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Biomedical subjects

F D Loop

Publications and source records attributed to F D Loop.

At least 37 records · Page 2Linked to original sources
PubMed1990

Ten-year survival of patients with mild angina or myocardial infarction without angina: a comparison of medical and surgical treatment.

Ten-year survival percentages were calculated for groups of 407 initially medically treated patients and for 390 patients who had early coronary bypass surgery; all had either mild angina pectoris or myocardial infarction without subsequent angina pectoris. Uncensored actuarial survival was 77% for medical patients and 83% for the surgical group. For 179 patients who had internal thoracic (mammary) artery grafting as part of their procedures, survival was 91% in contrast to 76% for those who had vein grafts only. A sharp drop of the survival curve for the vein graft group after the seventh year was not shown for those who had internal thoracic artery grafts. Survival was 71% for 280 patients treated medically only.

Angina Pectoris↗
PubMed1990

Appraisal of cerebrospinal fluid alterations during aortic surgery with intrathecal papaverine administration and cerebrospinal fluid drainage.

We have previously described a technique for intrathecal administration of papaverine and cerebrospinal fluid drainage to prevent paraplegia after aortic surgery. Herein we report the cerebrospinal fluid and hemodynamic alterations that occurred in 11 patients who had 30 mg of a specially prepared papaverine hydrochloride 10% dextrose solution injected before aortic cross-clamping and also had cerebrospinal fluid drainage. A mean of 26.6 ml (SD +/- 7.1 ml) was drained before and 34.6 ml (SD +/- 24.1 ml) was drained during aortic cross-clamping. The cerebrospinal fluid pressure increased significantly with anesthetic induction (p less than 0.03), during the period between anesthetic induction and cerebrospinal fluid drainage (p less than 0.005), and with aortic cross-clamping (p less than 0.05). These cerebrospinal fluid pressure alterations were similar to central venous pressure increases with a significant linear correlation between cerebral spinal fluid pressure and central venous pressure before anesthetic induction (r2 = 0.81, p less than 0.005), and both before (r2 = 0.94, p less than 0.005) and after (r2 = 0.74, p less than 0.005) aortic cross-clamping. As expected, cerebrospinal fluid pressure was significantly reduced by cerebrospinal fluid drainage before aortic cross-clamping (p less than 0.001). The administration of intrathecal papaverine had no significant effect on mean arterial pressure, systemic vascular resistance, cerebrospinal fluid pressure, nor the pH of cerebrospinal fluid. Neither were there any complications noted related to the technique. All the patients survived, and no new immediate postoperative paraparesis or paraplegia occurred.(ABSTRACT TRUNCATED AT 250 WORDS)

Aorta↗
PubMed1990

Reoperation for coronary atherosclerosis. Changing practice in 2509 consecutive patients.

We analyzed trends in clinical, angiographic, and operative variables and documented long-term survival in 2509 consecutive patients who underwent reoperation for myocardial revascularization at The Cleveland Clinic during a 20-year period (1967 to 1987). The patients were grouped into four cohorts by year of surgery. This analysis showed that vein graft atherosclerosis has become the leading indication for reoperation, and patient age and interval between operations continue to increase. Mortality rates ranged from 2% to 5% and, despite increasing comorbidity, more extensive coronary atherosclerosis, and worse left ventricular function, the hospital mortality rate was 2.9% from 1985 to 1987. Perioperative new Q-wave myocardial infarction occurred in 7% to 8% of patients from 1967 to 1984 but decreased to 4% in the 1985 to 1987 period (p = 0.04). Internal thoracic artery graft usage in reoperations increased from 27% in the 1967 to 1978 period to 67% in the 1985 to 1987 period. Advanced age and presence of left main coronary artery disease adversely influenced late survival more consistently than other factors. Patients operated on in 1967 to 1978 had fewer risk factors, which explains their higher survival rate compared with more recent cohorts. Factors associated with improved 10-year actuarial survival included age younger than 65 years, mild angina, no major comorbidity, no left main coronary artery disease, good left ventricular performance, and an internal thoracic artery graft.

Coronary Artery Disease↗
PubMed1990

Replacement of the ascending aorta. Early and late results.

From 1978 through 1987, 225 patients underwent operations that included replacement of the ascending aorta. One hundred twenty-three patients underwent composite aortic valve and ascending aortic replacement, 30 had aortic valve replacement with separate graft replacement of the ascending aorta, and 72 underwent replacement of the ascending aorta without aortic valve replacement. Thirty-one (13.8%) in-hospital deaths occurred. Univariate testing of preoperative and operative variables followed by logistic regression analyses identified miscellaneous aortic disease, coronary artery bypass grafting, aortic arch replacement, emergency operation, surgical date (1978 to 1983), and age (all p less than 0.05) as factors having independent association with in-hospital mortality. Follow-up of in-hospital survivors (mean interval 46 months, range 8 to 123 months) documented an overall 5-year survival rate of 76%, 83% after primary operation and 37% after reoperation. Univariate analyses followed by multivariate testing indicated that previous operation (p less than 0.0001) and a history of preoperative neurologic symptoms (p = 0.021) were associated with decreased late survival. At follow-up 88% of late survivors were free of symptoms. Seven patients have undergone reoperation 1 day to 69 months postoperatively. Although the in-hospital mortality for operations that include ascending aortic replacement exceeds that for isolated aortic valve replacement, the late death rate and rate of reoperation are low.

Adult↗
PubMed1989

Late follow-up of 781 patients undergoing percutaneous transluminal coronary angioplasty or coronary artery bypass grafting for an isolated obstruction in the left anterior descending coronary artery.

Seven hundred eighty-one patients with isolated left anterior descending coronary atherosclerosis treated with either coronary artery bypass grafting or percutaneous transluminal coronary angioplasty between January 1980 and December 1984 were studied to determine late survival and event-free survival. Follow-up was complete in 775 patients (99.4%). Actuarial survival at 5 years was 98% for surgical patients and 95% for angioplasty patients (p = 0.02). Five-year event-free survival (freedom from myocardial infarction, bypass grafting, angioplasty, and death) was 93% for surgical patients and 62% for angioplasty patients. This study suggests that the higher initial cost and complexity of bypass surgery may be justified by superior long-term results.

Angioplasty, Balloon, Coronary↗
PubMed1989

Surgical staging for simultaneous coronary and carotid disease: a study including prospective randomization.

Simultaneous carotid disease was documented in 275 (2.8%) of 9714 patients scheduled for coronary artery bypass (CAB), including 80 (29%) who had had previous neurologic events and 195 with severe (greater than or equal to 70% diameter), asymptomatic carotid stenosis. Preliminary carotid endarterectomy (CE) was feasible before CAB in only 24 patients with stable cardiac disease (group I). Another 129 patients with unstable disease (group II) had unilateral, asymptomatic carotid lesions and were prospectively randomized to receive either combined operations (IIA; n = 71) or CAB followed by delayed CE (IIB; n = 58). The remaining 122 patients (group III) had symptomatic or bilateral carotid stenosis and were managed on a selective basis without randomization. The operative mortality rate ranged from 4.2% to 5.2%, and the early stroke rates were 4.2% in group I, 7.8% in group II, and 11% in group III. Postoperative strokes occurred after CAB in nine (4.7%) of the 193 patients protected by preliminary or simultaneous CE, compared with six (7.4%) of the 81 who received only delayed CE. Nevertheless, the composite stroke risk for "reverse-staged" procedures in group IIB (14%) exceeded that for combined operations (2.8%) in group IIA (p = 0.045). The stroke rate was 11% (7/61) when delayed CE was performed within 2 weeks after CAB compared with 2.2% (1/46) with longer staging intervals.

Aged↗
PubMed1989

A 20-year experience in coronary artery reoperation.

We divided 2518 patients who underwent isolated coronary artery reoperation into four cohorts according to time. There were 436 patients reoperated on from 1967-1978, 439 in 1979-1981, 625 in 1982-1984, and 1018 in 1985-1987. The interval between operative procedures has lengthened from 50 months in the first cohort to 101 months in the most recent series. A review of angiographic indications reveals that vein graft atherosclerosis is the leading indication for coronary artery reoperation. Despite a changing population of reoperative surgical candidates in terms of diffuse coronary atherosclerosis and interim deterioration of left ventricular function, operative mortality has not increased. In the 1985-1987 cohort, hospital mortality was 2.7%. The perioperative myocardial infarction rate (new Q waves) of 4.0% in the most recent cohort shows a significant trend downward (P = 0.007), ascribed to better myocardial protection. The 5.4% return to the operating room for postoperative haemorrhage is significantly higher than the rate of bleeding after first surgery, but it has not changed in the past decade. Blood conservation has resulted in average blood usage of approximately two units per patient, but has risen to 2.7 units per patient in the most recent cohort. Other major morbidity is not appreciably different from that of the first operation. Internal thoracic artery patency in a largely symptomatic postreoperative population was 94% (241/256). Vein graft patency in the same time frame was 67% (726/1080). Approximately 50% of patients were angina-free 10 years postoperatively, which is below the percentage found after the first operation.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary Artery Disease↗
PubMed1989

Hospital readmissions: a re-evaluation of criteria.

A prospective study surveyed patients discharged from the Cardiology, Cardiovascular Surgery, and Gastroenterology services of the Cleveland Clinic Hospital during April and September 1987. The total number of hospital discharges during the study period was 5,349; the study population discharged during this period included 1,640 patients (30.7% of all hospital discharges). In the study population, 149 patients were readmitted (9.1%). The percentage of readmissions was similar for both months and similar to that reported in the literature. However, when readmissions were categorized into four subsets, significant differences were found. The four categories were: 1) complication of a previous admission (16.8% of readmissions), 2) recurrence of the disease process (11.4% of readmissions), 3) planned treatment (53% of readmissions), and 4) unrelated new diagnosis (16.1% of readmissions). The authors conclude that reviewing readmission rates without using these subdivisions can be misleading, and the results are inappropriate for evaluating the quality of medical care given in an acute care hospital. They recommend that these four subdivisions be included in future studies of readmission rates in acute care hospitals.

Delivery of Health Care↗
PubMed1989

Long-term results of mitral valve repair.

(1) Carpentier techniques of repair are the dominant method today because of durability and reproducible results. (2) Mitral valve repair results in high survival, low risk of anticoagulant-related complications, and low risk of infective endocarditis. (3) Long-term anticoagulation is avoided in approximately half of the patients; yet, over the long term, thromboembolism occurs significantly less with repair than with valve replacement. (4) The rate of reoperation after mitral valve repair is not significantly different from that of mechanical valve replacement up to 10 postoperative years. (5) Mitral valve repair for degenerative mitral regurgitation results in a higher freedom from reoperation at 5 years and beyond, compared with rheumatic causes of regurgitation. (6) Ischemic and congenital etiologies for mitral regurgitation demand repair whenever feasible. Results in these patient groups favor repair over other options.

Follow-Up Studies↗
PubMed1989

Coronary bypass surgery in chronic stable angina.

Over the last 20 years, operative mortality has decreased and late survival has improved for patients with chronic stable angina who have coronary artery bypass surgery. However, this favorable trend may not continue because the operation is now extended to elderly and high-risk patients. The most powerful predictors of operative mortality include indexes of left ventricular function, age, and the number of associated medical conditions. Female gender, severity of angina, and extent of coronary artery disease appear to be predictors of operative mortality in some series but not in all. Indexes of left ventricular dysfunction remain the most powerful predictors of late death, but the extent of coronary disease, older age, and presence of associated diseases (including noncardiac vascular disease) remain important determinants. Analyses of the randomized trials and registry studies reveal a consistent trend: in patients at high risk on the basis of clinical, functional, and anatomic characteristics, coronary artery bypass surgery prolongs survival in comparison with medical therapy alone. In patients determined to be at low risk, medical therapy is initially recommended with the realization that revascularization may be necessary subsequently if symptoms worsen or the severity of ischemia increases.

Angina Pectoris↗
PubMed1989

Primary isolated aortic valve replacement. Early and late results.

A total of 1689 consecutive patients underwent isolated aortic valve replacement at the Cleveland Clinic Foundation from 1972 through 1986. There were 57 (3.4%) in-hospital deaths. Multivariate analysis identified advanced age (p = 0.0014), preoperative blood urea nitrogen level greater than 25 mg/100 ml (p = 0.008), New York Heart Association function class (p = 0.015), and preoperative atrial fibrillation (p = 0.04) as independent variables associated with increased in-hospital mortality and the use of cardioplegia for myocardial protection (p = 0.006) as a factor decreasing mortality. Follow-up documented survival rates of 85% and 66% and event-free survival rates of 71% and 43% at 5 and 10 postoperative years, respectively. Advanced age, moderate or severe impairment of left ventricular function, coronary artery disease, and preoperative blood urea nitrogen level greater than 25 mg/100 ml were associated with decreased late survival and event-free survival (all p less than 0.05). Patients with bioprostheses had better survival (p = 0.003) and event-free survival (p = 0.0007) rates than patients with mechanical valves. Patients with bioprostheses had superior results only if not receiving warfarin, and they experienced more reoperations and endocarditis; those with mechanical prostheses had more strokes, myocardial infarctions, bleeding complications, and thromboembolic events. Analysis of patients grouped according to age at operation showed that bioprostheses were associated with improved survival and event-free survival for patients 40 years older or older. Younger patients experienced more reoperations and episodes of endocarditis, and older patients more thromboembolic complications. We conclude that 10-year results after isolated aortic valve replacement are influenced by both patient-related and management-related variables, and the impact of these factors is different for patients of different ages.

Adult↗
PubMed1989

Ventricular aneurysm resection. Trends in surgical risk.

From 1972 to 1987, 1,183 patients underwent ventricular aneurysm resection. At 4-year intervals, this series was divided into four subsets that differed in patient and management-related variables. Comparison of patients seen from 1972 to 1975 with those seen in 1984-1987 shows a significant increase in mean age to 59.4 years, with 31.6% older than 65 years, an increase to 43.4% of patients with congestive heart failure, and a decrease to 42.8% of patients with angina. In the most recent interval, 30.7% of patients had mammary grafts, 81.1% had associated grafts, and 47.2% of patients were completely revascularized. Mortality rate, however, increased to 8%. Deaths were attributed to cardiac causes in 59.7% of cases. Multivariate analysis identified emergent procedures, advancing age, left main trunk disease, and history of congestive heart failure as risk factors. We conclude that the incidence of aneurysm resection is decreasing and operative risk has been constant despite advancing patient age and more extensive operative procedure.

Aged↗
PubMed1989

New arteries for old.

The internal thoracic artery has emerged as the coronary bypass graft of choice. Initially it was favored because of proximity to the anterior descending artery, little discrepancy in size between graft and recipient vessels, and high early patency rate. Later investigation showed relative freedom from arterial degeneration. In contrast to the 40-60% patency rate for vein grafts at 10-12 years postoperatively, the arterial graft patency exceeds 90%. Theories about protection from atherosclerosis are now directed toward vasoactive properties of the arterial wall. Exercise scintigraphic studies indicate that flow from a thoracic artery graft to the anterior descending artery relieves ischemia at peak myocardial demand. As expected, an arterial conduit that provides consistently high long-term patency also significantly improves 10-year survival in patients with one-, two-, or three-vessel disease. This extended longevity applies to patients with normal and abnormal left ventricular function. Late myocardial infarction, reoperation, and hospitalization for cardiac causes are significantly reduced by performance of an internal thoracic artery graft to the anterior descending coronary artery. These results have stimulated greater usage of these arterial grafts as bilateral, free, and sequential anastomoses. Preliminary reports indicate that patency related to expanded use is similar to that obtained with an in situ left thoracic artery graft. Indications and relative contraindications to arterial grafting in context of these current findings are discussed in this overview.

Coronary Artery Bypass↗
PubMed1989

Coronary artery bypass grafting with the right gastroepiploic artery.

The excellent results of coronary artery bypass with the internal mammary artery and the increasing numbers of patients who need coronary reoperations, but for whom conventional bypass conduits are not available, have prompted us to evaluate alternative arterial bypass conduits. The right gastroepiploic artery has been used as a coronary bypass graft in 36 patients (32 men), whose ages ranged from 29 to 71 years. Twenty-two patients had had previous coronary bypass grafting and six of these were undergoing their third bypass operation. The right gastroepiploic artery was used as an in situ graft to the right coronary artery or circumflex branches for 17 patients and as an aorta-coronary ("free") graft in 19 patients, six to the left anterior descending or diagonal, six to the circumflex, and seven to the right coronary artery. In conjunction with right gastroepiploic artery grafting, 16 patients received bilateral internal mammary artery grafts and 17 received one internal mammary artery graft. Histologically, right gastroepiploic artery segments from 18 patients could not be distinguished from internal mammary artery segments, and no evidence of atherosclerosis was found. Two patients died in the hospital, one intraoperatively and one 3 months after the operation, of a perioperative stroke. Perioperative morbidity included wound complication in three and reexploration for bleeding in two. At late follow-up 1 to 38 months after operation, two late deaths had occurred and 21 patients were free of symptoms. Postoperative angiography (postoperative interval 1 week to 13 months) was performed in nine grafts, three in situ grafts to the right coronary artery and six free grafts that included two to the left anterior descending, three to the circumflex, and one to the right coronary artery. All right gastroepiploic artery grafts were patient. The right gastroepiploic artery is an arterial conduit that can be used as an in situ graft to posterior coronary vessels and as a free graft to any coronary arterial system. Early graft patency has been excellent, and the histologic similarity between the right gastroepiploic artery and the internal mammary artery suggest that the long-term results will be favorable.

Adult↗
PubMed1989

The predictive value of serum enzymes for perioperative myocardial infarction after cardiac operations. An autopsy study.

We evaluated the utility of serum enzyme and isoenzyme activities for detecting autopsy-proved perioperative myocardial infarction in patients who died after cardiac operations. We studied 79 patients who had autopsies performed after coronary artery bypass grafting or valve replacement, or both. Thirty-seven had histologic evidence of a perioperative myocardial infarction. We found statistically significant differences between the group of patients with infarction and the group without infarction when we compared the mean activities of creatine kinase, creatine kinase MB, aspartate aminotransferase, and the lactate dehydrogenase-1/lactate dehydrogenase-2 ratio. The postoperative changes in serum enzymes were analyzed by logistic regression for their relation to perioperative myocardial infarction. Creatine kinase MB exhibited the best diagnostic association with the presence of perioperative myocardial infarction. The lactate dehydrogenase-1/lactate dehydrogenase-2 ratio correlated to a lesser extent with infarction. Adjustment of the diagnostic cutoff to 133 U/L for creatine kinase-MB measured 15 hours after operation yielded a sensitivity of 0.60 and a specificity of 1.0. This study demonstrates that no combination of enzyme activity changes after operation can completely discriminate all patients with perioperative myocardial infarction from those without. Nonetheless, measurement of creatine kinase MB activity provide 96% accuracy for diagnosing infarction at a prevalence of 10%.

Aspartate Aminotransferases↗
PubMed1988

Applicability of mitral valvuloplasty techniques in a North American population.

Records of 520 patients who underwent mitral valve operations were reviewed to determine the pathophysiology, etiology, anatomy of the valve lesion and use of valvuloplasty techniques. Pure mitral regurgitation, present in 269 patients (52%), was the most common lesion while rheumatic valvulitis, seen in 286 patients (55%), was the most common etiology. Degenerative lesions were found in 168 patients, 33% of the total and 63% of the pure mitral regurgitation group. Two-hundred seventy patients (52%) were treated with valvuloplasty techniques. The incidence of reconstructive procedures was determined for each of the various patient subsets. Overall hospital mortality was 5.6% in the series: 8.4% for mitral replacement compared with 3% for mitral valvuloplasty (p = 0.007). Among patients undergoing primary isolated mitral procedures, hospital mortality for replacement was 7.5% compared with 1.4% for valvuloplasty (p = 0.018). Mitral valvuloplasty seems to provide a therapeutic alternative applicable to the spectrum of mitral valve pathology seen in a North American population.

Female↗
PubMed1988

Infections of the cardiac suture line after left ventricular surgery.

PURPOSE: Infections of the cardiac suture line after left ventricular surgery are rare but may be fatal if not diagnosed promptly and treated effectively. In order to alert physicians to this entity, we reviewed data from three patients who presented at the Cleveland Clinic Hospital and from 22 patients in the literature. PATIENTS AND METHODS: The three patients in the current report underwent treatment at the Cleveland Clinic Hospital. Additional cases of infection of the left ventricular suture line were identified by reviewing the English literature pertaining to surgery for left ventricular aneurysms, pseudoaneurysms, and postoperative cardiac infections. RESULTS: Infection presented on average 16 months after surgery with cardiocutaneous fistulae, chest wall masses, hemoptysis or other pleuropulmonary symptoms, or systemic illness with bacteremia resembling endocarditis. Staphylococci and gram-negative bacilli were the most frequent pathogens. Diagnosis was often delayed and mortality was high. Left ventricular false aneurysms were identified in 15 of the 25 patients. Bleeding from sinuses in the chest wall or epigastrium or repeated hemoptysis were important clinical clues. In some instances, ill-advised surgical or instrumental procedures precipitated life-threatening hemorrhage. Treatment with antibiotics alone was insufficient. Excision of all infected sutures and Teflon pledgets and adequate debridement of the infected suture line were required to achieve cures. CONCLUSION: Since infection of the left ventricular suture line has protean clinical manifestations and may present months or years after the initial surgery, a high index of suspicion is of paramount importance in diagnosing the condition. Institution of cardiopulmonary bypass and reoperation through median sternotomy is recommended to achieve a cure.

Aged↗