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Biomedical subjects

G J Reul

Publications and source records attributed to G J Reul.

At least 73 records · Page 4Linked to original sources
PubMed1985

Comparison of bioprosthetic and mechanical valve replacement for active endocarditis.

The choice between bioprosthetic or mechanical prosthetic valve replacement for active valvular endocarditis has been controversial. To establish the role of each, we reviewed the case histories of 185 patients who underwent valve replacement for active valvular endocarditis during the past 5 years. All patients had life-threatening, active bacterial endocarditis of a native or prosthetic valve. Group I (88 patients) had replacement with the Ionescu-Shiley pericardial valve and Group II (97 patients) with the St. Jude Medical valve. The male/female distribution, age range, and functional classification were the same in the two groups. Mean follow-up was approximately 20 months for both groups. Valve replacement was done because of native valve endocarditis in 76 patients in Group I and 49 patients in Group II. Of the remainder of the Group I patients, six had endocarditis of a bioprosthesis and six of a mechanical valve; of the remainder of Group II patients, 30 had endocarditis of a bioprosthesis and 18 of a mechanical valve. Early mortality was not significantly different between the two groups (14 deaths in each group). Of the 74 survivors in Group I, 15 underwent valve reoperation, 10 because of recurrent endocarditis and five because of sterile perivalvular leakage. The frequency of reoperation was significantly different (p less than 0.01) from that in Group II, in which only five patients underwent valve reoperation, four for recurrent endocarditis and one for sterile perivalvular leakage. The actuarial rate for freedom from reoperation was also significantly higher in Group II patients; 94.6% were free from reoperation at 4 years compared to 75% at 4 years in Group I patients (p less than 0.01). The actuarial survival rate, which also differed significantly between groups, was 78.7% at 4 years in Group I and 87.4% at 4 years in Group II (p less than 0.05). Patients receiving a bioprosthesis for active endocarditis had a significantly higher reoperation rate and a significantly greater incidence of recurrent endocarditis (p less than 0.01). Therefore, we prefer to use a mechanical valve for valve replacement in most patients who have active endocarditis.

Adolescent↗
PubMed1984

Coronary artery revascularization without cardiopulmonary bypass.

At the Texas Heart Institute between October 1969 and August 1983, there were 191 single bypass procedures performed without pump oxygenator support. These cases have been divided into two groups: Group I (160 patients) represents the time period from October 1969 through December 1981 and includes our experience with single vessel left anterior descending (LAD) coronary artery bypass without pump oxygenator support; Group II (31 patients) represents the period between January 1982 and August 1983 and includes our initial operative experience in patients with failed percutaneous transluminal coronary angioplasty (PTCA). Of 145 primary operations in Group I patients, 113 were single bypasses to the right coronary artery with a postoperative infarction rate of 3.5% (4/113). Single bypass to the left anterior descending (LAD) coronary artery in 32 patients who underwent operation early in the series was associated with a postoperative infarction rate of 18.7% (6/32) and is no longer performed without pump oxygenator support. Fifteen patients had previous coronary bypass operations and underwent single bypass without pump as a second procedure. Postoperative infarction rate in this redo group was 6.6% (1/15). Long-term follow-up data was obtained on all patients from 1 to 11 years after surgery (mean follow-up, 4 years). Four late cardiac deaths occurred at 2,3,4 and 7 years in the primary operation group (3.5%) 4/113. One late death occurred at 7 years in the redo group (6.6%) 1/15. In Group II, failed PTCA accounted for 39% of the 31 patients who underwent single right bypass without pump support; there were no perioperative infarctions and one death. Coronary bypass can be safely and effectively employed without pump oxygenator support if performed expeditiously and limited to right coronary lesions which have an adequate distal vessel. This technique has become more useful with the advent of attempted PTCA for single coronary lesions.

Journal Article↗
PubMed1984

Coronary artery bypass for unsuccessful percutaneous transluminal coronary angioplasty.

Of 518 consecutive patients undergoing percutaneous transluminal coronary angioplasty for 571 coronary lesions, 184 eventually underwent coronary artery bypass because of angioplasty failure. Delayed coronary bypass (1 week to 19 months) was done in 27 patients with no deaths. Immediate bypass was done in 87 patients with two deaths, both of which were caused by further dissection of the artery after angioplasty. Urgent bypass was required in 63 patients who were in unstable condition because of ischemia on the electrocardiogram (52 patients), unrelieved angina (57 patients), or hypotension (13 patients). There was one death in this group. In the remaining seven patients, urgent coronary bypass was done because of cardiac arrest (three deaths). Myocardial complications occurred in 23 of the 70 unstable patients, including the seven patients with cardiac arrest. There were only eight completed myocardial infarctions in the 70 unstable patients and a completed myocardial infarction rate of 11 of 184 (6.0%) overall. In the 10 patients in whom extracorporeal circulation was established within 25 minutes of myocardial insult, mortality and myocardial complications were completely avoided. The remaining patients in the urgent group were placed on cardiopulmonary bypass within 26 to 300 minutes (mean 82 minutes). Operative mortality (3.3%), completed myocardial infarction (6.0%), myocardial infarction in unstable patients (32.9%), postoperative hemorrhage (5.0%), and sternal problems (2.8%) were all significantly different from those in 3,500 consecutive coronary bypasses not following angioplasty, that were done in 1982.

Adult↗
PubMed1984

Long-term results of direct vertebral artery operations.

Arteriosclerotic occlusive disease of the vertebral arteries is common; however, vertebral artery operations are performed infrequently. From 1971 through 1983 more than 3000 cerebrovascular operations were performed; only 40 of these were direct vertebral artery operations. There were 22 women and 18 men, varying in age from 44 to 80 years (mean 61.6 years). Symptoms included dizziness or vertigo in 29 patients (73%), transient ischemic attacks in 17 (43%), syncope in eight (20%), and previous stroke in 14 (35%). Operative procedures were directed toward establishing normal antegrade vertebral flow by reimplantation (21 patients), patch graft (15 patients), or grafts (three patients). Two patients underwent bilateral procedures. There were no operative deaths. All except two patients (95%) were available for follow-up at 1 to 12 years (mean follow-up 7.75 years). There were eight late deaths from 1 to 9 years, with a 12-year actuarial survival rate of 75.8%. The eight patients who died were known to be without symptoms before death. Of the 30 survivors available for follow-up, 21 remained without symptoms, seven patients showed no improvement, two patients who had no symptoms had recurrence at 4 and 5 years, and one patient without symptoms had a stroke at 7 years. In this select group of patients with severe disease, direct vertebral artery operations have resulted in significant long-term relief of symptoms and prevention of transient ischemic attacks and strokes.

Adult↗
PubMed1983

Resection of aortic arch aneurysms: a comparison of hypothermic techniques in 60 patients.

Hypothermic circulatory arrest has been used to facilitate resection of aneurysms of the aortic arch. During a five-year period, two methods of hypothermic arrest were compared in 60 patients. In Group 1, 20 patients underwent deep hypothermia (14 degrees to 18 degrees C) and circulatory arrest to allow repair of the transverse arch under optimal conditions. A hospital mortality of 50% occurred and was attributed to uncontrolled hemorrhage and cerebral or cardiac complications. In Group 2, modified techniques were employed in 40 patients and included moderate levels of hypothermia (22 degrees to 26 degrees C) and simplified operative methods, which reduced the duration of circulatory arrest and shortened the length of perfusion. Pretreatment of plasma-soaked Dacron grafts by autoclaving eliminated serious bleeding problems. A marked improvement in patient survival (90%) and reduction in postoperative complications were observed after adoption of these modifications. The improved results in the present series have reconfirmed our belief that this type of intervention is the preferred approach to aneurysms of the aortic arch.

Adolescent↗
PubMed1983

Cor triatriatum: operative results in 25 patients.

Twenty-five patients with cor triatriatum underwent surgical correction at the Texas Heart Institute during a 21-year period from 1959 to 1980. Patients ranged in age from 4 months to 38 years. Diagnosis was established preoperatively in 14 patients (56%), at the time of operation for correction of associated lesions in 10 patients (40%), and during reoperation in 1 (4%). In the earlier part of this series, diagnosis was more common at the time of operation. Associated cardiovascular anomalies were present in 20 patients (80%), major anomalies in 14 others (56%). Simultaneous correction or palliation of associated lesions and total excision of the anomalous membrane were done in 18 patients utilizing temporary cardiopulmonary bypass. Cor triatriatum alone was repaired in 5 patients (20%) with the aid of extracorporeal circulation. Two patients underwent reoperation: 1 because of incomplete excision of the septum and the other because the condition had not been diagnosed during a first operation for correction of total anomalous pulmonary venous return. Excision of the membrane was accomplished utilizing the left atrium in 10 patients (40%), the right atrium in 12 (48%), or both in 3 (12%). Four patients (16%) died early after operation; all were infants who had severe associated cardiac anomalies. Among the 21 surviving patients, results were excellent in 20.

Adolescent↗
PubMed1983

The morphology of ascending aortic aneurysms.

To determine the frequency of morphologic abnormalities of the aorta, especially of the media, in patients with aneurysms of the ascending aorta, tissue specimens from surgically resected ascending aortic aneurysms of 339 patients were studied. Included were 232 men and 107 women; 53 (29 men, 23 women) had clinical signs of Marfan's disease. Features evaluated and graded included fragmentation of elastic fibers, cystic medial change, medial fibrosis, medial necrosis, atherosclerosis, periaortic fibrosis, and thickening of the vasa vasorum. Both elastic fragmentation and cystic medial change were present in a high percentage of patients. Cystic medial change was inversely correlated with increasing age of patients, especially in the group of patients without clinical evidence of Marfan's syndrome. Marked changes of these types in many younger patients without Marfan's syndrome could reflect a "tissue insufficiency" in early life that causes the aortic wall to weaken and dilate. Medial necrosis, fibrosis, and atherosclerosis were directly correlated with age. Hemodynamic events are considered to initiate injury and repair within the aortic wall. Dissection was more frequently seen with medial abnormalities than with atherosclerosis.

Adult↗
PubMed1983

The St. Jude medical valve: early clinical results in 253 patients.

The St. Jude Medical cardiac valve is a low-profile, bileaflet, central-flow prosthesis made entirely of pyrolytic carbon. A total of 261 St. Jude valves were implanted in 253 patients during a 25-month period. Perioperative mortality for the entire series was 9.1%, including patients undergoing reoperation for valve disease and those having associated cardiac procedures. There were four nonfatal thromboembolic episodes during the follow-up period, resulting in a risk of thromboembolism for aortic and mitral valves of 2.1% and 2.1% per patient year, respectively. There were no instances of structural failure of the valve, and no valve-related hemolysis occurred. Two-year actuarial survival was 95%. Hemodynamic studies indicate that the valve has the lowest transvalvular pressure gradient of any prosthetic mechanical valve available, and we believe it is the valve of choice for patients in whom a prosthetic mechanical valve is indicated.

Journal Article↗
PubMed1983

Early experience with the ionescu-shiley pericardial xenograft valve. Accelerated calcification in children.

Recognizing the problems of thromboembolism and anticoagulation in children and the high incidence of calcification in porcine valves in children, we hoped that the Ionescu-Shiley valve might be a good choice in the younger age group. We implanted 2,372 Ionescu-Shiley valves in 2,167 patients between 1978 and 1982, of which 30 were in children 16 years of age and younger. Although there have been no known instances of thromboembolism, valve infection, or valve disruption in this group of children, seven (23%) have already required reoperation for calcific stenosis. Although calcification appears maximal in postpubertal children less than 17 years of age, we consider it unwise currently to place these valves in any child and have returned to mechanical valves for this purpose.

Adolescent↗
PubMed1982

Improved cardiac function following left ventricular aneurysm resection: pre- and postoperative performance studies in 150 patients.

One hundred fifty patients underwent radionuclide left ventricular performance studies before and one week after resection of a left ventricular aneurysm. The patients were classified according to pre-and postoperative ejection fraction into five classes as follows: Class I > 50%, Class II = 41%-50%, Class III = 31%-40%, Class IV = 21%-30%, and Class V = < 21%. They were also classified into groups according to the size of the aneurysm and wall thickness. Operative mortality was 4.6% (7/150). One hundred one patients (67%) improved at least one "ejection-fraction class" postoperatively; whereas in a similar group of patients who underwent aortocoronary bypass without left ventricular aneurysm resection, only 42.3% (58/137) improved (p <.01). Preoperatively, ejection fraction was < 40% in 136 patients (90.6%); and postoperatively, it was > 40% in 59 patients (39.3%) (p <.01). Improvement of at least one "ejection-fraction class" occurred in 22 patients (47.8%) with small aneurysms, 54 patients (69.2%) with moderate size aneurysms (p <.05), and 25 patients (96.1%) with large aneurysms (p <.01). Sixty-nine patients (88.4%) with thin-walled aneurysms and 32 patients (44.4%) with thick-walled aneurysms improved (p <.01). Resection of a left ventricular aneurysm improves left ventricular function, particularly in patients with large, thin-walled aneurysms. A less aggressive surgical approach is warranted when dealing with thick-walled akinetic areas as patients with these lesions do not respond well to resection.

Journal Article↗
PubMed1982

Open aortic anastomosis: improved results in the treatment of aneurysms of the aortic arch.

Over a 7-month period, 15 consecutive patients underwent resection and reconstruction of the transverse aortic arch for a variety of pathologic lesions using moderate systemic hypothermia (24 degrees C) and brief circulatory arrest. Simplified surgical techniques were developed to allow rapid repair. The "open" aortic technique facilitated repair of arch aneurysms, aortic dissections and obstructive lesions of the arch tributaries. The mean cerebral ischemic time was 11.2 +/- 1.5 minutes (mean +/- SEM). Moderate hypothermia afforded adequate cerebral and myocardial protection during circulatory arrest and shortened the duration of extracorporeal bypass necessary for the cooling and rewarming phases (87 +/- 8 minutes). Dacron grafts preclotted by a new method greatly reduced postoperative blood loss. Since these simplified techniques were adopted, 14 patients (93%) have survived aortic arch replacement, with minimal postoperative morbidity. One patients with severe preoperative left ventricular dysfunction died of cardiac failure after operation. These results suggest that aortic arch replacement can be performed safely and with low operative risk.

Aorta, Thoracic↗
PubMed1981

Intracorporeal (abdominal) left ventricular assist devices or partial artificial hearts: A five-year clinical experience.

An intracorporeal (abdominal) left ventricular assist device (ALVAD) or partial artificial heart was designed, developed, extensively tested in vitro and in vivo, and subsequently approved for controlled clinical trials in institutions. The ALVAD is pneumatically actuated, synchronously or asynchronously, with an external console and is interposed between the apex of the left ventricle and infrarenal abdominal aorta. The implantation techniques are straightforward and replicable. The ALVAD was used in weaning from cardiopulmonary bypass to support the circulation in cardiogenic shock after infarction and as a bridge to cardiac transplantation. It was found that the profoundly depressed human left (and right) ventricles initially incapable of ejection can recover if totally supported with this device. This experience strongly suggests that ALVADs should be used early in instances of intra-aortic balloon pump inadequacy.

Adult↗
PubMed1980

Aortic valve replacement in preteenage children.

During the last 15 years, 26 children who ranged from 4 to 12 years old underwent subcoronary aortic valve replacement (AVR) at the Texas Heart Institute. The valve lesions resulted from congenital heart disease in 20 patients, 15 of whom had had a previous operation including 13 aortic valve procedures. Cystic medial necrosis necessitated AVR in 5 patients, all of whom had physical findings of Marfan's syndrome. One patient had rheumatic heart disease and required double-valve (aortic and mitral) replacement. Six different types of prosthesis were used: the Smeloff-Cutter, Starr-Edwards, Cooley-Cutter, Hancock porcine, Ionescu-Shiley, and Bjork-Shiley. The first patient in the series was the only early death (3.8%). Log-term follow-up data ranging from 1 month to 10 years were available on 20 patients. Three late deaths occurred (11.5%). All survivors are doing well and have good exercise tolerance. These data suggest that AVR performed in childhood is a safe, durable, and well-tolerated form of therapy. Later replacement, if necessary, can be accomplished with larger-sized prostheses. Our present choice is the Ionescu-Shiley bovine xenograft because of its superior hemodynamic characteristics and low incidence of embolic complications.

Age Factors↗
PubMed1979

Reoperation for recurrent coronary artery disease: causes, indications, and results in 168 patients.

Of the 13,049 patients who underwent coronary artery bypass surgery, 168 underwent a second or third operation because of the failure of the first. The early mortality was eight of 168. Good to excellent results were obtained in 141 patients. The cumulative survival rate was 82% at six years. Graft failure and the progression of atherosclerosis to a critical lesion were the most common reasons for reoperation, and perioperative myocardial infarction and incomplete initial operation were the least common. Long-term follow-up showed a peak of graft failure and progression of disease in nongrafted arteries at three years and decreased thereafter. Progression of distal disease in grafted arteries was not temporally related and was uncommon. Thrombosis of the vein graft could be related most frequently to the distal circulation rather than the vein graft itself.

Coronary Artery Bypass↗
PubMed1978

Total support of the circulation of a patient with post-cardiotomy stone-heart syndrome by a partial artificial heart (ALVAD) for 5 days followed by heart and kidney transplantation.

A patient with acute bacterial endocarditis in whom ischaemic contracture of the left ventricle (stone-heart syndrome) developed during aortic and mitral valve replacement had an emergency implantation of an intracorporeal partial artificial heart (an abdominal left-ventricular assist device of ALVAD). This device functioned as a total artificial heart for nearly 6 days, while a donor heart for transplantation was sought. The ALVAD was then removed, and the patient received allografts of a heart and a kidney. The transplanted heart functioned well, but the patient died 15 days later from gram-negative sepsis. There was no evidence of cardiac or renal allograft rejection.

Acute Disease↗