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Biomedical subjects

F J Puga

Publications and source records attributed to F J Puga.

At least 73 records · Page 4Linked to original sources
PubMed1993

Late results of valve replacement with the Björk-Shiley valve (1973 to 1982)

Cardiac valve replacement with use of only the Björk-Shiley prosthesis was performed in 1253 patients between January 1973 and December 1982. There were 828 patients having aortic valve replacement, 280 patients having mitral valve replacement, and 145 patients having double valve replacement with aortic and mitral valve prostheses. Patient outcome was stratified according to multiple variables, including valve position and valve model (spherical versus convexo-concave discs). No valve failure due to strut fracture was identified in 26 high-risk patients (mitral valve replacement with greater than or equal to 29 mm implanted in patients less than or equal to 50 years of age) followed up for a mean of 10 years postoperatively. Fifteen patients had late thrombosis of their Björk-Shiley prosthesis (0.28 per 100 patient-years), but there was no significant difference in risk of valve thrombosis comparing the spherical and convexo-concave discs (0.27 per 100 patient-years versus 0.27 per 100 patient-years). One hundred two patients had 128 thromboembolic episodes; rates of thromboembolism after aortic valve replacement, mitral valve replacement, and double valve replacement were 2.1, 4.3, and 4.6 per 100 patient-years, respectively. Percentages of patients free from thromboemboli after aortic valve replacement, mitral valve replacement, and double valve replacement were 93% +/- 1%, 86% +/- 2%, and 89% +/- 3% at 5 years postoperatively and 87% +/- 2%, 79% +/- 5%, and 77% +/- 8% 10 years postoperatively. There was no significant difference in the rates of thromboemboli for spherical and convexo-concave discs for all patients and for each of the subgroups. Ten-year actuarial survival estimates for patients dismissed alive from the hospital after aortic valve replacement, mitral valve replacement, and double valve replacement with the Björk-Shiley valve were 65% +/- 4%, 63% +/- 5%, and 55% +/- 8%, respectively. Overall event-free survival (freedom from death, thromboembolism, anticoagulant-related bleeding, endocarditis, and reoperation) was similar for the three patient groups. Performance of the Björk-Shiley valve as judged by late patient follow-up is similar to other mechanical valves, and modifications in disc design do not appear to have reduced the threat of late valve thrombosis and thromboemboli. Evidence does not support elective explantation of this prosthesis.

Adolescent↗
PubMed1992

Five- to fifteen-year follow-up after Fontan operation.

BACKGROUND: The purpose of this study was to estimate survival and quality of outcome and assess factors associated with outcome for patients out 5 to 15 years from their Fontan operation. METHODS AND RESULTS: We studied 352 patients who had the Fontan operation prior to 1985. The overall 1-, 5-, and 10-year survival was 77%, 70%, and 60%, respectively. The following factors were significantly associated with lower survival: univentricular heart or complex congenital anomalies other than tricuspid atresia, early calendar year of operation, heterotaxia syndromes, early age at operation, increased pulmonary artery pressure, atrioventricular valve dysfunction, and higher (worse) New York Heart Association class. Reoperations were necessary for 103 of the 352 patients. At least 20% of the survivors have or have had cardiac arrhythmias requiring antiarrhythmic medication or mechanical pacemaker insertion. Between 7% and 10% of the patients have had or had protein-losing enteropathy/hypoproteinemia. At 5 years postoperatively, 122 patients (34.7%) were alive with a better New York Heart Association functional classification than preoperatively. Fifty-eight patients (16.5%) were alive and in the same functional classification, but 126 (35.8%) died within the first 5 years or were in a worse functional classification. Thirty-nine patients were doing excellently and 29 patients poorly 5 years after the operation. Of the surviving patients, 43% can do as much exercise as their peers, whereas 3% are incapable of exercise. CONCLUSIONS: To assure good functional long-term outcome in addition to survival, clinicians must exclude from selection for Fontan operation patients known to be at high risk for death or poor outcome.

Adolescent↗
PubMed1992

Subaortic obstruction in hearts with a univentricular connection to a dominant left ventricle and an anterior subaortic outlet chamber. Results of a staged approach.

In 1984 we reported a 56% mortality after major cardiac operations for patients with univentricular connection to a dominant left ventricle, an anterior subaortic outlet chamber, and subaortic obstruction. Since then we have adopted a staged approach to this repair. Between 1984 and 1989 32 patients had such operations. The overall mortality has decreased (16%; p < 0.001). The current cohort was divided by subaortic gradient into three subgroups for comparison with the cohort reported in 1984. Staging improved the outcome in patients with gradients greater than 40 mm Hg (mortality of 17% compared with 67% from 1984; p = 0.05). Patients with gradients from 10 to 25 mm Hg who had a single-stage operation had the best outcome (mortality 6%). Survival has improved. Many factors, including increased awareness of the detrimental effects of subaortic obstruction, improved surgical techniques, better perioperative care, and the appropriate application of a staged repair, have contributed to this improvement. We recommend simultaneous relief of obstruction and a modified Fontan operation for patients with subaortic gradients less than 25 mm Hg. Those with gradients greater than 40 mm Hg should have repair in two stages. It is unclear whether a one-stage or two-stage approach is better for patients with gradients between these extremes.

Adolescent↗
PubMed1992

Velo-cardio-facial syndrome associated with ventricular septal defect, pulmonary atresia, and hypoplastic pulmonary arteries.

We report on 15 patients with velo-cardiofacial syndrome who had a severe form of tetralogy of Fallot (pulmonary atresia, ventricular septal defect, and hypoplastic pulmonary arteries). Noncardiac anomalies in these patients included typical facial and ear anomalies in 15, nasal speech in 13, palate anomalies in 10, and developmental delay in 10. Seven patients had significant bronchospasm, which has not been reported in association with the velo-cardio-facial syndrome. All 15 patients had severe abnormalities of the arborization of the pulmonary arterial tree, which also has not been reported in velo-cardio-facial syndrome. All patients underwent staging operations to prepare the true pulmonary vascular tree for complete repair of the defect (five underwent complete repair and three survived). Of the remaining 10 patients, 6 are awaiting further operation, 3 are not candidates for complete repair, and 1 has died.

Abnormalities, Multiple↗
PubMed1992

Late functional status of survivors of the Fontan procedure performed during the 1970s.

BACKGROUND: During the 1970s (1973-1979), 41 patients with tricuspid atresia and 25 patients with double-inlet left ventricle had a Fontan procedure performed at the Mayo Clinic. In the tricuspid atresia group, there were seven hospital deaths and six late deaths, leaving 28 survivors 11-16 years after surgery. In the double-inlet left ventricle group, there were six hospital deaths and six late deaths, leaving 13 survivors 11-13 years after surgery. METHODS AND RESULTS: The present status of 38 of the 41 long-term survivors was recently (September 1990) determined. Of these 38 patients contacted, 34 felt they were in excellent or good condition, three considered themselves in fair condition, and one was in poor condition. Nineteen of the 38 (50%) were receiving no cardiovascular medications. Twenty-eight (76%) were employed full-time or were full-time students with three others working part-time. Only four patients (11%) felt physically incapable of working or attending school. Seven patients have graduated from college since their Fontan procedure with three others presently enrolled. Present occupations include architect, lawyer, industrial manager with a master's degree, policeman, truck driver, horseback riding instructor, and artist. Nine patients are married, and one woman tolerated a pregnancy without difficulty. The most troublesome late problems requiring medical therapy were atrial dysrhythmia in seven patients (18%) and protein-losing enteropathy in two patients (5%). CONCLUSIONS: Surgical mortality of the Fontan procedure for tricuspid atresia and double-inlet left ventricle is now less than 10%, and that, plus these late results, justify continued application of this operation in patients with these lesions.

Adult↗
PubMed1991

Early and late results of the modified Fontan procedure for double-inlet left ventricle: the Mayo Clinic experience.

Between May 1974 and March 1989, 155 patients with double-inlet left ventricle had the Fontan procedure performed at the Mayo Clinic. Age at operation ranged from nearly 2 to 41 years (median 10). The operative mortality rate from 1974 through 1980 (39 patients) was 21%, but from 1981 through 1989 (116 patients) it was reduced to 9%. The 17 late deaths were secondary to reoperation (n = 8), progressive myocardial failure (n = 5), sudden arrhythmia (n = 3) and bleeding varices (n = 1). Neither operative nor late mortality rate was significantly related to age at operation. At follow-up of 6 months to 11 years (mean 4.9 years) in 111 patients, 88% were in good or excellent condition and 12% were in fair or poor condition. The Fontan operation can be performed with a mortality risk of less than 10% in properly selected patients with double-inlet left ventricle. Late results are encouraging when contrasted with the clinical course of patients before this operative approach was utilized.

Academic Medical Centers↗
PubMed1990

Long-term outcome after surgical repair of isolated atrial septal defect. Follow-up at 27 to 32 years.

BACKGROUND: Atrial septal defects have been surgically correctable for more than 30 years. The long-term survival rates among patients treated in the early era of cardiac surgery are poorly documented, but such data are of critical importance to the future medical care, employability, and insurability of these patients. METHODS: To determine the natural history of surgically corrected atrial septal defects, we studied all 123 patients who underwent repair of an isolated defect (ostium secundum or sinus venosus) at the Mayo Clinic between 1956 and 1960, 27 to 32 years after the procedure. The follow-up status of all patients was determined by written questionnaires and telephone interviews. Hospital records and death certificates were obtained if interim hospitalization or death had occurred. RESULTS: The overall 30-year actuarial survival rate among survivors of the perioperative period was 74 percent, as compared with 85 percent among controls matched for age and sex. The perioperative mortality was 3.3 percent (four deaths). Actuarial 27-year survival rates among patients in the younger two quartiles according to age at operation (less than or equal to 11 years and 12 to 24 years) were no different from rates among controls--97 percent and 93 percent, respectively. In the two older quartiles (25 to 41 years and greater than 41 years), 27-year survival rates were significantly less (P less than 0.001)--84 percent and 40 percent, respectively--than in controls (91 and 59 percent). Independent predictors of long-term survival according to multivariate analysis were age at operation (P less than 0.0001) and systolic pressure in the main pulmonary artery before operation (P less than 0.0027). When repair was performed in older patients, late cardiac failure, stroke, and atrial fibrillation were significantly more frequent. CONCLUSIONS: Among patients with surgically repaired atrial septal defects, those operated on before the age of 25 have an excellent prognosis, but older patients require careful, regular supervision.

Actuarial Analysis↗
PubMed1990

Cardiogastric fistula occurring 9 years after resection of left ventricular aneurysm.

An 83-year-old man, 9 years after repair of a postinfarction aneurysm of the left ventricle, developed fever, anemia, and congestive heart failure. Extensive evaluation of the gastrointestinal tract revealed no evidence of ulcer disease. While in the hospital, he developed massive hematemesis and melena and died 2 days later. At autopsy, a communication existed between a left ventricular pseudoaneurysm and the stomach to form a cardiogastric fistula. Infection of the left ventricular pseudoaneurysm may have precipitated the gastric perforation. This represents an extremely rare late complication of aneurysmectomy procedures and, to our knowledge, is the first case to be reported in the absence of primary gastrointestinal pathology.

Aged↗
PubMed1990

The modified Fontan operation for children less than 4 years old.

Of 500 patients who had a modified Fontan operation at this institution between 1973 and 1987, 54 (33 boys and 21 girls) were less than 4 years old. This retrospective study related preoperative clinical and hemodynamic data to subsequent survival. Twenty patients less than 4 years old had tricuspid atresia, 13 had double inlet ventricle and 21 had other complex heart defects. There were 14 early deaths (less than 30 days after operation) and 6 late deaths. Multivariate analysis of survival for the entire group of 500 patients revealed the following factors to be significantly associated with poorer survival: absence of tricuspid atresia (p = 0.011), asplenia (p less than 0.001), age less than 4 years at operation (p = 0.042), atrioventricular valve dysfunction (p = 0.017), early calendar year of operation (p less than 0.001) and the presence of either one or more of the following: left ventricular ejection fraction less than 60%, mean pulmonary artery pressure greater than 15 mm Hg and pulmonary arteriolar resistance greater than 4 U.m2 (p less than 0.001). On the basis of this study of 500 patients, age less than 4 years at operation appears to be an independent risk factor for poorer survival after the modified Fontan operation.

Child, Preschool↗
PubMed1990

Fontan operation in 176 patients with tricuspid atresia. Results and a proposed new index for patient selection.

Between 1973 and March 1989, 176 patients with tricuspid atresia had the Fontan procedure performed at the Mayo Clinic. Age range at the time of surgery was 7 months to 42 years, with 43 patients (24%) 16 years old or older. Hospital mortality rates were 17% (nine of 54) from 1973 through 1980 and 8% (10 of 122) from 1981 through 1989. There have been 10 late cardiovascular deaths. Postoperative follow-up of 139 survivors (range, 6 months to 14 years; mean, 5.5 years) revealed 91% to be in excellent or good condition and 9% to be in fair or poor condition. Patients in fair or poor condition had poor stamina and/or fluid retention with intermittent pleural effusion, ascites, and so on. Two factors that clearly influence operative and late results are preoperative pulmonary arteriolar resistance (Rpa) and left ventricular diastolic function. A preoperative catheterization index devised by adding Rpa to left ventricular end-diastolic pressure divided by QpI plus QsI may be helpful in selecting candidates most likely to survive and benefit from the Fontan operation. In our experience, if this index is less than 4.0, then the postoperative right atrial mean pressure will be 20 mm Hg or less, a circumstance associated with 95% early and 89% overall survival rates.

Adolescent↗
PubMed1990

Repair of transposition of the great arteries with intact ventricular septum and left ventricular outflow tract obstruction.

Repair of transposition of the great arteries in patients with intact ventricular septum and fixed left ventricular outflow tract obstruction has been restricted to atrial baffle procedures, with or without attempts to relieve or bypass the left ventricular outflow obstruction. However, the suboptimal results of these procedures, coupled with excellent functional results with the arterial switch operation in patients without obstruction, has made anatomic correction the goal in repairing these anomalies. We report a technique for the anatomic correction of transposition of the great arteries, intact ventricular septum, and fixed left ventricular outflow tract obstruction. Its consideration in these difficult cases is advocated.

Child↗
PubMed1989

Thrombotic obstruction of disc valves: clinical recognition and surgical management.

Twenty-seven patients underwent reoperation because of thrombotic obstruction of a disc-type cardiac valve prosthesis. Preoperative clinical features included effort dyspnea in 81%, new-onset angina in 44%, a new murmur in 89%, and an abnormal opening or closing sound associated with the prosthetic valve in 56%. Symptoms were present for 1 week or more before reoperation in 86%, although many patients were referred only after acute exacerbation of heart failure and development of pulmonary edema. Noninvasive studies confirmed prosthetic valve malfunction in only 33%, but cardiac catheterization documented thrombotic obstruction in all 15 patients in whom it was performed. In 14 of the 27 patients, prothrombin time was in the therapeutic range at the time of admission. Prompt reoperation for valve replacement or thrombectomy was performed with an operative mortality of 11%, and long-term outcome was satisfactory in all but 1 hospital survivor. These findings emphasize the importance of considering the diagnosis of thrombosed heart valves in patients with mechanical heart valves who are seen with nonspecific symptoms.

Adult↗
PubMed1989

Surgical pathology of the pulmonary valve: a study of 116 cases spanning 15 years.

The gross surgical pathologic features of the pulmonary valve were reviewed in 116 patients (63 male and 53 female) who had undergone a cardiac operation with pulmonary valve excision at our institution during the period 1973 through 1987. Although the mean age was 12 years, subjects ranged in age from 3 months to 73 years, and 25 patients, including 19 with congenital heart disease, were older than 20 years of age. Among 105 patients who had pure pulmonary stenosis, 61 (58%) had tetralogy of Fallot, 18 had isolated pulmonary stenosis, 23 had other congenital cardiac anomalies, and 3 had carcinoid heart disease. Five patients had pure pulmonary regurgitation (four with tetralogy and one with infective endocarditis), and four had combined pulmonary stenosis and regurgitation (two with congenital cardiac anomalies and two with carcinoid heart disease). In two patients, the valve was neither stenotic nor regurgitant. Thus, congenital heart disease accounted for 110 of the 116 cases (95%), and tetralogy of Fallot was the most commonly observed form (65 cases). Bicuspid pulmonary valve was the most common anomaly and was present in 58% of patients with tetralogy but in only 17% of those with isolated pulmonary stenosis.

Adolescent↗