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Biomedical subjects

F D Loop

Publications and source records attributed to F D Loop.

At least 73 records · Page 4Linked to original sources
PubMed1992

Myocardial protection during cardiac operations. Decreased morbidity and lower cost with blood cardioplegia and coronary sinus perfusion.

The efficacy of myocardial protection with a single aortic crossclamp and blood cardioplegia was evaluated in 819 consecutive patients stratified for preoperative condition by means of a new clinical risk scoring system. A protocol using either antegrade or antegrade/retrograde blood cardioplegia was compared with antegrade crystalloid cardioplegia in 2582 similar, consecutive, and concurrent patients. In the blood cardioplegia cohort, 97 (11.8%) patients had 129 complications compared with 407 (15.8%) patients and 675 complications in the crystalloid cardioplegia group (p = 0.006). In high-risk patients, combined antegrade/retrograde cardioplegia significantly reduced myocardial infarction, stroke, and respiratory and wound complications. Despite the significantly longer aortic crossclamp time required for blood cardioplegia, patients undergoing crystalloid cardioplegia were 1.7 (95% confidence interval 1.3, 2.1) times more likely to have a morbid event. Time in the intensive care unit, length of hospitalization, and length-of-stay outlier status were significantly decreased in the blood cardioplegia compared with the crystalloid cardioplegia group. The net savings in hospital cost amounted to $2196 per case. When compared separately with crystalloid cardioplegia, combined antegrade/retrograde blood cardioplegia accounted for most of the morbidity reduction by significantly reducing perioperative myocardial infarction, wound complications, and length of stay in patients having reoperations. Antegrade/retrograde blood cardioplegia did not influence 1-year survival or event-free survival, even when risk was considered.

Aged↗
PubMed1992

Vein graft disease: the clinical impact of stenoses in saphenous vein bypass grafts to coronary arteries.

The influence of coronary artery stenoses on patient survival and event-free survival is known, but no studies have reported the long-term outcome of patients with stenoses in saphenous vein bypass grafts. We retrospectively studied 723 patients who underwent a postoperative angiographic study that documented a stenosis of 20% to 99% in at least one saphenous vein graft and who did not undergo reoperation or percutaneous transluminal coronary angioplasty within 1 year after that catheterization. The mean follow-up interval was 83 months (range 1 to 237 months). For comparison, a group of 573 patients who underwent a postoperative catheterization that did not show any vein graft stenosis were also followed up. Cox regression analyses were used to identify predictors of late survival, reoperation-free survival, and event-free survival. For the entire group of patients with stenotic vein grafts, moderate or severe impairment of left ventricular function (p less than 0.001), interval between operation and catheterization (p less than 0.001), older age (p = 0.001), triple-vessel or left main coronary artery disease (p = 0.004), and stenosis of the vein graft to the left anterior descending coronary artery (p = 0.09) were associated with decreased late survival. Patients with an operation-to-catheterization interval greater than or equal to 5 years were at particularly high risk, and multivariate analyses of that subgroup confirmed that a stenotic graft to the left anterior descending artery was a strong predictor of decreased survival (p less than 0.001), decreased reoperation-free survival (p less than 0.001), and decreased event-free survival (p less than 0.001). Patients greater than or equal to 5 years postoperatively with greater than or equal to 50% stenosis of vein grafts to the left anterior descending artery had survival of 70% and 50% at 2 and 5 years after catheterization, compared with 97% and 80% for those with greater than or equal to 50% stenosis of the native left anterior descending artery (p = 0.002). Late vein graft stenoses are more dangerous than native coronary stenoses. Late stenoses in saphenous vein grafts to the left anterior descending coronary artery predict a high rate of death and cardiac events and are an indication for reoperation.

Cardiac Catheterization↗
PubMed1992

Atheroembolism from the ascending aorta. An emerging problem in cardiac surgery.

As the ages of patients undergoing cardiac operations have increased, noncardiac causes of death have increased. To identify these causes of death, we analyzed the autopsy findings in 221 patients undergoing myocardial revascularization or valve operations between 1982 and 1989. Mean age was 65.6 +/- 9.5 years and the range was from 32 to 94 years; 130 patients (58.8%) were male. Autopsies were complete in 129 patients (58.4%) and limited to the chest and abdomen in the remainder. Embolic disease was identified in 69 patients (31.2%). Atheroemboli or abnormalities consistent with atheroemboli were identified in 48 patients (21.7%). Fourteen patients had thromboembolism and 7 had disseminated intravascular coagulation. The prevalence of atheroembolic disease increased dramatically from 4.5% in 1982 to 48.3% in 1989 (p = 0.001). Atheroembolic disease was found in the brain in 16.3% of patients, spleen in 10.9%, kidney in 10.4%, and pancreas in 6.8%. Thirty (62.5%) of the 48 patients had multiple atheroembolic sites. Atheroemboli were more common in patients undergoing coronary artery procedures (43/165; 26.1%) than in those undergoing valve procedures (5/56; 8.9%) (p = 0.008). There was a high correlation of atheroemboli with severe atherosclerosis of the ascending aorta. Atheroembolic events occurred in 46 of 123 patients (37.4%) with severe disease of the ascending aorta but in only 2 of 98 patients (2%) without significant ascending aortic disease (p less than 0.0001). Forty-six of 48 patients (95.8%) who had evidence of atheroemboli had severe atherosclerosis of the ascending aorta. There was a direct correlation between age, severe atherosclerosis of the ascending aorta, and atheroemboli. Incremental risk factors for atheroembolic are peripheral vascular disease and severe atherosclerosis of the ascending aorta.

Age Factors↗
PubMed1992

Mitral valve repair for bacterial endocarditis.

Twenty-two patients with mitral insufficiency resulting from native valve endocarditis underwent mitral valve repair. Six patients had acute endocarditis with positive blood cultures and active valve infection. Sixteen patients were cured of active infection, but mitral insufficiency developed as a result of prior infection. Mean age was 48.5 +/- 21.7 years; 13 (59%) were male. Mean New York Heart Association functional class was 2.6 +/- 1.2. Multiple valve lesions were present in 11 (50%) patients. Valve abnormalities included leaflet perforation in 13 patients, chordal rupture or elongation in 14, vegetations in 5; and annular abscess in 1. In patients with acute endocarditis all macroscopically infected tissue was excised. Multiple techniques were required to achieve valve competence. Suture or patch closure of perforation was done in 14 patients, chordal shortening or transfer in 9, leaflet resection and closure in 4, leaflet resection with pericardial patching in 5, and annuloplasty in 15. Mitral valvuloplasty was combined with other procedures in 11 (50%) patients. There were two (9%) hospital deaths, both occurring in patients with healed endocarditis. There was one (9%) death in a patient undergoing an isolated procedure and one (9%) in a patient undergoing a combined procedure. Mean follow-up was 24 +/- 16.8 months and was complete. Seventeen (85%) were in New York Heart Association functional class I, and three (15%) were in class II. There were no late deaths, reoperations, recurrent endocarditis, thromboembolic events, or other valve-related morbidity. We conclude that mitral valve repair for insufficiency resulting from bacterial endocarditis (1) is possible in acute and healed disease, (2) has a low operative mortality, and (3) has resulted in patients free of recurrent infection and valve-related morbidity and mortality. Mitral valve repair is an attractive alternate to valve replacement in bacterial endocarditis.

Endocarditis, Bacterial↗
PubMed1991

Mitral valve repair for ischemic mitral insufficiency.

Over a 5-year period, 1,292 patients had operation on their native mitral valves. Ischemia was the cause of mitral insufficiency in 84 patients (6.5%). Sixty-five patients (77.4%) had mitral valve repair. Mean age was 66 +/- 10 years; 35 patients (53.8%) were women. Mean degree of preoperative insufficiency was 3.2 +/- 0.7; mean preoperative New York Heart Association functional class was 3.3 +/- 0.7. Eleven patients (16.9%) had acute and 54 (83.1%) had chronic mitral insufficiency. Valve prolapse was present in 26 patients (40%). Restrictive leaflet motion secondary to regional or global left ventricular dilatation occurred in 39 patients (60%). All patients had associated myocardial revascularization followed by transatrial valvuloplasty. Multiple techniques were employed to achieve valve competence: leaflet resection (3), chordal shortening (15), papillary muscle reimplantation (10), papillary muscle shortening (3), and annuloplasty (63). There were six (9.2%) hospital deaths (acute, 9.1%; chronic, 9.3% [not significant]; prolapse, 11.5%; restrictive, 7.7% [not significant]). The mean degree of postoperative mitral insufficiency was 0.6 +/- 0.8 in 51 patients. At a mean follow-up of 3.1 +/- 1.6 years, patient survival was 96% for patients with valve prolapse and 48% for those with restrictive leaflet motion (p = 0.02). New York Heart Association functional class was improved in all groups. Ischemic mitral insufficiency is an uncommon cause of mitral valve disease that is amenable to repair in the majority of cases of both acute and chronic onset. The operative mortality is low, and operation is associated with superior survival in patients with valve prolapse.

Aged↗
PubMed1991

Integrated pump switch for antegrade/retrograde cardioplegia.

A method of centralizing management of antegrade and retrograde blood cardioplegia delivery at the heart-lung machine is described. Operation of a manually flow-directed pump switch, controlled by the perfusionist, improves safety and efficiency.

Heart Arrest, Induced↗
PubMed1991

Mitral valve repair for mitral insufficiency.

Degenerative mitral valve disease has become the major cause of mitral regurgitation in North America; it is incumbent on surgeons to know repair techniques and to document their results. Fortunately, improvements in myocardial protection have been concurrent with the evolution of mitral valve repair in our country. The steep learning curve may be traversed, and the majority of degenerative mitral valves may be successfully repaired. Serial echo Doppler studies provide documentation of successful repair and monitor the patient's progress objectively. Echocardiography also provides a forum for communication between surgeons and cardiologists and, for the first time, the presence and amount of residual mitral regurgitation can be quantitated.

Echocardiography, Doppler↗
PubMed1990

Frequency of acute myocardial infarction in valve repairs versus valve replacement for pure mitral regurgitation.

Three hundred thirty-five consecutive isolated mitral valve operations for mitral regurgitation in patients with no significant coronary artery disease were reviewed over a 26-month period for the presence of a perioperative acute myocardial infarction (AMI). Of 224 patients undergoing mitral valve repair 12 (5.4%) had electrocardiographic and cardiac enzyme evidence of perioperative AMI develop. Of 111 patients undergoing mitral valve replacement none had perioperative AMI develop as determined by electrocardiographic and enzyme criteria (p = 0.01). All 12 infarctions after valve repair involved the inferior wall by electrocardiographic or echocardiographic criteria. Although no patient had significant clinical difficulty in recovery, 7 of the 12 patients (58%) were left with Q waves upon hospital discharge. The etiology of the AMI is believed to be air emboli introduced at the time of testing valve competence during left ventricular insufflation under pressure. Changes in surgical technique may reduce or eliminate this complication.

Aspartate Aminotransferases↗
PubMed1990

J. Maxwell Chamberlain memorial paper. Sternal wound complications after isolated coronary artery bypass grafting: early and late mortality, morbidity, and cost of care.

Of 6,504 consecutive patients who underwent isolated coronary bypass grafting in 1985 to 1987, 72 (1.1%) patients experienced sternal wound complications. Ten patients (14%) with wound complications died of multi-system failure. Only the patients with negative cultures fared well; of the bacterial culture categories, polymicrobial infection carried the worst prognosis. Effects of recurring infection were seen throughout the first year. Patients, grouped according to conduits received, experienced these wound complication rates: vein grafts only, 11/1,085 (1.0%); one internal thoracic artery, 38/4,073 (0.9%); and bilateral internal thoracic artery grafts, 23/1,346 (1.7%). There were no significant differences in wound complication rates between primary and reoperation patients or among conduit groups. By logistic regression analysis, the relative risk for patients with diabetes and bilateral internal thoracic artery grafting was 5.00 (95% confidence interval, 2.4 to 10.5). Operation time as a continuous variable increased the relative risk of wound complication 1.47 times per hour (1.3 to 1.7); obesity, 2.90 times (1.8 to 4.8); and blood units as continuous variable, 1.05 times per unit (1.01 to 1.10). Bilateral internal thoracic artery grafting in nondiabetic patients carried no greater risk of wound complication than that in patients with vein grafts only or with one internal thoracic artery graft.

Aged↗
PubMed1990

Incidence and prognostic significance of intraventricular conduction abnormalities after coronary bypass surgery.

To determine the incidence and prognostic significance of new postoperative conduction disturbances, 2,000 consecutive patients who underwent primary elective coronary bypass surgery were evaluated. One hundred eleven (5.5%) of the 2,000 patients developed a new intraventricular conduction defect that persisted to hospital discharge. Right bundle branch block occurred in 86 (85%), left bundle branch block in 5 (4%) and nonspecific intraventricular conduction defect in 9 (11%). One hundred of these 111 patients were successfully matched with others in the study population who had maintained normal intraventricular conduction during the operative period. Patients were matched on the basis of age, gender, absence of preoperative conduction disturbances, left ventricular function and bypass grafts to the same vessels. Follow-up of the two groups for a period of 1 to 76 months (mean 60 months) failed to show any difference in survival or cardiac events such as myocardial infarction, repeat coronary bypass surgery, coronary angioplasty and permanent pacemaker implantation. The appearance of right or left bundle branch block or a nonspecific intraventricular conduction defect after coronary bypass surgery does not appear to have an unfavorable impact on the long-term prognosis of these patients.

Bundle-Branch Block↗
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↗