Search PubMed⌕ Search

Biomedical subjects

G J Reul

Publications and source records attributed to G J Reul.

At least 55 records · Page 3Linked to original sources
PubMed1990

Role of perfusion pressure and flow in major organ dysfunction after cardiopulmonary bypass.

The role of perfusion pressure and flow during cardiopulmonary bypass with moderate hypothermia and hemodilution in the development of new postoperative renal or clinically apparent cerebral dysfunction was examined in 504 adults. Cardiopulmonary bypass flow was targeted at greater than 40 mL.kg-1.min-1 and pressure at greater than 50 mm Hg. Flows and pressures less than target occurred in 21.6% and 97.1% of patients, respectively. Fifteen patients (3.0%) suffered new renal and 13 (2.6%) new central nervous system dysfunction. Low pressure or flow during cardiopulmonary bypass, expressed in absolute values or in intensity-duration units, were not predictors of either adverse outcome. Multivariate analysis identified use of postoperative intraaortic balloon counterpulsation (p less than 10(-6], excessive blood loss in the ICU (p less than 10(-4], need for vasopressors before cardiopulmonary bypass (p less than 10(-4], postoperative myocardial infarction (p less than 10(-3], emergency reoperation (p less than 0.002), excessive postoperative transfusion (p less than 0.02), and chronic renal disease (p less than 0.03) as independent predictors of postoperative renal dysfunction. Independent predictors of postoperative central nervous system dysfunction were cardiopulmonary resuscitation in the intensive care unit (p less than 10(-6], intracardiac thrombus or valve calcification (p less than 0.02), and chronic renal disease (p less than 0.03). Age greater than 65 years (40.7% of patients) did not predict either outcome. We conclude that failure of the native circulation during periods other than cardiopulmonary bypass rather than the flows and pressures considered here is the major cause of renal and clinically apparent central nervous system dysfunction after cardiac operations.

Adult↗
PubMed1990

Modified total cavopulmonary connection: an alternative approach in the presence of left superior vena cava.

A technical modification to the total cavopulmonary connection in the presence of left superior vena cava (LSVC) is described. Systemic venous to pulmonary artery continuity is achieved by direct anastomosis of the right superior vena cava (RSVC) to the right pulmonary artery. Blood from the inferior vena cava (IVC) is diverted by an intraatrial baffle to the coronary sinus. The LSVC is then anastomosed to either the left pulmonary artery or the main pulmonary artery in an end-to-side or side-to-side manner. By using this technique, we maintain the basic principle of excluding the right atrial chamber from the systemic venous circuit, thereby reducing the potential obstructive complications that have been noted with other forms of complex intraatrial baffles. We have used this technique successfully in three patients with various forms of complex congenital cardiac defects.

Adolescent↗
PubMed1990

Lower extremity pain after sexual intercourse: a case report of embolization due to femorofemoral bypass graft occlusion.

We describe a case of recurrent thromboembolism to the femoral-popliteal circulation in a patient with prior femorofemoral bypass graft placement. Two separate embolic events occurred, each within a short time after sexual intercourse. Normal circulation to the lower extremity was restored via percutaneous laser-assisted balloon angioplasty, but the source of emboli was corrected surgically via removal of the occluded femorofemoral graft. We propose that distal thrombosis in a patient with prior femorofemoral bypass may indicate an occluded graft as a source of embolization; therefore, consideration should be given to removal of the graft.

Journal Article↗
PubMed1989

Bioprosthetic versus mechanical valve replacement in patients with infective endocarditis.

During the 5-year period, 1979-1984, at the Texas Heart Institute, 4,598 patients underwent cardiac valve replacement procedures of which 185 were for acute infective endocarditis. Staphylococcus and streptococcus accounted for 80% of the cases and congestive heart failure was a leading indication in 63%. The purpose of this article is to evaluate the recurrence of endocarditis dependent upon whether the patient had an Ionescu-Shiley bioprosthetic pericardial valve or a mechanical valve (St. Jude Medical). Actuarial freedom from both early and late reoperation was higher for prosthetic valves than bioprosthetic valve patients. We conclude that mechanical valves are the valves of choice in acute infective endocarditis which apparently is the results of less biologic tissue available for exposure to infection by the offending organisms.

Actuarial Analysis↗
PubMed1988

Surgical management of extracranial carotid artery aneurysms: report of 17 cases.

This article reviews the operative techniques, results, and complications associated with the treatment of 17 extracranial carotid artery aneurysms encountered in an overall experience of 6,096 carotid endarterectomies during a 24-year period. All 17 patients were operated upon because of severe symptoms and the potential for stroke. Eight patients underwent an aneurysmorrhaphy with Dacron-patch angioplasty; 7 had resection of the aneurysm, with end-to-end anastomosis and Dacron-patch angioplasty; and 2 underwent clipping of the aneurysm. There was 1 hospital death, in the case of a patient who sustained a postoperative myocardial infarction. Three patients had a postoperative neurologic deficit; this complication was permanent in 1 case and transient in 2. During long-term follow-up, no late stroke occurred; nevertheless, 3 patients died of a myocardial infarction, for an overall 5-year survival rate of 77%. On the basis of this study, we conclude that accessible aneurysms of the extracranial carotid artery can be excised with an acceptable morbidity and mortality.

Journal Article↗
PubMed1987

The management of aortoduodenal fistula by in situ replacement of the infected abdominal aortic graft.

Conventional surgical wisdom dictates the complete removal of infected abdominal aortic graft, oversewing of the aorta, and restoration of lower limb bloodflow by extra-anatomic bypass grafting. Dissatisfied with this approach because of the high incidence of local complications, mortality, and loss of limb, 20 patients with secondary aortoduodenal fistula had duodenal repair, excision of the old graft, and placement of a new graft in the same location. A similar technique was used in three patients with erosion of an aortic graft into the jejunum. Length of follow-up averaged 5.2 years, and was more than 1 year in each instance. Of the eighteen patients who survived the repair, three have had early recurrent rupture or false aneurysm of the proximal aortic anastomosis, with consequent death in two, but fifteen patients (83%) have had no further related problem. There was no loss of limb. Use of greater omentum as a protective barrier seemed helpful. Optimal antibiotic usage, and the idea that varying degrees of graft infection require different approaches, require further definition. In conclusion, in situ graft replacement is the correct operative strategy in this challenging group of patients.

Aorta, Abdominal↗
PubMed1987

Early experience with a new PTFE graft below the inguinal ligament.

Between July 1984 and July 1985, 65 expanded polytetrafluoroethylene grafts (Vitagraft) were implanted in the infrainguinal position in 51 patients, including 41 men and 10 women, with an average age of 63 years. The indications for surgery were severe claudication (36 grafts) or ischemic necrosis of the extremities (29 grafts). Thirteen of the patients (25%) had had a previously placed infrainguinal graft of another type that had failed, requiring reoperation. Proximal vascular reconstruction (consisting of ten aorto-femoral and two femoro-femoral bypasses) was performed in 12 patients who had 16 grafts. Simultaneous aortocoronary bypass surgery was done in conjunction with a femoral-popliteal bypass in six patients. The site of distal anastomosis was the suprageniculate popliteal artery in 21 grafts (32%), the infrageniculate popliteal artery in 33 grafts (51%), tibio-peroneal trunk in seven grafts (11%), and the posterior tibial artery in four grafts (6%). The mean follow-up was 9.6 months (range, 1 to 16 months). Two grafts (3.0%) failed early (< 30 days). Another three grafts (4.6%) occluded between 1 and 6 months postoperatively, and five occluded after 6 months. The cumulative patency rate at 15 months was 78.8%. Limb salvage was not possible in three patients, who underwent amputation because of multiple previous operations and a lack of distal run-off. There were no operative deaths, graft infections, aneurysms, or untoward reactions (including seromas) along the graft tracts. At this early follow-up date, we have not encountered the complications normally associated with other grafts; our early results indicate that continued clinical use is warranted.

Journal Article↗
PubMed1986

Durability and low thrombogenicity of the St. Jude Medical valve at 5-year follow-up.

Between November, 1978, and December, 1983, 736 patients had valve replacement with the St. Jude Medical valve prosthesis. There were 478 patients with aortic valve replacement (AVR), 188 with mitral valve replacement (MVR), 63 with double valve replacement, and 7 with tricuspid valve replacement (they were not included in this study). The mean age at the time of operation was 46.7 years for patients having AVR and 48.6 years for those having MVR and AVR + MVR. Follow-up totaled 1,116 patient-years (range, 4 to 82 months). Early (30-day) mortality was lowest for isolated MVR (2.3%) and AVR (3.7%), and increased with reoperation or when associated procedures were combined with valve replacement. Patients undergoing reoperation or having associated procedures made up 49% of the AVR and 54% of the MVR groups. All patients were advised of the need for long-term anticoagulation with warfarin sodium. Nine patients (7 with AVR, 1 with MVR, 1 with AVR + MVR) had suspected or confirmed episodes of systemic thromboembolism, a linearized incidence of 0.99% per patient-year for AVR, 0.36% per patient-year for MVR, and 0.98% per patient-year for AVR + MVR. Eight patients with AVR underwent reoperation for prosthetic valve endocarditis (5 of the 8 patients had endocarditis prior to initial valve replacement). There were no instances of structural valve failure. There were 37 late deaths. Actuarial survival at 5 years (excluding early mortality, 95% confidence limits) was 89.8% for AVR, 84.8% for MVR, and 95.2% for AVR + MVR.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMed1986

Addition of papaverine to cardioplegia does not reduce myocardial necrosis.

In a randomized, double-blind prospective study involving 495 patients, we investigated whether the addition of papaverine, 60 mg, to our existing regimen of cold cardioplegia would reduce myocardial necrosis during elective coronary artery bypass operations. Twenty-one (4.2%) patients sustained acute postoperative myocardial infarctions (MI), and 7 (1.4%) died during hospitalization. Neither MI nor death was related to papaverine supplementation. Among 469 patients without postoperative MI, levels of the myocardial-specific isoenzyme of creatine phosphokinase measured 10 hours after aortic cross-clamping were related to ischemic cross-clamp time, but not to papaverine supplementation of cardioplegia. At declamping after completion of distal anastomoses, ventricular fibrillation was more common after cardioplegia without papaverine (32% versus 9%). No other differences between the two groups were found in intraoperative and postoperative hemodynamics, difficulty of weaning from bypass, or postoperative volume requirements. We identified three risk factors for postoperative MI: ECG evidence of new ischemia prior to bypass, unusual technical difficulty with distal anastomoses for the surgeon, and prolonged time of ischemia. We conclude that addition of papaverine to our cardioplegia regimen did not affect outcome or nonspecific myocardial necrosis.

Clinical Trials as Topic↗
PubMed1986

Apicoaortic conduits for complex left ventricular outflow obstruction: 10-year experience.

We interposed valved conduits between the left ventricular apex and aorta in 38 patients over a 10-year period. Indications included tunnel subaortic stenosis, aortic annular hypoplasia, tubular supravalvular aortic hypoplasia, and severe calcification of the ascending aorta. Operative mortality was 11%, but 78% of the survivors were alive at 5 years, and 70% had had no major complication. The results were better in adolescents and adults than in young children. Although complications included calcific degeneration of the valve and disruption of the conduit at the site of insertion into the ventricular apex, we continue to believe in the utility of this procedure in a few patients with complex left ventricular outflow tract obstruction.

Adolescent↗
PubMed1986

The effect of coronary bypass on the outcome of peripheral vascular operations in 1093 patients.

One of the greatest risks in peripheral vascular operations is the presence of significant coronary artery disease. To assess the proper timing and demonstrate a possible protective effect of coronary artery bypass (CAB), 1093 patients who underwent one or more peripheral vascular operations in addition to CAB from 1976 through 1984 were analyzed. During that same period, 24,441 patients underwent CAB procedures, and 8530 patients underwent major vascular operations. Carotid endarterectomy (493 patients), abdominal aneurysm resection (130 patients), renal artery bypass (12 patients), aortofemoral bypass (77 patients), femoral-popliteal-tibial bypass (190 patients), and combined vascular procedures (191 patients) were included. The patients were divided into three groups according to severity of disease, which determined timing of the procedure. Group I (255 patients) underwent simultaneous CAB and peripheral vascular operation because of unstable coronary artery disease and severe vascular disease. The early mortality rate for group I was 4% (10 patients). Seven of the 10 deaths were cardiac. In group II, 279 patients had CAB and peripheral vascular operation during the same hospital admission with the same operative mortality rate (4%, 10 patients). Six deaths were from cardiac causes, three from neurologic causes, and one from hemorrhage. In group III, 559 patients underwent CAB first, then peripheral vascular operation during a separate hospital admission. There were no cardiac-related deaths and only one neurologic-related death (operative mortality rate, 0.2%). These data demonstrate the protective effect of CAB in patients who undergo elective vascular surgery. The increased risk in patients undergoing simultaneous or same admission procedures was related to the severity of the vascular and coronary artery disease and not to the combined operations. Operative complications were not increased by performing simultaneous or same admission procedures.

Actuarial Analysis↗
PubMed1986

Early and late results of coronary endarterectomy. Analysis of 3,369 patients.

The effectiveness of coronary revascularization has been questioned in patients with diffuse coronary disease. Over a 14 year period (1970 to 1984), 30,464 patients underwent surgical revascularization at our institution. Coronary artery bypass alone was done in 27,095 patients and was combined with coronary endarterectomy in 3,369 patients (12.4%). Analysis of preoperative variables revealed an increased incidence of male sex, diabetes mellitus, low ejection fraction (less than 30) and multiple vessel disease in patients requiring endarterectomy. The early results after revascularization indicated a small increase in surgical risk after endarterectomy. The 30 day mortality for bypass alone was 2.6% versus 4.4% for coronary endarterectomy (p less than 0.01). Multivariate analysis identified independent predictors of operative risk: ejection fraction less than 30%, reoperation, age, absence of hyperlipidemia, endarterectomy, and female sex. Early mortality was significantly increased by endarterectomy in the left anterior descending coronary artery (8.5%) compared to endarterectomy in arteries other than the left anterior descending (4.2%) (p less than 0.01). In a sample of 4,473 patients, myocardial complications were also found to be increased after coronary endarterectomy. The incidence of perioperative myocardial infarction in patients undergoing bypass alone was 2.6% versus 5.4% for patients undergoing bypass plus endarterectomy (p less than 0.01). Both fatal and nonfatal cardiac arrests increased (bypass alone, 1.7%; endarterectomy, 3.5%; p less than 0.01). This suggests the failure mode of unsuccessful endarterectomy. Early mortality after coronary endarterectomy decreased substantially from 1970-1976 (6.4%) to 1977-1984 (3.5%; p less than 0.01). Actuarial analysis at 5 years and longer has shown very little difference in the long-term survival rate (coronary bypass, 90%; coronary endarterectomy, 86%), freedom from angina (coronary artery bypass, 58%; coronary endarterectomy, 52%), and freedom from reoperation (coronary artery bypass, 97%; coronary endarterectomy, 98%). Despite the small increase in surgical risk, the early and late results support the selective application of coronary endarterectomy in patients with diffuse distal disease and demonstrate the beneficial long-term effects.

Actuarial Analysis↗
PubMed1985

Hypothermic circulatory arrest for cardiovascular lesions: technical considerations and results.

During a six-year period (1979 to 1984), the technique of hypothermic circulatory arrest was used to operate on 128 patients. Our technique included induction of hypothermia (20 degrees to 24 degrees C) by femoral artery cannulation for return of oxygenated blood, "open" aortic reconstruction, and brief periods of circulatory arrest (range, 5 to 31 minutes; mean, 13 minutes). Eighty patients had dissecting aneurysms of the ascending aorta (42 acute, 38 chronic), 28 had fusiform aortic arch aneurysms, and 13 had annulo-aortic ectasia. Seven had other procedures. Ages ranged from 14 to 79 years (mean, 54 years). Of the 113 patients (88%) who survived the operation and were discharged, 107 are currently alive and well. Only 15 of the 21 deaths occurred within 30 days of operation, and 5 (33%) were in severely hypotensive patients whose operations were begun during active resuscitation. Of the 80 patients admitted with ascending aortic or arch dissection, an in-hospital mortality of 7.5% was achieved. A marked reduction was observed in such complications as postoperative hemorrhage, renal failure, and pulmonary insufficiency with our current hypothermic perfusion methods. Moreover, none of the five neurological complications could be attributed to anoxic cerebral injury during the period of circulatory arrest. This experience indicates that moderate levels of hypothermia provide adequate cerebral protection for most cardiovascular procedures, and our results encourage continued use of this method.

Adolescent↗
PubMed1985

Surgical management of refractory supraventricular tachycardia in infants and children.

Sixty-seven children underwent attempted surgical correction of refractory supraventricular arrhythmias using a combination of intraoperative electrophysiologic mapping followed by surgical division or cryoablation of an aberrant conduction pathway or atrial ectopic focus. The patients ranged in age from 4 months to 18 years (mean 11.4 years). Fifty-five patients (82%) had an abnormal conduction pathway crossing the atrioventricular junction (Kent bundle). Thirty-six (65%) of these 55 patients had classic Wolff-Parkinson-White syndrome with a delta wave of pre-excitation on the surface electrocardiogram. Nineteen (35%), however, demonstrated only retrograde conduction across the Kent bundle and had a normal surface electrocardiogram when tachycardia was not present. Kent bundles were isolated to the following locations: right anterior or lateral in 19 (34.5%), left posterior or lateral in 22 (40%), posteroseptal in 10 (18%), anteroseptal in 2 (4%) and both right and left in 2 (4%). Follow-up evaluation of as long as 8 years (mean 34.9 months) has shown seven immediate failures and one late recurrence of arrhythmia (14.5%). Recent refinements in technique and the use of cryoablation for septal aberrant pathways have improved these results. There have been two failures (8%) in the last 25 attempts. Twelve patients underwent surgery for an atrial ectopic focus by the following techniques: cryoablation in seven patients, excision in one patient and both excision and cryoablation in four patients. At a mean follow-up of 16.6 months, there was one late recurrence in the group with an atrial ectopic focus.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1985

Valve failure with the Ionescu-Shiley bovine pericardial bioprosthesis: analysis of 2680 patients.

Early reports on the excellent hemodynamic function and low thromboembolic rates of the Ionescu-Shiley bovine pericardial bioprosthetic valve (BPV) encouraged us to use it as our choice for valve replacement in 2680 patients from 1978 through 1983. Analysis of these patients at 5-year follow-up (mean 21.6 months) demonstrated the following important trends. Despite anticoagulation therapy in 48%, thromboembolism occurred in 88 patients for a linearized rate of 1.87% emboli per patient-year and was not time-related. The highest incidence of thromboembolism was in mitral valve replacement (MVR) (2.76% per patient-year). The actuarial freedom from reoperation resulting from valve failure at 5 years was 82% in aortic valve replacement (AVR), 87.1% in MVR, and 92.6% in AVR/MVR. The most distressing causes for reoperation were valve calcification (33 patients, 0.68% per patient-year) and leaflet disruption (11 patients, 0.23% per patient-year). Valve calcification was related to age, small valve size, and AVR position and increased with time, especially at the 4- to 5-year intervals. In patients under 30 years of age, calcification occurred in 18.7% at a mean time of 40.8 months in AVR and in 8.2% at 44 months in MVR, for an overall rate of 11.6%. Over the age of 30 years, it occurred in 14 patients (0.6%) at a mean time of 44 months. Leaflet disruption was not related to age and occurred later in AVR (50 to 58 months) than MVR (1.5 to 61 months). Events increased with time (mean range 37 to 58 months). Because of calcification and leaflet disruption, valve failure causing reoperation has increased significantly at the 4- to 5-year intervals even when valve replacement in patients under 30 years of age is excluded. If this trend continues, the valve failure rate will be exceedingly high on further follow-up. Thus we have limited the use of the BPV to a selected group of patients in whom valve longevity is less important than effective orifice size, thromboembolic rate, and freedom from anticoagulation.

Actuarial Analysis↗