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Biomedical subjects

G K Sethi

Publications and source records attributed to G K Sethi.

At least 19 recordsLinked to original sources
PubMed2001

Changes in health-related quality of life following coronary artery bypass graft surgery.

BACKGROUND: There are limited data to help clinicians identify patients likely to have an improvement in quality of life following CABG surgery. We evaluated the relationship between preoperative health status and changes in quality of life following CABG surgery. METHODS: We evaluated 1,744 patients enrolled in the VA Cooperative Processes, Structures, and Outcomes in Cardiac Surgery study who completed preoperative and 6-month postoperative Short Form-36 (SF-36) surveys. The primary outcome was change in the Mental Component Summary (MCS) and Physical Component Summary (PCS) scores from the SF-36. RESULTS: On average, physical and mental health status improved following the operation. Preoperative health status was the major determinant of change in quality of life following surgery, independent of anginal burden and other clinical characteristics. Patients with MCS scores less than 44 or PCS scores less than 38 were most likely to have an improvement in quality of life. Patients with higher preoperative scores were unlikely to have an improvement in quality of life. CONCLUSIONS: Patients with preoperative health status deficits are likely to have an improvement in their quality of life following CABG surgery. Alternatively, patients with relatively good preoperative health status are unlikely to have a quality of life benefit from surgery and the operation should primarily be performed to improve survival.

Activities of Daily Living↗
PubMed2000

Mild renal failure is associated with adverse outcome after cardiac valve surgery.

The present study was performed to ascertain whether the presence of mild renal failure (defined as a serum creatinine concentration of 1. 5 to 3.0 mg/dL) is an independent risk factor for adverse outcome after cardiac valve surgery. An extensive set of preoperative and postoperative data was collected in 834 prospectively evaluated patients undergoing cardiac valve surgery at 14 Veterans Affairs Medical Centers. Univariate and multivariable analyses were performed to determine whether an independent association of mild renal dysfunction with adverse outcomes was present. Patients with mild renal failure had significantly greater 30-day mortality rates (P = 0.001; 16% versus 6%) and frequency of postoperative bleeding (P = 0.023; 16% versus 8%), respiratory complications (P = 0.02, 29% versus 16%), and cardiac complications (P = 0.002; 18% versus 7%) than patients with normal renal function (serum creatinine <1.5 mg/dL) when controlling for multiple other variables. The presence of a serum creatinine concentration of 1.5 to 3.0 mg/dL is significantly and independently associated with adverse outcomes after cardiac valve surgery.

Age Factors↗
PubMed2000

Outcomes 15 years after valve replacement with a mechanical versus a bioprosthetic valve: final report of the Veterans Affairs randomized trial.

OBJECTIVES: The goal of this study was to compare long-term survival and valve-related complications between bioprosthetic and mechanical heart valves. BACKGROUND: Different heart valves may have different patient outcomes. METHODS: Five hundred seventy-five patients undergoing single aortic valve replacement (AVR) or mitral valve replacement (MVR) at 13 VA medical centers were randomized to receive a bioprosthetic or mechanical valve. RESULTS: By survival analysis at 15 years, all-cause mortality after AVR was lower with the mechanical valve versus bioprosthesis (66% vs. 79%, p = 0.02) but not after MVR. Primary valve failure occurred mainly in patients <65 years of age (bioprosthesis vs. mechanical, 26% vs. 0%, p < 0.001 for AVR and 44% vs. 4%, p = 0.0001 for MVR), and in patients > or =65 years after AVR, primary valve failure in bioprosthesis versus mechanical valve was 9 +/- 6% versus 0%, p = 0.16. Reoperation was significantly higher for bioprosthetic AVR (p = 0.004). Bleeding occurred more frequently in patients with mechanical valve. There were no statistically significant differences for other complications, including thromboembolism and all valve-related complications between the two randomized groups. CONCLUSIONS: At 15 years, patients undergoing AVR had a better survival with a mechanical valve than with a bioprosthetic valve, largely because primary valve failure was virtually absent with mechanical valve. Primary valve failure was greater with bioprosthesis, both for AVR and MVR, and occurred at a much higher rate in those aged <65 years; in those aged > or =65 years, primary valve failure after AVR was not significantly different between bioprosthesis and mechanical valve. Reoperation was more common for AVR with bioprosthesis. Thromboembolism rates were similar in the two valve prostheses, but bleeding was more common with a mechanical valve.

Aged↗
PubMed1999

Health-related quality of life as a predictor of mortality following coronary artery bypass graft surgery. Participants of the Department of Veterans Affairs Cooperative Study Group on Processes, Structures, and Outcomes of Care in Cardiac Surgery.

CONTEXT: Health-related quality of life has not been evaluated as a predictor of mortality following coronary artery bypass graft (CABG) surgery. Evaluation of health status as a mortality predictor may be useful for preoperative risk stratification. OBJECTIVE: To determine whether the Physical and Mental Component Summary scores from the preoperative Short-Form 36 (SF-36) health status survey predict mortality following CABG surgery after adjustment for known clinical risk variables. DESIGN: Prospective cohort study conducted between September 1992 and December 1996. SETTING: Fourteen Veterans Affairs hospitals. PATIENTS: Of the 3956 patients undergoing CABG surgery only and who were enrolled in the Processes, Structures, and Outcomes of Care in Cardiac Surgery study, the 2480 who completed a preoperative SF-36. MAIN OUTCOME MEASURE: All-cause mortality within 180 days after surgery. RESULTS: A total of 117 deaths (4.7%) occurred within 180 days of CABG surgery. The Physical Component Summary of the preoperative SF-36 was a statistically significant risk factor for 6-month mortality after adjustment for known clinical risk factors for mortality following CABG surgery. In multivariate analysis, a 10-point lower SF-36 Physical Component Summary score had an odds ratio (OR) of 1.39 (95% confidence interval [CI], 1.11-1.77; P=.006) for predicting mortality. The SF-36 Mental Component Summary score was not associated with 6-month mortality in multivariate analyses (OR, 1.09; 95% CI, 0.92-1.29; P=.31). CONCLUSIONS: The Physical Component Summary score from the preoperative SF-36 is an independent risk factor for mortality following CABG surgery. The baseline Mental Component Summary score does not appear to be predictive of mortality. Preoperative patient self-report of the physical component of health status may be helpful for risk stratification and clinical decision making for patients undergoing CABG surgery.

Coronary Artery Bypass↗
PubMed1999

Arizona experience with CardioWest Total Artificial Heart bridge to transplantation.

BACKGROUND: We hypothesized that bridge to transplantation with the CardioWest Total Artificial Heart would succeed in a large percentage of patients. Further, we hypothesized that this success rate would not be significantly decreased by infection or thromboembolism. METHODS: From 1993 to March 1999, 24 patients received implants with the intention of bridge to transplantation. Data were collected prospectively. Heparin, coumadin, aspirin, ticlopidine, dipyridamole, and pentoxifylline were used for anticoagulation. RESULTS: Four patients died while on device support. Nineteen of 23 patients (83%) were transplanted. All 19 survived long term. One patient remains on CardioWest Total Artificial Heart support 6 weeks after implant. There was one stroke on the day of transplantation. There was a second stroke on the day of implantation. Neither stroke caused significant residual deficits. Both were in close relationship to an operative procedure. There were no serious device-related infections. CONCLUSIONS: The CardioWest Total Artificial Heart salvaged 20 of 24 critically ill patients. Neither infections nor neurologic problems were significant. We believe it is the device of choice for decompensating patients with biventricular failure who have adequate body and heart size.

Adult↗
PubMed1999

Stroke in cardiac surgical patients: determinants and outcome.

BACKGROUND: Despite improving outcomes in cardiac surgical patients, stroke continues to remain a major complication. Few prospective studies are available on postoperative stroke. The present study was conducted to elucidate the incidence and predictors of stroke in a large group of cardiac surgical patients. METHODS AND RESULTS: Prospective data collected on 4,941 patients undergoing cardiac surgery were subjected to univariate and logistic regression analyses (98.4% men; 72% older than 60 years; 9.1% with history of prior stroke; 80.4% underwent isolated coronary artery bypass grafting). Stroke predictors include history of stroke and hypertension, older age, systolic hypertension, bronchodilator and diuretic use, high serum creatinine, surgical priority, great vessel repair, use of inotropic agents after cardiopulmonary bypass, and total cardiopulmonary bypass time (p < 0.05 for all comparisons). Median intensive care unit and hospital stays were longer, and hospital mortality and 6-month mortality were higher for patients with stroke (p < 0.001). CONCLUSIONS: Stroke after cardiac surgical procedures is a morbid event. Identification of predictors and development of strategies to modify these factors should lead to a lower incidence of stroke.

Adult↗
PubMed1999

Renal failure predisposes patients to adverse outcome after coronary artery bypass surgery. VA Cooperative Study #5.

BACKGROUND: More than 600,000 coronary artery bypass graft (CABG) procedures are done annually in the United States. Some data indicate that 10 to 20% of patients who are undergoing a CABG procedure have a serum creatinine of more than 1.5 mg/dl. There are few data on the impact of a mild increase in serum creatinine concentration on CABG outcome. METHODS: We analyzed a Veterans Affairs database obtained prospectively from 1992 through 1996 at 14 of 43 centers performing heart surgery. We compared the outcome after CABG in patients with a baseline serum creatinine of less than 1.5 mg/dl (median 1.1 mg/dl, N = 3271) to patients with a baseline serum creatinine of 1.5 to 3.0 mg/dl (median 1.7, N = 631). RESULTS: Univariate analysis revealed that patients with a serum creatinine of 1.5 to 3.0 mg/dl had a higher 30-day mortality (7% vs. 3%, P < 0.001) requirement for prolonged mechanical ventilation (15% vs. 8%, P = 0.001), stroke (7% vs. 2%, P < 0.001), renal failure requiring dialysis at discharge (3% vs. 1%, P < 0.001), and bleeding complications (8% vs. 3%, P < 0.001) than patients with a baseline serum creatinine of less than 1.5 mg/dl. Multiple logistic regression analyses found that patients with a baseline serum creatinine of less than 1.5 mg/dl had significantly lower (P < 0.02) 30-day mortality and postoperative bleeding and ventilatory complications than patients with a serum creatinine of 1.5 to 3.0 mg/dl when controlling for all other variables. CONCLUSION: These results demonstrate that mild renal failure is an independent risk factor for adverse outcome after CABG.

Aged↗
PubMed1998

Endomyocardial biopsy in the heterotopic heart transplant patient.

We present a technique for rapid and easy endomyocardial biopsy of the heterotopic transplanted heart. With a recent resurgence in heterotopic heart transplantation, we believe that ours is a sound technique in obtaining both routine surveillance biopsies as well as evaluating "right-sided pressures" in the "piggy-back" heart.

Biopsy↗
PubMed1998

The CardioWest total artificial heart bridge to transplantation: 1993 to 1996 national trial.

BACKGROUND: We performed a controlled study of a total artificial heart in bridge to transplantation. We hypothesized that the CardioWest total artificial heart used in a selected population of decompensating cardiac transplantation candidates would result in improved survival compared with matched controls. METHODS: The CardioWest trial started in 1993 in six United States institutions under an investigational device exemption from the Food and Drug Administration. Four centers contributed 27 implant and 18 matched retrospective control patients. RESULTS: Of the implant patients, 25 (93%) received a transplant, 24 (89% of the total, 96% of those transplanted) were discharged and are currently surviving. In the control group, 10 patients died awaiting transplantation, 8 received a transplant, and 7 were discharged with 6 surviving (p = 0.00001). All adverse events were documented with respect to time. Thirteen serious adverse events occurred, 11 of which occurred in the 2 patients that died during implant. CONCLUSIONS: In a selected group of patients with endstage heart disease, use of the CardioWest total artificial heart is lifesaving. When compared with the series of matched retrospective controls, a significant improvement in survival was found in the CardioWest implant group.

Adolescent↗
PubMed1998

Biventricular cannulation for the Thoratec ventricular assist device.

The Thoratec biventricular assist device has been used extensively as a bridge to heart transplantation. Right atrial cannulation has always been used during right ventricular support, however diminished filling and output of the right ventricular assist device have been noticed when compared with filling and output of the left ventricular assist device. We describe a technique to directly cannulate the right ventricle to maximize filling and output of the right ventricular assist device.

Cardiac Catheterization↗
PubMed1998

Identification and voluntary reduction of vancomycin use for perioperative antibiotic prophylaxis during coronary artery bypass graft surgery.

Vancomycin prophylaxis for coronary artery bypass graft surgery without prosthetic valve implantation voluntarily decreased from 94% to 18% in one medical center. Median hospital stay (10 vs 9 days, P = .30) and number of postoperative infections (17.0% vs 14.3%, P = .60) did not differ among patients who received vancomycin and those who did not.

Adult↗
PubMed1997

Atrial fibrillation after cardiac surgery: a major morbid event?

OBJECTIVE: The purpose of the study was to investigate the incidence, predictors, morbidity, and mortality associated with postoperative atrial fibrillation (AF) and its impact on intensive care unit (ICU) and postoperative hospital stay in patients undergoing cardiac surgery in the Department of Veterans Affairs (VA). SUMMARY BACKGROUND DATA: Postoperative AF after open cardiac surgery is rather common. The etiology of this arrhythmia and factors responsible for its genesis are unclear, and its impact on postoperative surgical outcomes remains controversial. The purpose of this special substudy was to elucidate the incidence of postoperative AF and the factors associated with its development, as well as the impact of AF on surgical outcome. METHODS: The study population consisted of 3855 patients who underwent open cardiac surgery between September 1993 and December 1996 at 14 VA Medical Centers. Three hundred twenty-nine additional patients were excluded because of lack of complete data or presence of AF before surgery, and 3794 (98.4%) were male with a mean age of 63.7+/-9.6 years. Operations included coronary artery bypass grafting (CABG) (3126, 81%), CABG + AVR (aortic valve replacement) (228, 5.9%), CABG + MVR (mitral valve replacement) (35, 0.9%), AVR (231, 6%), MVR (41, 1.06%), CABG + others (95, 2.46%), and others (99, 2.5%). The incidence of postoperative AF was 29.6%. Multivariate logistic regression analysis of factors found significant on univariate analysis showed the following predictors of postoperative AF: preoperative patient risk predictors: advancing age (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.48-1.75, p < 0.001), chronic obstructive pulmonary disease (OR 1.37, 95% CI 1.12-1.66, p < 0.001), use of digoxin within 2 weeks before surgery (OR 1.37, 95% CI 1.10-1.70, p < 0.003), low resting pulse rate <80 (OR 1.26, 95% CI 1.06-1.51, p < 0.009), high resting systolic blood pressure >120 (OR 1.19, 95% CI 1.02-1.40, p < 0.026), intraoperative process of care predictors: cardiac venting via right superior pulmonary vein (OR 1.42, 95% CI 1.21-1.67, p < 0.0001), mitral valve repair (OR 2.86, 95% CI 1.72-4.73, p < 0.0001) and replacement (OR 2.33, 95% CI 1.55-3.55, p < 0.0001), no use of topical ice slush (OR 1.29, 95% CI 1.10-1.49, p < 0.0009), and use of inotropic agents for greater than 30 minutes after termination of cardiopulmonary bypass (OR 1.36, 95% CI 1.16-1.59, p < 0.0001). Postoperative median ICU stay (3.6 days AF vs. 2 days no AF, p < 0.001) and hospital stay (10 days AF vs. 7 days no AF, p < 0.001) were higher in AF. Morbid events, hospital mortality, and 6-month mortality were significantly higher in AF (p < 0.001): ICU readmission 13% AF vs. 3.9% no AF, perioperative myocardial infarction 7.41 % AF vs. 3.36% no AF, persistent congestive heart failure 4.57% AF vs. 1.4% no AF, reintubation 10.59% AF vs. 2.47% no AF, stroke 5.26% AF vs. 2.44% no AF, hospital mortality 5.95% AF vs. 2.95% no AF, 6-month mortality 9.36% AF vs. 4.17% no AF. CONCLUSIONS: Atrial fibrillation after cardiac surgery occurs in approximately one third of patients and is associated with an increase in adverse events in all measurable outcomes of care and increases the use of hospital resources and, therefore, the cost of care. Strategies to reduce the incidence of AF after cardiac surgery should favorably affect surgical outcomes and reduce utilization of resources and thus lower cost of care.

Aged↗
PubMed1997

International experience with the CardioWest total artificial heart as a bridge to heart transplantation.

As the number of potential heart donors remains constant and the number of potential recipients continuous to increase, the need for circulatory devices to bridge patients becomes more important. The CardioWest total artificial heart (TAH) is a pneumatic, implantable system that totally replaces the failing ventricles. It has been utilized worldwide as a bridge to heart transplantation in 79 patients. There were 73 males and six females who received the TAH. Currently three patients remain on the device waiting for transplantation. A total of 55 patients (70%) were transplanted of which 50 survived (91% of patients transplanted) and were discharged home. Idiopathic/dilated cardiomyopathy was the most common etiology followed by ischemic cardiomyopathy. The mean duration of implant was 34 days (range 0-186 days) and the mean age of the group was 45 years (range 16-62 years). Twenty-one patients died while on the device. Multiple organ failure was the major cause of death. There were a total of 255 complications in this group that included reoperation, bleeding, hepatic failure, renal failure, respiratory failure, neurologic events, thromboembolic events, infections, device malfunction, and fit complications. This represented a mean complication rate of three events per patient. The survival rate for the CardioWest TAH of 91% of the patients who reached transplantation is an improvement over that of the Symbion registry (55% of those transplanted) probably as a result of a better patient selection and better control of the coagulation system. These results are also comparable to those survival results obtained with other biventricular and left ventricular assist devices currently available.

Adolescent↗
PubMed1996

Heart-lung transplantation in situs inversus.

Reconstruction was accomplished in a 2 heart-lung recipients with situs inversus resulting in a left-sided systemic venous atrium. We created a large common atrium that was closed on the left side, leaving an atrial cuff on the inferior right quadrant. To this we anastomosed the donor right atrium, which had been opened laterally between the cavae. This resulted in some clockwise rotation of the ventricles and anterior positioning of the apex. The right pulmonary veins passed superior to the atrial anastomosis and posterior to the donor right atrium. Cardiopulmonary function was excellent in both cases.

Adolescent↗
PubMed1996

A novel mechanism for cyclosporine: inhibition of myocardial ischemia and reperfusion injury in a heterotopic rabbit heart transplant model.

BACKGROUND: Advances in myocardial preservation techniques and immunosuppressive drug therapy have resulted in heart transplantation as an acceptable treatment for end-stage heart failure. However, excessive periods of global myocardial ischemia followed by reperfusion can progress to irreversible graft injury. It has been reported that cyclosporine A (in addition to its well-characterized immunosuppressive actions) can blunt certain features of ischemia and reperfusion injury. This study was performed to examine the ability of cyclosporine A to attenuate such injury in a model of heart transplantation. METHODS: Twenty rabbit heterotopic transplants were divided into four study groups: (1) 30-minute ischemic control hearts; (2) 30-minute ischemic cyclosporine A-treated hearts; (3) 4-hour ischemic control hearts; and (4) 4-hour ischemic cyclosporine A-treated hearts. A single dose of cyclosporine A (10 mg/kg intravenously) or vehicle was administered to both the donor and recipient rabbits 45 minutes before heart explantation and heart transplantation, respectively. RESULTS: After transplantation and 30 minutes of reperfusion, the 4-hour ischemic control hearts showed a significant (p < 0.01) leftward shift in the left ventricular end-diastolic pressure versus left ventricular volume curve compared with the 30-minute ischemic control hearts. This finding represents higher end-diastolic pressures and incomplete diastolic relaxation caused by ischemia and reperfusion. Cyclosporine A administration to the donor and recipient rabbits resulted in a significant improvement (p < 0.01) in diastolic relaxation (shift in the left ventricular end-diastolic pressure versus left ventricular volume curve back to the right) compared with 4-hour ischemic control hearts. Cyclosporine A-treated hearts also showed significant improvements in the rate of diastolic pressure fall (p < 0.05) and tau (the isovolumetric pressure decay constant) (p < 0.01) compared with ischemic control hearts. CONCLUSIONS: These results indicate that single doses of cyclosporine A to both the donor and recipient inhibit the dysfunction in extent and rate of left ventricular relaxation caused by prolonged global ischemia and reperfusion. Possible mechanisms for cyclosporine A's myocardial protective actions are presented in the discussion.

Animals↗
PubMed1995

Simplified technique of heart-lung transplantation.

Well-known complications of heart-lung transplantation include mediastinal bleeding and phrenic nerve injury. Conventional technique places the hila behind the phrenic nerves. We have placed the hila in front of the phrenic nerve in our last 10 patients, using direct caval anastomoses when feasible. This minimizes traction on and dissection around the phrenic nerves, and allows anterior rotation of the heart-lung block for easier hemostasis of the posterior mediastinum after implantation.

Dissection↗
PubMed1995

Why it is important to demonstrate linkages between outcomes of care and processes and structures of care.

This first article of the supplement describes the rationale for the Department of Veterans Affairs Cooperative Study, Processes, Structures, and Outcomes in Cardiac Surgery, which was designed to demonstrate statistically and clinically meaningful linkages between processes and structures of care and the outcomes of that care. United States health care is in an era of great enthusiasm for the use of health care outcomes to assess and improve quality of care. An important reason for this enthusiasm is the concern that processes and structures of care, which traditionally have been selected arbitrarily without valid linkages to favorable outcomes, may not result in the desired outcomes of care. Furthermore, health care outcomes are intrinsic to the definition of quality of care and should be relatively free of preconceived biases about how care should be provided. However, the limitations to outcomes-directed quality improvement have been inadequately recognized. These limitations include the following: (1) mortality, the most commonly used outcome, is usually sufficiently rare, resulting in inadequate statistical power; (2) nonfatal outcomes are much more difficult to measure reliably; (3) outcomes may not be measurable for an extended period of time after the care episode, making linkage to quality improvement inefficient; and (4) patients often desire good processes of care as well as favorable outcomes. A review of the literature found relatively few reports linking processes and structures of care to favorable outcomes. Significant relationships between processes of care and outcomes have been reported for several medical conditions (congestive heart failure, acute myocardial infarction, pneumonia, and stroke) when the patient has been considered the unit of analysis. However, there is a paucity of published meaningful process-outcome or structure-outcome linkages for surgical conditions or for any conditions when the hospital has been the focus of analysis. The authors concluded that quality improvement will proceed most efficiently and effectively if all three elements of Donabedian's quality triad (processes, structures, and outcomes) are used and if the processes and structures chosen have been demonstrated to be associated with desired outcomes of care.

Cardiac Surgical Procedures↗