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Biomedical subjects

F J Puga

Publications and source records attributed to F J Puga.

At least 127 records · Page 7Linked to original sources
PubMed1985

Truncus arteriosus with single pulmonary artery: influence of pulmonary vascular obstructive disease on early and late operative results.

Nineteen patients with truncus arteriosus and single pulmonary artery had corrective operations at the Mayo Clinic from 1969 to 1983. At operation, their ages ranged from 4 months to 20 years (mean 8.1 years). The preoperative pulmonary resistance divided by 2 was used to predict the degree of pulmonary vascular obstructive disease at operation. The influence of elevated pulmonary resistance and the intraoperative postrepair ratio of pulmonary artery to left ventricular pressure on operative and late mortality were examined. The outcome of patients with single pulmonary artery was compared with the outcome of 148 patients with truncus arteriosus and two pulmonary arteries operated on during the same period. Patients with a single pulmonary artery had an operative mortality similar to that of patients with two pulmonary arteries (32 versus 28%, p greater than 0.05). Late mortality was, however, significantly greater (p less than 0.001) for patients with a single pulmonary artery. Elevated ratios of intraoperative postrepair pulmonary artery to left ventricular pressure were associated with significantly higher (p less than 0.02) operative and late mortality, but elevated preoperative pulmonary resistance was not (p greater than 0.10). Truncus arteriosus with single pulmonary artery is associated with poor postoperative survival, and although elevated pulmonary resistances preoperatively did not predict outcome, elevated intraoperative postrepair pulmonary artery to left ventricular pressure ratios were associated with increased operative and late survival, suggesting a deleterious role of pulmonary hypertension.

Adolescent↗
PubMed1985

Total correction of tetralogy of Fallot at age 40 years and older: long-term follow-up.

Whether total surgical correction of tetralogy of Fallot in adults aged 40 years old or older has acceptable operative risk and gratifying long-term results is unknown. The Mayo Clinic experience (June 1960 to May 1982) with 30 patients 40 to 60 years old (mean 47) who had total surgical correction of tetralogy of Fallot was reviewed. Preoperatively, 4 patients (13%) were in functional class I, 9 (30%) in class II and 17 (57%) in classes III and IV. Eight patients (27%) had had preoperative complications: five had a cerebrovascular accident and three had infective endocarditis. Only 11 patients (37%) had had palliative surgery 16 to 34 years (mean 22) before total surgical correction. Total surgical correction was successful in all patients. Right ventricular to left ventricular (RV/LV) pressure ratio of 0.65 or less was achieved in 28 (93%) of the 30 patients. One patient died of ventricular fibrillation (RV/LV ratio = 0.8) 2 days postoperatively, one had complete heart block and one had a cerebrovascular accident 7 days after operation. At follow-up of 5 to 266 months (mean 110), there were seven late deaths: two sudden at 5 and 21 years, respectively, after operation, one from myocardial infarction at 11 years, one from cerebrovascular accident at 11 years, one from congestive heart failure (RV/LV ratio = 1.0) at 8 years and two from noncardiac causes. Of the 22 patients who survived, 16 are in class I, 5 are in class II and 1 is in class III.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1985

Pulmonary blood supply in patients with pulmonary atresia and ventricular septal defect.

The heart and lung specimens in 31 cases of pulmonary value atresia and ventricular septal defect were studied at autopsy. Three types of natural arterial blood supply to the lungs were identified: 1) ductus arteriosus (patient or ligamentous) (12 cases); 2) major collateral arteries (20 cases); and 3) diffuse small pleural arterial plexus coexisting with either ductus arteriosus or major collateral arteries (17 cases). The ductus arteriosus and major collateral arteries did not coexist in the same lung in these cases. Confluent central pulmonary arteries were present in 22 (71%) of the 31 cases, involving 7 (58%) of the 12 cases of ductus arteriosus, 14 (70%) of the 20 cases with major collateral arteries and 1 case with an aorticopulmonary window. The pulmonary trunk (atretic or patent) was identifiable in 24 (77%) of the 31 cases. A lung or lungs that connected to a ductus (or ligamentum) had a complete and unifocal intrapulmonary arterial distribution (without arborization abnormalities). Major collateral blood supply was frequently multifocal and associated with arborization abnormalities. The size of the central pulmonary arteries was not related to the type of arterial blood source but seemed to be related to the amount of blood flow actually reaching the vessels, This study demonstrated a complex systemic arterial system supplying the lungs in these cases. The size, sources and relation among the ductus, the pulmonary artery confluence, the large and small collateral vessels and the intrapulmonary system are far more varied than has ever been reported previously. Careful and thorough premortem studies are crucial if surgical intervention is contemplated.

Adolescent↗
PubMed1985

Results of the modified Fontan operation for congenital heart lesions in patients without preoperative sinus rhythm.

Preoperative sinus rhythm has been a criterion for the Fontan operation. However, of 297 patients who underwent the Fontan operation between October 1973 and February 1984, 12 (4%) did not have sinus rhythm. The age at operation ranged from 4 to 34 years (median 15). Nine patients had a univentricular heart, two had tricuspid atresia and one had a complex form of transposition. In all 12 patients, 3 to 8 of the 10 proposed criteria for operability were not met. An atrioventricular (AV) conduction abnormality was present in seven patients, six with complete AV block and one with AV dissociation. The patient with complex transposition had complete AV block and atrial fibrillation. Postoperatively, all seven patients continued to have an AV conduction abnormality, and those with complete AV block had a permanent pacemaker implanted. Six of the 12 study patients had atrial flutter or fibrillation refractory to antiarrhythmic medications. Postoperatively, four of the six patients had sinus rhythm. Two of the six patients had complete AV block (including the patient with complex transposition) and both had a permanent pacemaker implanted. Three of the 12 patients died (mortality rate 25%). The nine survivors were followed up for 6 to 55 months; no late deaths occurred. All had marked clinical improvement. This study demonstrates that 1) complete AV block is not a contraindication to the Fontan operation, 2) some patients may not require AV synchrony postoperatively for survival, and 3) postoperative atrial flutter or fibrillation may cease or be easier to control after the Fontan operation.

Adolescent↗
PubMed1985

Results of triple valve replacement in 91 patients: perioperative mortality and long-term follow-up.

Between 1961 and 1984, 91 patients underwent simultaneous triple valve replacement at the Mayo Clinic. Of the 273 prosthetic valves used, 77% were Starr-Edwards. Perioperative (30 day) mortality was 24% to 27% between 1962 and 1974 and 7% between 1975 and 1983 (p = .17). In patients with NYHA class IV symptoms, perioperative mortality was 44%, and in those with milder symptoms, it was 8% (p less than .0001). The median follow-up was 7.5 years (range, 6 weeks to 20 years). Cumulative survival, which was calculated taking into consideration perioperative mortality, was 64% at 1 year, 55% at 5 years, 40% at 10 years, and 25% at 15 years. Multivariate analysis identified preoperative functional class and age as predictors of late survival. Among causes of late mortality were sudden death in 32.5%, congestive heart failure in 15%, thromboembolism in 12.5%, prosthetic valve dysfunction in 7.5%, and infective endocarditis in 5%. Late complications included systemic emboli in 42% (embolic rate, 12.3 events per 100 patient-years), bleeding in 22%, myocardial infarction in 16%, and infective endocarditis in 6%. Eight patients required reoperation for prosthetic valve dysfunction, and 12 patients had permanent pacemakers. Of the 29 patients still alive, 79% are in NYHA class I or II. In summary, perioperative mortality after triple valve replacement appears to be declining; long-term survival in 30 day survivors is similar to that after single valve replacement and excellent symptomatic improvement can be obtained, although morbidity is high.

Aortic Valve↗
PubMed1985

Two-dimensional echocardiographic detection of mediastinal pheochromocytoma.

A patient had a functioning pheochromocytoma in the aorticopulmonary region of the middle mediastinum. Two-dimensional echocardiography, utilizing the suprasternal approach, was useful in detecting the tumor and in defining its anatomic relationships to other vascular structures within the mediastinum.

Adult↗
PubMed1985

Cardiorespiratory response to exercise after repair of tetralogy of Fallot.

We studied 24 patients who had a graded exercise test 1 to 16 years after correction of tetralogy of Fallot. Maximal oxygen consumption was subnormal in 19 of the patients. We found no relationship between age at repair, postoperative right ventricular pressure, right ventricular-to-pulmonary artery pressure gradient, or ratio of right ventricular and left ventricular pressure and degree of exercise intolerance. The stroke volume response to exercise was normal in only three of eight patients. Twenty-five percent of patients had arrhythmia just prior to, during, or after exercise. The arrhythmias were independent of the factors of age at repair, age at exercise, previous operation, presence of an outflow tract patch, or residual right ventricular outflow tract obstruction. The ventilatory responses to exercise were normal. Persistent exercise intolerance may be due, in part, to abnormal ventricular function.

Journal Article↗
PubMed1985

Early and late results of pericardiectomy for constrictive pericarditis.

Records of 231 patients (171 males, 60 females; aged 10 months to 83 years [median 45 years]) who underwent operation for constrictive pericarditis at the Mayo Clinic from 1936 through 1982 were reviewed. All had had hemodynamically significant pericardial constriction preoperatively, and pericardial disease was confirmed at operation. Preoperatively, 69% were in New York Heart Association Class III or IV and 81% had peripheral edema or ascites. Pericardiectomy was performed through a left anterolateral thoracotomy (34%), a median sternotomy (27%), a U incision (Harrington) (21%), or a bilateral anterior thoracotomy (18%). Postoperatively, 28% of patients had evidence of low cardiac output; 70% of the 32 deaths within 30 days of operation were due to low cardiac output. Operative risk was significantly (p less than 0.001) related to preoperative disability (1% for Class I or II; 10% for class III; 46% for Class IV). Median postoperative follow-up was 9 years (longest was 43 years). Probability of survival for patients dismissed alive from the hospital was 84% at 5 years, 71% at 15 years, and 52% at 30 years. Long-term survival (excluding operative mortality) was not significantly influenced by the disability class preoperatively, the operative approach, or the development of low cardiac output in the immediate postoperative period. At the end of the follow-up interval, there were 141 patients in whom functional capacity could be assessed; 140 were in Class I or II. We conclude that a poor hemodynamic result after complete pericardiectomy relates to the preoperative degree of constriction and resultant cardiomyopathy. We recommend early pericardiectomy when pericardial constriction is diagnosed, and we continue to use a left anterolateral thoracotomy as the preferred approach for most patients.

Adolescent↗
PubMed1985

Fifteen-year experience with surgical repair of truncus arteriosus.

From 1965 until March, 1982, 167 patients underwent surgical repair of truncus arteriosus. The age at operation ranged from 18 days to 33 years (mean 6 years). There were 48 hospital deaths (28.7%). The following factors had a positive correlation with the possibility of a surgical death: age at operation less than 2 years (p less than 0.001), a postrepair pulmonary arterial/left ventricular pressure ratio greater than 0.5 for patients with two pulmonary arteries (p less than 0.001) and greater than 0.6 for patients with unilateral absence of a pulmonary artery (p less than 0.02), and a postrepair right ventricular/left ventricular pressure ratio greater than 0.8 (p less than 0.008). The 119 hospital survivors were followed up for a total of 829 person-years. Late survival rate at 5 years was 84.4% and at 10 years, 68.8%. Preoperative factors that correlated with a reduced long-term survival rate were as follows: increasing age at operation (p = 0.004), the presence of moderate or severe truncal valve insufficiency (p = 0.008), lower pulmonary/systemic flow ratio (p = 0.04), and unilateral absence of a pulmonary artery (p less than 0.001). Thirty-six patients required reoperation during the follow-up period (30%) primarily for replacement of the right ventricular-pulmonary arterial conduit and/or for truncal valve replacement. The long-term results obtained in these patients support the need for early repair of the anomaly, improvement in the methods for control or repair of the truncal valve insufficiency, and the continued search for better extracardiac valved conduits.

Adolescent↗
PubMed1985

Replacement of obstructed right ventricular-pulmonary arterial valved conduits with nonvalved conduits in children.

Six to thirty percent of right ventricular-to-pulmonary arterial (RV-PA) valved conduits in children fail within 5 years. Experience with correction of tetralogy of Fallot has shown that a competent pulmonary valve is not essential for excellent late results in most patients. Between March 1980 and November 1984, 26 patients who were 12.5 +/- 3.3 years old underwent conduit replacement 6.7 +/- 2.4 years after definitive repair of congenital heart defects in which a xenograft RV-PA valved conduit had been used. A new Dacron tube graft (n = 15) or pericardial (n = 8), dura mater (n = 2), or Dacron patch (n = 1) over the previous conduit bed was used as replacement. Preoperative mean right ventricular systolic pressure was 90.5 +/- 20 mm Hg and mean gradient across the conduit was 67.9 +/- 24.5 mm Hg. After replacement with a nonvalved conduit, right ventricular systolic pressure was reduced to 45.2 +/- 10.8 mm Hg (p less than .001), with a gradient of 8.9 +/- 7.6 mm Hg (p less than .001). There were no operative deaths. Follow-up at 19.5 +/- 14.9 months (range = 0 to 53) showed that all patients were in New York Heart Association class I (n = 21) or class II (n = 5). In the absence of pulmonary hypertension, hypoplastic pulmonary arteries, significant right ventricular dysfunction, or unrepaired tricuspid regurgitation, replacement of an obstructed conduit with a nonvalved conduit gives excellent early results and may diminish the need for late reoperation.

Adolescent↗
PubMed1985

Outcome of the Fontan procedure in patients with tricuspid atresia.

Between 1973 and 1983, 90 patients with tricuspid atresia underwent the Fontan operation at the Mayo Clinic. Operative mortality was 12% overall and decreased to 7% during the second 5 year period. At postoperative follow-up of 65 patients (1 to 10 years, mean 4), 50 (86%) of 58 present survivors were in excellent condition. There had been seven late deaths. Catheterization 0.5 to 8 years (mean 2.7) postoperatively in 25 patients disclosed a mean right atrial pressure of 14 mm Hg (range 6 to 21) and a mean cardiac index at rest of 3.0 (range 1.8 to 4.2). Mean left ventricular end-diastolic pressure was 8.5 mm Hg postoperatively compared with 16.5 mm Hg preoperatively; the decrease was secondary to a decreased ventricular volume load (mean volume load index 10.2 preoperatively, 3.0 postoperatively). We recommend that patients with tricuspid atresia have the Fontan operation by age 6 years to protect myocardial function.

Adolescent↗
PubMed1985

Relationship of pulmonary artery size to mortality in patients undergoing the Fontan operation.

The size of the pulmonary arteries, measured intraoperatively, was correlated with operative mortality in 90 patients who underwent the Fontan operation. There was no significant difference in the cross-sectional area of the right and left pulmonary arteries/body surface area (PA index) between survivors and nonsurvivors. There was no significant difference in mortality rates between patients with a PA index greater than 250 and those with a PA index less than 250 mm2/m2. Survival was observed with cross-sectional area as low as 188 mm2/m2.

Adolescent↗
PubMed1985

Surgical management of effusive pericardial disease. Influence of extent of pericardial resection on clinical course.

Surgical drainage for effusive pericardial disease is usually accompanied by pericardial resection to obtain tissue for analysis and to lessen the chance of recurrent effusion or late constriction. The purpose of this study was to determine the relationship between the extent of resection and the development of late complications. From 1960 through 1983, 145 patients with pure pericardial effusive disease underwent operative drainage. The effusions were malignant in 72 patients (49.7%) and benign in 73 (50.3%). The patients were divided into three groups according to the extent of resection: complete in 72 patients (49.7%), partial in 36 (24.8%), and window in 37 (25.5%). The 30 day mortality was 19.4% for patients with malignant effusions and 5.5% for those with benign effusions (p less than 0.05). All survivors had immediate improvement in symptoms. The actuarial 1 year survival rate was 23.4% (mean 4.2 months) for patients with malignant disease and 85.6% for patients with idiopathic effusions (p less than 0.001). Survival was not influenced by the extent of resection. Fifteen patients (10.3%) had late constriction or recurrent effusion. Six of these required reoperation, all after having had a window procedure. Actuarial probability of reoperation or late complication was greater with window procedures than other resections, both for all patients (p = 0.0001) and for those with benign disease (p = 0.0001). Transthoracic complete pericardiectomy is the procedure of choice for effusive pericardial disease. Subxiphoid drainage has immediate advantages for selected patients but has a statistically greater chance of late complications.

Adolescent↗
PubMed1985

Concomitant cardiac and pulmonary operations.

From 1965 through 1983, 43 patients underwent concomitant cardiac and pulmonary procedures at our institution. Most patients presented with cardiac symptoms and were incidentally found to have a roentgenographically indeterminate lung nodule. The pulmonary diagnosis of 38 patients was unknown preoperatively, and nine of these had a malignant lesion. All 43 cardiac procedures necessitated extracorporeal circulation. Thirty-one patients had benign pulmonary disease, 10 had bronchogenic carcinoma, and two had metastatic carcinoma. Concomitant pulmonary procedures were performed via median sternotomy and included single wedge resections in 32 patients, lobectomy in seven, multiple wedge resections in three, and pneumonectomy in one. Most resections were performed either before or after institution of bypass, without systemic anticoagulation. Of the two operative deaths (4.6%), one was related to intraparenchymal pulmonary hemorrhage after multiple wedge resections during anticoagulation. Thus, pulmonary resections performed during anticoagulation may be associated with increased risk and probably should be avoided. The second death was cardiac in origin and not related to pulmonary resection. The remaining patients recovered uneventfully. Definitive correction of both cardiac and pulmonary disease can be performed at one operation via a single incision with safety and benefit to the carefully selected patient.

Adolescent↗
PubMed1985

Surgical treatment of double-orifice mitral valve in atrioventricular canal defects. Experience in 25 patients.

Double-orifice mitral valve is an uncommon but surgically important condition. The experience in 25 cases of double-orifice mitral valve associated with atrioventricular canal defects was reviewed. This constituted 4.3% of the 581 cases of atrioventricular canal defects operated upon between 1961 and July, 1984. The combined mitral orifice area ranged from 85% to 91% of normal in those patients whose valves were sized intraoperatively. Ten associated cardiac defects were repaired in six patients. Of 23 patients having cleft mitral valve, 21 had partial closure of the cleft. There was one operative death (4.0%), which occurred early in the series in a patient in whom the tissue bridge was severed and massive mitral regurgitation resulted. In the remaining 24 patients the tissue bridge was left intact, and all survived operation. No patient had clinically significant mitral stenosis during a follow-up of 1 to 14 years (mean 4.9 years). Two patients (8%) developed progressive mitral regurgitation and required mitral valve replacement 3 and 11 years postoperatively. One of these patients died and a second death occurred suddenly 2 years following operation. All survivors are in Functional Class I or II. The noncleft orifice of a double-orifice mitral valve usually is competent and rarely requires closure. The cleft, because it constitutes a type of parachute (single papillary muscle) valve, should be closed partially so as to relieve valve incompetence without causing undue stenosis. The incidence of late development of mitral regurgitation is similar to that of atrioventricular canal without double-orifice mitral valve. Repair of atrioventricular canal associated with double-orifice mitral valve can be achieved with a low operative mortality and excellent late results.

Adolescent↗
PubMed1984

Effect of dipyridamole and aspirin on late vein-graft patency after coronary bypass operations.

To study the prevention of occlusion of aortocoronary-artery bypass grafts, we concluded a prospective, randomized, double-blind trial comparing long-term administration of dipyridamole (begun two days before operation) plus aspirin (begun seven hours after operation) with placebo in 407 patients. Results at one month showed a reduction in the rate of graft occlusion in patients receiving dipyridamole and aspirin. At vein-graft angiography performed in 343 patients (84 per cent) 11 to 18 months (median, 12 months) after operation, 11 per cent of 478 vein-graft distal anastomoses were occluded in the treated group, and 25 per cent of 486 were occluded in the placebo group. The proportion of patients with one or more distal anastomoses occluded was 22 per cent of 171 patients in the treated group and 47 per cent of 172 in the placebo group. All grafts were patent within a month of operation in 94 patients in the placebo group and 116 patients in the treated group; late development of occlusions was reduced from 27 per cent in the placebo group to 16 per cent in the treatment group. The results show that dipyridamole and aspirin continue to be effective in preventing vein-graft occlusion late after operation, and we believe that such treatment should be continued for at least one year.

Adult↗
PubMed1984

Results of the Damus-Stansel-Kaye procedure for transposition of the great arteries and for double-outlet right ventricle with subpulmonary ventricular septal defect.

From 1975 through 1982, the Damus-Stansel-Kaye procedure was performed on 20 patients with complete transposition of the great arteries (TGA) and on 4 with double-outlet right ventricle (DORV) and subpulmonary ventricular septal defect (VSD). The patients ranged from 6 days to 20 years old (median age, 13 months). Associated anomalies included atrial septal defect (24 patients), VSD (14), and others (25). Thirteen patients had had palliative operations previously. Of the 14 hospital deaths (58%), 13 occurred among the 17 patients with one or more risk factors: age less than 18 months, weight less than 10 kg, and left ventricular peak systolic pressure less than 75% of systemic pressure. Follow-up ranged from 12 to 87 months (mean, 51 months). One patient died of cardiac failure two years postoperatively, and 2 required conduit replacement at 40 and 50 months because of stenosis. All 9 survivors are free from major symptoms. The Damus-Stansel-Kaye repair is most suitable for patients with TGA or DORV with subpulmonary VSD who are older than 18 months, weight more than 10 kg, and have a "prepared left ventricle," and whose coronary artery anatomy precludes transplantation.

Adolescent↗