP groups with respect to NYHA functional class and left ventricular function (P = .044). Thirty-day mortality was lower in the repair (1.8%, P = .046) and MVR/SVP (1.5%. P = NS) groups than the MVR/NoSVP group (5.0%). Overall survival at 7 years was better in the repair (71.2 +/- 5.6%. P = .022) and MVR/SVP (66.2 +/- 12.4%, P = .017) groups than the MVR/NoSVP group (63.5 +/- 3.4%). Myocardial failure caused 66 of 107 complication-related deaths. Multivariate analysis confirmed independent beneficial effects of repair on 30-day mortality (odds ratio, 0.27, P < .05) and of repair and MVR/SVP on overall mortality (hazard ratios, 0.43, P < .001 and 0.40, P < .05, respectively) and complication-related death hazard ratios, 0.38, P < .001 and 0.35, P < .05, respectively). Preoperative NYHA class III or IV symptoms and left ventricular impairment were independent risk factors for death and myocardial failure. CONCLUSIONS: Mitral valve repair is superior to replacement. If repair is not feasible, the subvalvular apparatus should be preserved. Early surgery before the development of severe symptoms and demonstrable left ventricular impairment is also needed to optimize outcome.
A simplified technique for complete orthotopic cardiac transplantation is described. The potential technical difficulties and surgical considerations are discussed.
OBJECTIVE: Domino cardiac transplantation affords flexible and optimal organ utilization, provides hearts unaffected by brain death, allows prospective tissue matching, and subsequent transplantation with short allograft ischemic times. A retrospective review of our experience with domino cardiac transplantation has been made. METHODS: Seventy-two of 119 patients who underwent heart-lung transplantation from 1988 on served as domino cardiac donors (40 males, 32 females; mean age of 32 years; mean weight of 51 kg). The domino donor diagnoses were cystic fibrosis (n = 47), bronchiectasis (n = 9), primary pulmonary hypertension (n = 6), emphysema (n = 7), pulmonary fibrosis (n = 2) and Eisenmenger's syndrome (n = 1). Forty-seven domino hearts were transplanted at our institution and 25 were exported to other centres in the United Kingdom. The 72 domino cardiac recipients were 62 males and 10 females, mean age of 47 years, mean weight of 60 kg, with ischemic heart disease (n = 32), cardiomyopathy (n = 36) and other conditions (n = 4). RESULTS: There were four deaths (5.6%) at less than 30 days (2 from multiple organ failure, 1 from primary allograft failure and 1 from acute rejection). Actuarial survival estimates and 1 and 5 years were 77 +/- 5.2% nd 69 +/- 6.3%, respectively. This compared favourably with survival data obtained in 234 non-domino cardiac recipients. In the patients transplanted at Papworth, there was no difference in the incidence of rejection (0.6 +/- 0.05 versus 0.7 +/- 0.03 events per 100 patient days for the first 12 months) or in the freedom from graft atherosclerosis (74 +/- 3% versus 70 +/- 3% at 5 years) between the domino and non-domino groups. CONCLUSIONS: The use of domino hearts donated by recipients of heart-lung transplants is beneficial and is associated with an excellent early and longer-term outcome.
BACKGROUND: Patients admitted for resection of lung tumours frequently experience lengthy delays in diagnosis and preoperative investigations. This study was conducted to quantify this delay between presentation and definitive treatment and to assess the factors responsible for such a delay. METHODS: All patients undergoing lung resection for a tumour at a single surgical unit in 1993 were studied. The date of each consultation, investigation, and referral was identified, and the extent of any delay determined. RESULTS: The mean total delay from presentation to operation was 109 days. Within this period an average of one month occurred before referral to a respiratory specialist who then spent two months investigating the patient. After referral to a surgeon, surgery took place within a mean interval of 24 days. CONCLUSIONS: These delays to definitive treatment appear unacceptable. Points at which the efficiency of the diagnostic process could be improved are discussed. The length of delay did not correlate with tumour stage in this study.
Extubation of ventilated infants with severe unilateral pulmonary interstitial emphysema is difficult because the function of normal lung tissue is impaired. Continued positive pressure ventilation worsens hyperinflation on the side with interstitial emphysema, leading to cardiorespiratory compromise. Resection of affected single lobes is well described, but there are no reported cases of multiple lobectomies in very low birthweight infants. We describe a case where resection of both right upper and middle lobes was successful, allowing extubation within a few days of surgery. Computed tomography (CT) of the chest was helpful in making the decision to treat this infant by surgery.
BACKGROUND: The presence of a systemic disease has traditionally been considered a contraindication to lung transplantation. METHODS: We present a retrospective review of 19 patients undergoing lung transplantation for end-stage pulmonary disease associated with a systemic illness since 1984. There were 11 male and 8 female patients, aged from 23 to 59 years (median 43 years) with end-stage pulmonary involvement by sarcoidosis (11 patients), Langerhan's cell histiocytosis (three patients), systemic vasculitis (four patients: three with systemic lupus erythrematosis, one with Churg-Strauss), and common variable immunodeficiency (one patient). Ten patients received a heart-lung transplant, and eight patients received a single lung transplant. One patient underwent single lung transplantation after an earlier heart-lung transplant. RESULTS: The 30-day mortality was 5.3%. Nine patients died overall. Two of these had systemic lupus erythrematosis with anticardiolipin antibodies and died from complications of their underlying vasculitis. The mean 1- and 2-year actuarial survivals for all patients were 71% (standard error +/- 10.8%) and 64% (standard error +/- 11.9%), respectively. All patients surviving longer than 3 months achieved an improvement in functional status to New York Heart Association class I or II, and a significant increase occurred in mean forced expiratory volume in 1 second and forced vital capacity. Disease recurrence without clinical significance occurred in two patients with sarcoidosis. Of the nine patients who died, seven had autopsies and none showed evidence of disease recurrence in the lungs. CONCLUSIONS: Patients with systemic diseases can be considered for lung transplantation and each case should be judged on its individual merits. However, patients with systemic lupus erythrematosis (particularly when associated with anticardiolipin antibodies) should probably not be offered lung transplantation because they are likely to develop further complications of their underlying vasculitis.
Right-sided infective endocarditis is uncommon but is increasingly seen as a reflection of the prevalence of drug abuse, chronic intravenous catheters and associated congenital malformations. Isolated pulmonary valve endocarditis has rarely been reported and there has been only one previous report of isolated pulmonary valve fungal endocarditis. This resolved with antimicrobials. We describe a case of isolated mycotic pulmonary valve endocarditis resistant to existing anti-fungal chemotherapy, which necessitated pulmonary valve resection and replacement with a homograft.
Thirty-three patients requiring cardiac valve surgery were administered meropenem 1000 mg by a 5 to 10 min iv injection. Samples of blood, cardiac valve and atrial muscle tissue were removed at valvectomy and analysed for meropenem by high performance liquid chromatography (HPLC) with UV detection. The plasma concentrations observed in the samples from these patients were higher than those reported when meropenem 1000 mg was administered to healthy volunteers by 5 min iv injection. No clinical adverse events attributable to meropenem were reported and the single 1000 mg dose was well tolerated. The penetration of meropenem into cardiac muscle and valve tissue was rapid and in excess of that expected solely on the basis of distribution into extracellular fluid. The concentrations achieved in the tissues were in excess of the MICs of the pathogens commonly causing endocarditis.
BACKGROUND: The first successful single lung transplantation was carried out in 1983 for pulmonary fibrosis. Because of the inherent advantages of single lung transplantation, a transplantation programme has been started for patients with end stage lung disease due to emphysema. METHODS: Between October 1990 and August 1993 25 patients with severe emphysema (15 men, mean age 51 years) received a single lung transplant at our institution. All patients were severely disabled with a mean (SD) 12 minute walking distance of 281 (165) metres. There were five deaths in the series, four in the first 20 days and one on day 503. Two patients suffered graft compression by air trapping in the native lung. Bronchial narrowing requiring insertion of endobronchial stenting occurred in four patients. RESULTS: Mean (SD) FEV1 improved from a preoperative value of 17.8(13%) predicted to a six month value of 53.6(13)%, and FEV1/FVC from 23.8(12)% to 68.6(15)%. After the transplant 12 patients are in New York Heart Association (NYHA) class I and the rest of the survivors are in NYHA II. Actuarial survival was 82% at one year and 74% at three years. CONCLUSIONS: Single lung transplantation is an effective treatment for end stage lung disease due to emphysema and carries an acceptable mortality and morbidity.
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A retrospective study of 219 consecutive patients who underwent mitral valve repair for mitral regurgitation or mixed mitral valve disease with at least moderate regurgitation was undertaken. The etiology was degenerative in 151 (68.9%) patients, endocarditis in 24 (10.9%), rheumatic in 22 (10.0%), ischemic in 13 (5.9%), congenital in five (2.3%) and cardiomyopathy in two (0.9%). The average age was 64.8 +/- 10.9 years, the average follow up 30.2 +/- 24.1 months. Pre-operatively, 74% were in NYHA functional class III or IV. Left ventricular function was assessed by angiography and echocardiography, and moderate or severe impairment (ejection fraction < or = 40%) was assumed to represent significant left ventricular dysfunction. There were six (2.7%) hospital deaths, four of which were due to left ventricular dysfunction. The seven-year mortality and seven-year combined mortality and morbidity were 14.4% and 37.1% respectively for complications related to left ventricular dysfunction, and 2.5% and 24.2% respectively for unrelated complications. Subgroup analysis showed that five-year mortality and five-year combined mortality and morbidity due to left ventricular dysfunction were significantly worse in patients who had pre-operative left ventricular dysfunction than those who did not: 28.5% vs. 6.1% (p < 0.001) and 52.4% vs. 17.8% (p < 0.001). There was nevertheless a significant incidence of postoperative left ventricular dysfunction in patients with satisfactory preoperative left ventricular function. In this group, five-year mortality and five-year combined mortality and morbidity due to left ventricular dysfunction were higher in patients who were in NYHA class III or IV preoperatively than in those who were not: 11.2% vs. 0% (NS) and 25.9% vs. 0% (p < 0.01) respectively, particularly if they also had early (3-10 days) post-operative left ventricular dysfunction: 20.4% (p < 0.001) and 41.7% (p < 0.001) respectively. Despite preservation of the mitral apparatus, left ventricular dysfunction remains a major cause of mortality and morbidity following mitral valve repair for mitral regurgitation.
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We studied the haemodynamic effects of inhaled nitric oxide 40 p.p.m. in two groups of patients after cardiac surgery (mitral valve surgery or coronary artery bypass grafting). Nitric oxide caused a significant reduction in pulmonary vascular resistance after mitral valve surgery in patients who had pre-existing pulmonary hypertension, but no change in haemodynamic state in the coronary artery bypass group of patients, who had normal pulmonary arterial pressures.
As the numbers of heart and lung transplant recipients have increased it has become possible to identify major risk factors for early (within 3 months) and later (after 3 months) death after this procedure. For 100 patients receiving organs between April 1984 and February 1991, and followed up until February 1992, patient characteristics, operative details, and early morbidity were assessed for their effects on early and later deaths. Recipient age, sex, and preoperative diagnosis did not have a significant effect on early (within 3 months) or later death. Positive cytomegalovirus antibody status of donor or recipient conferred greater risk of death within 90 days (odds ratio [OR] = 3.24, P = 0.06). Greater than 2 L blood in the first 24 hr after operation (OR = 6.00, P = 0.05), and ventilation for greater than 24 hr (OR = 4.87, P = 0.006) were significant prognostic indicators of early death. After the first 3 months, the main risk factor for death was rejection in the first 3 months (OR = 1.38 per episode, P = 0.008). Early infection in general and CMV infection in particular were associated with a small increase in risk. This study confirms the importance of matching donor and recipient for CMV and shows that difficulties during operation, reflected in postoperative bleeding and ventilation times increased the chance of early death. Later death was associated with early acute rejection. A detrimental effect of infection, including CMV infection, either does not exist, or is too small to be detected in a study of this size.