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Biomedical subjects

F J Puga

Publications and source records attributed to F J Puga.

At least 91 records · Page 5Linked to original sources
PubMed1989

Utility of temporary atrial epicardial electrodes in postoperative pediatric cardiac patients.

The utility of atrial electrograms recorded from temporary bipolar atrial epicardial electrodes in postoperative pediatric cardiac patients was assessed by (1) examining the accuracy of the surface electrocardiographic tracings and (2) analyzing the treatment modalities used for the arrhythmias diagnosed on the basis of the atrial electrograms. Atrial electrograms were obtained simultaneously with single-lead surface electrocardiographic recordings from 20 pediatric patients (ages 7 months to 11 years) after intracardiac repair of congenital heart defects. Interpretations of 25 surface recordings by five pediatric cardiologists were compared with analyses of the electrograms. Sinus rhythm was interpreted correctly by most reviewers 100% of the time, whereas atrioventricular conduction disturbances and narrow QRS tachycardias were identified correctly 77% and 14% of the time, respectively. Of those rhythms incorrectly interpreted, 89% had some type of active therapeutic intervention. Single-lead surface electrocardiographic recordings are imprecise for evaluating postoperative rhythms in pediatric cardiac patients, and our experience suggests that rhythms for which active intervention is necessary may be more difficult to interpret correctly by surface monitoring alone.

Arrhythmias, Cardiac↗
PubMed1989

Exercise tolerance and cardiorespiratory response to exercise before and after the Fontan operation.

To determine the effect of the Fontan operation on exercise tolerance and cardiorespiratory response to exercise, we compared the preoperative and postoperative responses to graded exercise to maximal effort in 20 patients who underwent a modified Fontan procedure. The mean interval between preoperative and postoperative exercise testing was 1.8 years. Postoperatively, total work performed, duration of exercise, and maximal oxygen uptake were significantly increased. Although cardiac output increased during exercise, the response was subnormal, and stroke volume was unchanged. The heart rate and systolic blood pressure during maximal exercise were not significantly changed from preoperative values, but the diastolic blood pressures during rest and maximal exercise were significantly increased postoperatively. Systemic arterial blood oxygen saturation increased after the modified Fontan operation, but during exercise, a mild but significant desaturation occurred (93% compared with 90%). The ventilatory equivalent for oxygen decreased toward normal during exercise. The respiratory rate and oxygen consumption during resting remained unchanged from preoperative values. For this subset of patients, these data indicate that exercise tolerance improves, cardiac output and stroke volume responses to exercise are subnormal, and ventilatory response to exercise decreases toward normal after the modified Fontan operation.

Adolescent↗
PubMed1989

A novel approach to atrial endocardial pacing.

We describe a patient who had tricuspid valve replacement and in whom dual-chamber pacing was accomplished by using a ventricular epicardial lead and by placing an atrial endocardial lead through the wall of the atrial appendage and positioning the tip against the endocardial surface of the atrial appendage. A ligature was placed around the atrial appendage where the lead passed through the wall of the right atrial appendage. This obviated the need for a second procedure to place the atrial lead in a transvenous fashion. After 5 years of follow-up the patient continues with normal DVI pacing.

Aged↗
PubMed1989

Complete repair of pulmonary atresia, ventricular septal defect, and severe peripheral arborization abnormalities of the central pulmonary arteries. Experience with preliminary unifocalization procedures in 38 patients.

From 1982 to 1987, 38 consecutive patients with pulmonary atresia and ventricular septal defect underwent staged unifocalization procedures in preparation for final intracardiac repair of the anomaly. Thirty-six patients had concordant visceroatrial, atrioventricular, and ventriculoarterial connections. A central pulmonary artery confluence was present in 19 patients and absent in the remaining group. All patients with central pulmonary arteries had inadequate peripheral pulmonary arterial arborization. Systemic collateral arteries were present in all 38 patients. The objectives of the unifocalization procedures were the interruption of extracardiac sources of pulmonary arterial blood flow, the restoration of segmental, lobar, and pulmonary arterial confluence, the replacement of missing central pulmonary arterial branches, and the creation of a central, accessible source of pulmonary arterial blood flow. A total of 54 unifocalization procedures were performed in the 38 patients. These procedures included 85 permanent connecting anastomoses, 15 temporary anastomoses to the ascending aorta, 13 angioplasty procedures, and 15 modified Blalock-Taussig shunts. Three patients died after unifocalization (two early and one late). By the end of the study, eight patients were still waiting for further unifocalization procedures or angiographic assessment. Four patients were rejected for further surgical treatment because of persistent, uncorrectable defects of the pulmonary arterial arborization pattern. Twenty-three patients underwent complete intracardiac repair with two deaths (one early and one late). Postrepair, intraoperative right ventricular/left ventricular systolic pressure ratio after complete surgical repair ranged from 0.4 to 1.0 (mean = 0.63, standard deviation = 0.14). At the end of follow-up, 21 survivors of complete repair were free of significant symptoms. Unifocalization procedures designed to improve the pulmonary arterial arborization pattern of patients with pulmonary atresia and ventricular septal defect with or without central pulmonary arteries can prepare a significant number of these patients for successful intracardiac repair of the anomaly.

Adolescent↗
PubMed1989

Surgical treatment of complex congenital heart disease with modified Fontan procedure.

Between October 1973 and mid-January 1987, 500 patients underwent a modified Fontan operation at the Mayo Clinic. This included 163 patients with tricuspid atresia, 154 patients with double inlet ventricle, and 183 patients with other complex single ventricle malformations. There have been 80 hospital deaths (16%). In the last 5 years there have been 39 deaths (11.7%). Lowest mortality was seen in patients with tricuspid atresia (11% overall, 5.8% last 5 years) and highest mortality was seen in patients with complex lesions. Younger age at operation, elevated pulmonary artery pressure, elevated right atrial pressure following operation, and prolonged bypass times were significant risk factors. The modified Fontan procedure provides effective palliation for complex congenital cardiac anomalies which have no other satisfactory treatment. Criteria for operability have been extended beyond those originally proposed for this operation. The operative mortality continues to decline with increasing experience, late results are good, and longevity appears to be increased. The Fontan operation has been increasingly utilized as the definitive surgical palliation for patients with functional single ventricle. At the Mayo Clinic, over 600 patients have undergone a modified Fontan operation since our first case in October 1973. This presentation gives the results of the first 500 cases and describes the various preoperative and perioperative factors which may influence a successful outcome.

Adolescent↗
PubMed1989

The outcome of surgical treatment of hypertrophic obstructive cardiomyopathy. Experience over 15 years.

From 1972 through 1987, 115 patients between the ages of 1 and 83 years (mean, 44.5 years) underwent operation for hypertrophic obstructive cardiomyopathy. Methods of relief of left ventricular outflow obstruction were septal myectomy/myotomy (n = 109), mitral valve replacement (n = 4), and myectomy/myotomy plus mitral valve replacement (n = 2); concomitant procedures included coronary artery bypass (n = 19) and aortic valve replacement (n = 9). Systolic gradient (peak-to-peak) from the left ventricle to the aorta decreased from 70 +/- 38 mm Hg (mean +/- standard deviation) to 9 +/- 11 mm Hg. There were six hospital deaths, for an overall operative risk of 5.2%; one death occurred among 83 patients less than age 65 years (operative risk, 1.2%), and five deaths occurred in 32 older patients (operative risk, 15.6%; p = 0.008 for difference between age groups). Four (22.2%) of 18 patients with a residual gradient greater than 15 mm Hg died, compared with two (2.1%) of 97 patients with a lower gradient (p = 0.003). Follow-up ranged from 0.5 to 16 years (mean, 5.1 years), and 5-year actuarial survival rate, including hospital deaths, was 84% +/- 4%. The 5-year survival rate was decreased in patients who had operative procedures other than myectomy/myotomy (69% versus 91%, p less than 0.005) and in patients aged 65 years or older (54% versus 93%, p less than 0.005). No correlation was found between preoperative symptoms, functional class, left ventricle-aorta pressure gradient, or mitral valve insufficiency and operative or late mortality. Preoperative symptoms were relieved in 57 (76%) of 75 patients with dyspnea, 49 (83%) of 59 patients with angina, and 22 (96%) of 23 patients with syncope. This experience confirms the effectiveness of operation for relief of symptoms in patients with the obstructive form of hypertrophic cardiomyopathy. The current operative mortality rate is low, especially in patients less than 65 years of age (1.2%). Our experience suggests that incomplete relief of left ventricular outflow obstruction may increase the risk of early postoperative death.

Adolescent↗
PubMed1989

Results of operation for hypertrophic obstructive cardiomyopathy in children and adults less than 40 years of age.

Forty-seven consecutive patients aged 1-38 years underwent operation for hypertrophic obstructive cardiomyopathy (HOCM) between 1972 and 1986. Isolated myectomy-myotomy was performed in 43 patients, three patients underwent myectomy and concomitant aortic valve repair, and one patient underwent concomitant mitral valve replacement. The peak systolic pressure gradient from the left ventricle to the aorta decreased from 70 +/- 33 mm Hg (mean +/- SEM) preoperatively to 10 +/- 15 mm Hg immediately after repair (p less than 0.001). Moderate or severe mitral insufficiency was identified in 16 patients preoperatively and was corrected by myectomy alone in 15. There was no operative mortality; two late deaths occurred during follow-up (median, 5 years; maximum, 16 years) for estimated 5- and 10-year survivals of 97 +/- 2% and 88 +/- 10%, respectively. Reoperation was required for aortic valve replacement (n = 2), remyectomy (n = 2), and permanent pacemaker implantation (n = 3). Preoperative symptoms were relieved in 24 of 29 (83%) patients with dyspnea, in 18 of 19 (95%) with angina, and in six of 10 (60%) with syncope. These results support myectomy-myotomy for symptomatic children and young adults with HOCM. Also, it appears that late survival after myectomy-myotomy in these young patients may be improved over that observed in historical controls treated with medications alone; operation should be considered for asymptomatic children and adults less than 40 years of age with large (greater than 80 mm Hg) left ventricular outflow gradients.

Adolescent↗
PubMed1989

Glenn shunt: effect on pleural drainage after modified Fontan operation.

After the Fontan operation, patients who had a prior Glenn anastomosis should have less pleural drainage than patients without a prior Glenn anastomosis because innominate and pleural vein and thoracic duct pressures are unaltered in the former group. To test this hypothesis, we studied 92 patients who had had a Fontan operation between 1973 and 1986--46 with a prior Glenn anastomosis and 46 without a prior Glenn anastomosis (controls)--who were matched for age, gender, diagnosis, and number of prior shunt operations. The volume of pleural drainage was significantly less (p less than 0.05) in the patients with a prior Glenn anastomosis (median 1,959 ml or 48.2 ml/kg) than in the control patients (median, 3,220 ml or 83.4 ml/kg). Similar results were obtained among the patients matched for prior right thoracotomy (n = 28; 1,270 ml and 2,942 ml; p = 0.028). There was no significant difference between the two groups with respect to ventricular end-diastolic pressure, mean right atrial pressure, mean pulmonary artery pressure, duration of total or differential (right side versus left side) effusion, duration of hospital stay, or hospital or late death.

Adolescent↗
PubMed1988

Results of the modified Fontan operation in adults.

The results of the modified Fontan procedure were examined in 77 patients 18 years of age and older who underwent operation at this institution between October 1973 and December 1986. This series represents 16% of the patients undergoing the modified Fontan operation during that period. Of the 77 patients (46 men and 31 women), 29 had tricuspid atresia, 30 had double-inlet ventricle and 18 had other complex lesions. There were 5 (6%) hospital deaths, compared with 67 (17%) for patients of all ages undergoing the Fontan operation during the same period. Patient age 18 years and older was not a significant risk factor. There were 8 late deaths. Detailed follow-up data were available on 61 (95%) survivors from 5 months to 12 years (mean 4 years) postoperatively. Fifty-seven (93%) of the patients were in New York Heart Association class I or II, 20 (33%) were taking no medication and 11 (18%) were taking digoxin alone. Seventeen (28%) patients complained of persistent ascites or edema. The study indicated that (1) the modified Fontan operation can be performed with low mortality in adults, (2) the long-term outcome is favorable and (3) persistent ascites or edema may be a problem in some patients.

Adolescent↗
PubMed1988

Impact of two-dimensional and Doppler echocardiography on care of children aged two years and younger.

To determine the impact of 2-dimensional (2-D) and Doppler echocardiography on the care of children aged 2 years and younger with suspected cardiac disease, the clinical management and outcome for the years 1975 (pre-2-D/Doppler era, 161 patients) and 1985 (2-D/Doppler era, 206 patients) were compared. Differences were: (1) decreased catheterization at our institution (48% vs 21%, p less than 0.0001); (2) trend toward decreased recatheterization of patients with referral catheterization (62% vs 38%, p = 0.08); (3) increased operation without preoperative catheterization (10% vs 37%, p less than 0.001); and (4) decreased preoperative catheterization for 7 anomalies (patent ductus arteriosus, ventricular septal defect, atrial septal defect, atrioventricular canal, aortic stenosis, tetralogy of Fallot and complete transposition of great arteries). Operative mortality rates were not statistically different in the years compared. Also, the operative mortality rates in 1985 for patients with and without preoperative catheterization were not statistically different. In 1975, cardiac catheterization changed the primary clinical diagnosis in 21%. In 1985, the primary diagnosis was not changed by catheterization; however, 2-D and Doppler echocardiography changed the diagnosis in 18%. The change in utilization of cardiac catheterization appears to be most closely related to the maximal utilization of a substitute imaging and hemodynamic modality--namely, 2-D and Doppler echocardiography.

Cardiac Catheterization↗
PubMed1988

Pulmonary valve insertion during reoperation for tetralogy of Fallot.

Our experience with pulmonary valve insertion during reoperation for residual lesions after initial open repair of tetralogy of Fallot in 15 patients is reported. Preoperatively, 14 patients were in moderate to severe congestive heart failure, and all 15 had decreased right ventricular (RV) function at cardiac catheterization. All 15 patients had pulmonary insufficiency but not as an isolated finding. The most common residual lesions encountered were ventricular septal defect in 9, tricuspid insufficiency in 11, and peripheral pulmonary arterial stenosis in 6. Tissue valves were inserted in all patients. Mean peak RV-left ventricular pressure ratio measured in the operating room decreased from 0.61 +/- 0.10 (+/- the standard deviation) to 0.47 +/- 0.17 (p less than 0.05). There were no operative deaths. At follow-up (mean, 33 months), all but 1 patient were in New York Heart Association Class I or II. Pulmonary valve insertion should be considered during reoperation for tetralogy of Fallot when pulmonary insufficiency and RV failure are present.

Adult↗
PubMed1988

Chest pain in a young woman.

Chest pain in a young person is often caused by chest wall tenderness, associated with mitral valve prolapse, or attributed to psychologic factors. Ischemic cardiac pain may be overlooked because of its rare occurrence in this age group. A 35-year-old woman complained of substernal chest pressure precipitated by exertion and relieved by rest. The symptom had been noted for 15 years. Worsening of the symptom during dancing prompted her to seek medical advice. She had no other illnesses, was taking no medications, was a nonsmoker, and had no family history of coronary disease. Physical examination disclosed a grade 1 (on the basis of 1 to 6) systolic ejection murmur, an ejection click, and a grade 2 diastolic murmur. An exercise test produced symptoms at 4 minutes. Coronary arteriography showed the absence of a left coronary ostium and filling of the entire coronary system from the right ostial injection through collateral vessels from the right coronary artery. Surgical repair was recommended. Operative intervention showed a dysplastic bicuspid aortic valve with a membrane that covered the left coronary ostium. Excision of the membrane reestablished antegrade blood flow to the left coronary system. A follow-up exercise test revealed normal findings. Because chest pain in a young person is rarely ischemic in origin, benign or noncardiac causes are usually considered; however, if the history suggests ischemic pain, the possible presence of unusual cardiovascular abnormalities should not be disregarded.

Adult↗
PubMed1988

Modified Fontan procedure for biventricular hearts with complex forms of double-outlet right ventricle.

The surgical management of patients with biventricular hearts and complex double-outlet right ventricle with noncommitted ventricular septal defect, hypoplastic ventricles, common atrioventricular orifice, straddling tricuspid valve, and straddling mitral valves is controversial. More recently at our institution, 23 of these patients underwent Fontan-type procedures as an alternative to the intraventricular tunnel repair. In all cases, the presence of more than one associated anomaly would have prevented adequate biventricular correction. The ventricular septal defects were of the inlet type in 14 patients, inlet and subpulmonary in one, multiple in one, subpulmonary in three, and subaortic in four. Twenty-one patients had atrioventricular junction anomalies, and 14 had hypoplastic ventricles (left ventricle in 11 and right ventricle in three). Pulmonary stenosis was present in 13 patients and pulmonary atresia in two. At operation, an extracardiac conduit was used in two patients and an atriopulmonary direct anastomosis in 21. There were six hospital deaths (26%). Seventeen patients had a mean follow-up period of 25 months. At the follow-up evaluation, nine patients were assigned to New York Heart Association Class I and seven to Class II; one patient assigned to Class IV died at 9 months postoperatively. Cumulative mortality was 30.4% (seven deaths). Univariate analysis identified hypoplastic left ventricle with any type of ventricular septal defect and atrioventricular junction as the only incremental risk factor for early and late outcome (p less than 0.01), which also influenced functional status and use of drug therapy (p less than 0.01) at the time of follow-up.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1988

Surgical pathology of the truncal valve: a study of 12 cases.

The truncal valves of 12 patients (eight females and four males) who had undergone valve replacement were studied. The patients ranged in age from 14 months to 21 years (mean, 10 years). All truncal valves were purely regurgitant: nine were severe, two were moderate, and one was mild. Eight of the valves were tricuspid, two were bicuspid, one was quadricuspid, and one was unicommissural. Each valve was thickened, but none was the site of endocarditis. The thickening tended to be greatest along the distal portion of each cusp and resulted primarily from expansion of the spongiosa and fibrosa layers. In seven of the 12 valves, the spongiosa disrupted the fibrosa. In 11 valves, fibrous pads were also observed along the cuspid surfaces. These histopathologic features are indistinguishable from those described for floppy mitral valves and support the concept that floppy valves may result from a congenital abnormality in valvular structure.

Adolescent↗
PubMed1988

Surgical pathology of the common atrioventricular valve: a study of 11 cases.

Eleven patients (six females and five males) underwent partial or complete excision of common atrioventricular valves. Their ages ranged from 11 months to 23 years (mean, 8 years). Six patients had complex congenital heart disease: three with asplenia, two with polysplenia, and one with a hypoplastic left ventricle and severe pulmonary stenosis. Pure regurgitation characterized all 11 valves and was severe in eight. Neither active nor healed endocarditis was observed in any valve. Of the 11 valves, nine were thickened, and eight had features of floppy valves, including hooding deformity, inadequate chordal insertions, and disruption of the fibrosa by the spongiosa. In ten valves fibrous pads also involved the leaflet surfaces. These observations support the concept that floppy valves may result from congenital abnormalities in valvular development.

Adolescent↗
PubMed1988

Intraoperative two-dimensional Doppler echocardiography. A preliminary study for congenital heart disease.

Intraoperative two-dimensional echocardiograms were performed in 30 patients (group I) and two-dimensional Doppler color flow imaging was performed in 30 additional patients (group II) with various forms of congenital heart disease. A comparative complete two-dimensional Doppler and color flow examination was performed in group II patients 10 to 14 days postoperatively. Standard intraoperative two-dimensional echocardiograms demonstrated excellent correlation with preoperative findings and allowed assessment of valvular regurgitation or shunt when combined with echocardiographic contrast injections. However, intraoperative and postoperative two-dimensional color flow imaging was obtained more easily and rapidly and allowed recognition of more postoperative residual defects. Color flow imaging appears to be a useful method for intraoperative assessment of surgical repair of congenital cardiac defects. Twenty-one residual lesions were correctly diagnosed intraoperatively, whereas seven residual lesions were demonstrated only during later postoperative examination. This preliminary experience has also demonstrated several areas for future development and improvement of these techniques. Combined two-dimensional Doppler and contrast echocardiographic studies may allow better disclosure of residual defects.

Adolescent↗