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Biomedical subjects

G M Deeb

Publications and source records attributed to G M Deeb.

At least 37 records · Page 2Linked to original sources
PubMed1999

The impact of new technology on a clinical practice.

The use of xenograft stentless tissue valves has increased because of excellent hemodynamics and availability. This article describes the impact of the incorporation of this new technology into a single institutional practice over time. A time span for continual usage of the new stentless Freestyle valve was divided into four distinct chronological groups and evaluated. Data on 266 consecutive patients receiving the Freestyle prosthesis were analyzed with regard to demographics, degree of illness, complexity of surgery, and outcomes to discover any distinct changes over time with respect to experience and acquired confidence and surgical expertise. Findings among the four groups were compared using Student's t-test. The only change in patient demographics was younger age (mean age decreased from 70 to 62 years). The number of procedures rose steadily, and the degree of illness increased as noted in the increase between groups in the percentage of patients with comorbidities (from 45% to 92%). The complexity of surgery score steadily increased (from 1.9 to 2.5); however, the mean cross-clamp time did not change. The surgical mortality rate for the entire study was 3.4%. In group 1, the mortality was 7.5% but decreased rapidly and remained steady throughout the rest of the study. The use of the Freestyle stentless conduit in a single practice over time shows a distinct learning curve. With experience, valves are placed in younger, sicker patients who require more complex surgery. Surgical outcomes and efficiency improve with acquired surgical expertise.

Adult↗
PubMed1999

Impact of intraoperative post-pump aortic regurgitation with stentless aortic bioprostheses.

Stentless aortic bioprosthesis performance may be affected by geometric distortion, and intraoperative echocardiography typically is used to assess prosthetic valve function. The impact of minimal or mild post-pump aortic regurgitation has not been previously investigated. Intraoperative post-pump transesophageal echocardiograms and follow-up transthoracic echocardiograms (up to 3 years' postoperatively) were reviewed for 96 patients who underwent implantation of Freestyle (Medtronic) stentless aortic bioprostheses. Minimal or mild aortic regurgitation was present post-pump in 50 of 96 (52%) patients. On early follow-up examination (n = 80), no patient had more than mild aortic regurgitation. Aortic regurgitation had completely resolved in 24 of 39 (62%) patients with post-pump aortic regurgitation, including 15 of 19 (79%) patients with minimal paravalvular regurgitation. The incidence of mild aortic regurgitation at 2 and 3 years did not appear different between patients with and those without post-pump aortic regurgitation. Minimal or mild aortic regurgitation is common on intraoperative post-pump transesophageal echocardiography immediately after implantation of stentless aortic bioprostheses. Resolution is common, especially of small paravalvular jets. Minimal or mild post-pump aortic regurgitation infrequently results in even mild aortic regurgitation on early follow-up evaluation and does not appear to predict clinically significant progression of aortic regurgitation on long-term follow-up evaluation.

Adult↗
PubMed1998

Intermediate-term outcome of mitral reconstruction in cardiomyopathy.

OBJECTIVE: Severe mitral regurgitation is a frequent complication of end-stage cardiomyopathy that contributes to heart failure and predicts a poor survival. We studied the intermediate-term outcome of mitral reconstruction in 48 patients who had cardiomyopathy with severe mitral regurgitation and were operated on between June 1993 and June 1997. METHODS: Ages ranged from 33 to 79 years (63 +/- 6 years) with left ventricular ejection fractions of 8% to 25% (16% +/- 3%). All patients were receiving maximal drug therapy and were in New York Heart Association class III-IV with severe, refractory 4+ mitral regurgitation. Operatively, all 48 had undersized flexible annuloplasty rings inserted, 7 had coronary bypass grafts for incidental disease, 11 had prior bypass grafts, and 11 also had tricuspid valve repair. RESULTS: One operative death occurred as a result of right ventricular failure. Postoperative transesophageal echocardiography revealed mild mitral regurgitation in 7 patients and no mitral regurgitation in 41. There were 10 late deaths, 2 to 47 months after mitral reconstruction. The 1- and 2-year actuarial survivals have been 82% and 71%. At a mean follow-up of 22 months, the number of hospitalizations for heart failure has decreased, and 1 patient has had heart transplantation. Significantly, New York Heart Association class improved from 3.9 +/- 0.3 before the operation to 2.0 +/- 0.6 after the operation. Twenty-four months after the operation, left ventricular volume and sphericity have decreased, whereas ejection fraction and cardiac output have increased. CONCLUSION: Whether this favorable modification of left ventricular function and geometry will persist remains unknown. However, mitral repair for cardiomyopathy with mitral regurgitation allows new strategies for these patients.

Actuarial Analysis↗
PubMed1998

Intraoperative monitoring of danaparoid sodium anticoagulation during cardiovascular operations.

PURPOSE: Patients with cardiovascular disorders frequently need anticoagulation for diagnostic studies, surgical procedures, and therapy. Heparin-induced thrombocytopenia is a relatively common complication of heparin therapy that can result in thrombosis and subsequent limb loss or death, necessitating use of alternative anticoagulants. METHODS: Two patients who needed cardiac surgery had thrombocytopenia induced by exposure to heparin and heparin-coated tubing. Several assays were examined for their ability to monitor intraoperative anticoagulation of a factor Xa inhibitor, danaparoid sodium. RESULTS: In vitro, celite and kaolin activated dotting times and activated partial thromboplastin time were prolonged linearly in the presence of increasing concentrations of danaparoid sodium. Aprotinin did not alter the linearity of the response but did alter its slope. In vivo, activated clotting times and activated partial thromboplastin time were insensitive to clinically significant changes in danaparoid sodium plasma levels during cardiopulmonary bypass. Correction in activated partial thromboplastin time lagged 2 hours behind clinically important changes in anti-factor Xa levels. Only anti-factor Xa levels were adequate to monitor intraoperative danaparoid sodium levels. CONCLUSION: Anticoagulation for cardiopulmonary bypass can be successfully performed with danaparoid sodium and intraoperative anti-factor Xa monitoring.

Adult↗
PubMed1998

Aprotinin versus epsilon-aminocaproic acid for aortic surgery using deep hypothermic circulatory arrest.

OBJECTIVE: To compare the relative efficacy of aprotinin and epsilon-aminocaproic acid (EACA) in decreasing blood loss and transfusion requirements after aortic surgery involving deep hypothermic circulatory arrest (DHCA). DESIGN: A retrospective chart review. SETTING: A university medical center. PARTICIPANTS: Forty-nine patients who had undergone thoracic aortic surgery with the use of circulatory arrest. INTERVENTIONS: Charts were examined for variables believed to influence postoperative blood loss, including the use of medications, and for the amount of postoperative chest tube drainage and perioperative transfusion. MEASUREMENTS AND MAIN RESULTS: Median chest tube output (CTO) at 6 and 12 hours postoperatively was nearly identical in patients treated with aprotinin or EACA (660 and 1,015 v 700 and 950 mL for aprotinin and EACA at 6 and 12 hours, respectively), as were total perioperative blood transfusions. Complications were not significantly different between groups with the exception of a trend toward increased incidence of renal failure in the group receiving EACA. CONCLUSION: Aprotinin and EACA appear to be equally efficacious in reducing perioperative blood loss and transfusion requirements in patients undergoing aortic surgery involving DHCA. Questions of safety remain about the use of EACA in this setting that could not be addressed by this small retrospective study. A prospective, placebo-controlled study is warranted to confirm the absolute efficacy of these agents and to better define safety issues.

Adult↗
PubMed1998

Long-term outcome following case management after coronary artery bypass surgery.

Patient outcome following coronary artery bypass grafting (CABG) has come under increasing governmental, social, and economic scrutiny. To insure quality patient outcome after CABG, many new policies and programs have been instituted. One of these, case management, was developed as a tool for identification and quantification of patient clinical sequences and resource utilization. This present study examines the influence of case management on length of stay and patient outcome following CABG. One hundred forty randomized, retrospectively analyzed CABG patients from 1990, prior to case management, were compared against 140 age-and case-matched randomly controlled CABG patients from 1994 after case management was in place. Patients' demographics were similar. The outcome data showed that intensive care unit (ICU) use and total length of stay were significantly decreased. Furthermore, resource utilization as monitored by chest X-ray, electrocardiography, and laboratory testing were decreased as well. Finally, mortality was decreased despite an increase in risk-adjusted acuity of the patients. There appeared to be no effect of gender or age on the benefit derived from case management. These data demonstrate that the influence of case management is beneficial for resource utilization and patient outcome following CABG and that these types of patient care policy advancements should be encouraged.

Aged↗
PubMed1998

Evaluating and improving the delivery of heart care: the University of Michigan experience.

With increasing pressure to curb escalating costs in medical care, there is particular emphasis on the delivery of cardiovascular services, which account for a substantial portion of the current healthcare dollar spent in the United States. A variety of tools were used to improve performance at the University of Michigan Health System, one of the oldest university-affiliated hospitals in the United States. The tools included initiatives to understand outcomes after coronary bypass operations and coronary angioplasty through use of proper risk-adjusted models. Critical pathways and guidelines were implemented to streamline care and improve quality in interventional cardiology, management of myocardial infarction, and preoperative assessment of patients undergoing vascular operations. Strategies to curb unnecessary costs included competitive bidding of vendors for expensive cardiac commodities, pharmacy cost reductions, and changes in nursing staff. Methods were instituted to improve guest services and partnerships with the community in disease prevention and health promotion.

Cardiology Service, Hospital↗
PubMed1997

Preoperative amiodarone as prophylaxis against atrial fibrillation after heart surgery.

BACKGROUND: Atrial fibrillation occurs commonly after open-heart surgery and may delay hospital discharge. The purpose of this study was to assess the use of preoperative amiodarone as prophylaxis against atrial fibrillation after cardiac surgery. METHODS: In this double-blind, randomized study, 124 patients were given either oral amiodarone (64 patients) or placebo (60 patients) for a minimum of seven days before elective cardiac surgery. Therapy consisted of 600 mg of amiodarone per day for seven days, then 200 mg per day until the day of discharge from the hospital. The mean (+/-SD) preoperative total dose of amiodarone was 4.8+/-0.96 g over a period of 13+/-7 days. RESULTS: Postoperative atrial fibrillation occurred in 16 of the 64 patients in the amiodarone group (25 percent) and 32 of the 60 patients in the placebo group (53 percent) (P=0.003). Patients in the amiodarone group were hospitalized for significantly fewer days than were patients in the placebo group (6.5+/-2.6 vs. 7.9+/-4.3 days, P=0.04). Nonfatal postoperative complications occurred in eight amiodarone-treated patients (12 percent) and in six patients receiving placebo (10 percent, P=0.78). Fatal postoperative complications occurred in three patients who received amiodarone (5 percent) and in two who received placebo (3 percent, P= 1.00). Total hospitalization costs were significantly less for the amiodarone group than for the placebo group ($18,375+/-$13,863 vs. $26,491+/-$23,837, P=0.03). CONCLUSIONS: Preoperative oral amiodarone in patients undergoing complex cardiac surgery is well tolerated and significantly reduces the incidence of postoperative atrial fibrillation and the duration and cost of hospitalization.

Aged↗
PubMed1997

Increased sarcolemmal glucose transporter abundance in myocardial ischemia.

Many clinical and laboratory studies suggest that an increase in glucose uptake and metabolism by ischemic myocardium helps protect myocardial cells from irreversible injury. We have examined whether increased sarcolemmal abundance of cardiomyocyte glucose transporters plays a role in this adaptive response. We have shown that acute myocardial ischemia in perfused rat hearts results in increased sarcolemmal abundance of the major glucose transporter, GLUT4, by causing translocation of GLUT4 molecules from an intracellular compartment to the sarcolemma. In nonischemic control hearts only 18 +/- 2.8% of GLUT4 molecules were on the sarcolemma whereas in ischemic hearts this increased to 41 +/- 9.3%. Insulin also caused translocation of GLUT4 molecules to the sarcolemma, and resulted in 61 +/- 2.6% of GLUT4 molecules on the sarcolemma. The combination of ischemia and insulin did not result in additive increases in sarcolemmal GLUT4 abundance. In more persistent or chronic ischemia, the other major myocardial glucose transporter, GLUT1, appears to play an important role. The mRNA for this transporter, which is constitutively expressed on cardiomyocyte sarcolemma, was increased 2.0-fold in regions of hibernating myocardium in humans with coronary heart disease as well as in persistently hypoxic rat neonatal cardiomyocytes in primary culture. In neither of these conditions was GLUT4 mRNA expression increased. Thus, acute myocardial ischemia increases sarcolemmal glucose transporter abundance mainly by translocating previously synthesized GLUT4 molecules from an intracellular compartment, whereas more chronic ischemia also increases GLUT1 abundance via enhanced mRNA expression. Increased GLUT1 and GLUT4 abundance may participate in the augmented glucose uptake of ischemic myocardium and therefore may help protect ischemic myocardium from irreversible injury.

Animals↗
PubMed1997

Surgical delay for acute type A dissection with malperfusion.

BACKGROUND: An acute type A aortic dissection is considered a surgical emergency. Review of the risk factors for a type A dissection showed that preoperative malperfusion was associated with a 22% (2/9) intraoperative mortality and an 89% (8/9) hospital mortality. Intraoperative deaths were secondary to pulmonary failure resulting from capillary leak; the remaining patients died of multiorgan failure resulting from reperfusion injury. METHODS: The surgical delay approach was adopted for malperfused patients, and treatment in these patients included percutaneous reperfusion, with aortic fenestration and branch stenting where appropriate. Twenty patients had a type A dissection and malperfusion shown by pulsed-wave Doppler echocardiography, transesophageal echocardiography, or spiral computed tomographic scanning. Malperfusion was documented by angiography. After reperfusion, all patients' conditions were stabilized in the intensive care unit; intravenous beta-blockers were administered to decrease the maximum rate of increase of left ventricular pressure. Once patients completely recovered from the consequences of malperfusion, surgical repair was performed. Statistical comparison of the non-delay and delay groups was performed using Fisher's exact test and Student's t test. Multiple logistic regression analysis was used to establish independent predictors for mortality. RESULTS: The mean delay to repair was 20 days (2 to 67 days). Four (31%) patients were discharged home and readmitted for operation. Three patients (15%) died preoperatively, 1 of retrograde dissection and rupture and 2 of reperfusion injury. Seventeen underwent surgical repair, with two deaths (12%); 15 (75%) were discharged, with an average follow-up of 16.8 months (p < 0.003). Delay was the only independent predictor of outcome. CONCLUSIONS: Patients with an acute type A dissection and malperfusion should undergo percutaneous reperfusion, and surgical repair should be delayed until the reperfusion injury resolves.

Adult↗
PubMed1997

The dissected aorta: part III. Anatomy and radiologic diagnosis of branch-vessel compromise.

PURPOSE: To determine the anatomic, hemodynamic, and radiologic characteristics of branch-vessel compromise in patients with aortic dissection. MATERIALS AND METHODS: Sixty-two patients with aortic dissection were evaluated with aortography (n = 62), intravascular ultrasound (US) (n = 35), and manometry (n = 56). Branch-vessel compromise with ischemia was suspected in 40 of these patients. Radiologic and manometric findings were correlated with clinical findings of ischemia. Femoral artery pulse strength was correlated with access from the respective femoral artery to the true and false lumina of the dissected aorta. RESULTS: Twenty-six of 40 patients suspected of having ischemia had angiographic evidence of branch-vessel compromise, and intravascular US helped identify two types of branch-vessel compromise in them: static (dissection intersected and narrowed the vessel origin) and dynamic (dissection spared the vessel origin, but the dissection flap appeared to compress the true lumen at or above the origin and covered the origin). False-lumen pressure in classic dissections exceeded (n = 16) or equaled (n = 30) true-lumen pressure. Branch vessels that arose exclusively from the false lumen were well perfused. Findings of a dissection flap oriented concave toward the false lumen were 91% sensitive and 72% specific for a true-lumen pressure deficit. CONCLUSION: Intravascular US and manometric findings clarify the mechanisms of branch-vessel compromise after aortic dissection and provide a rational guide for percutaneous treatment.

Adolescent↗
PubMed1997

Mediators of ischemia-reperfusion injury of rat lung.

In rats, we characterized the mediators of lung reperfusion injury after ischemia. Animals underwent left lung ischemia. After 90 minutes of ischemia, reperfusion for up to 4 hours was evaluated. Lung injury, as determined by vascular leakage of serum albumin, increased in ischemic-reperfused animals when compared with time-matched sham controls. Injury was biphasic, peaking at 30 minutes and 4 hours of reperfusion. The late but not the early phase of reperfusion injury is known to be neutrophil dependent. Bronchoalveolar lavage of ischemic-reperfused lungs at 30 minutes and 4 hours of reperfusion demonstrated increased presence of serum albumin, indicative of damage to the normal vascular/airway barrier. Lung mRNA for rat monocyte chemoattractant protein-1 and tumor necrosis factor-alpha peaked very early (between 0.5 and 1.0 hour) during the reperfusion process. Development of injury was associated with a decline in serum complement activity and progressive intrapulmonary sequestration of neutrophils. Administration of superoxide dismutase before reperfusion resulted in reduction of injury at 30 minutes of reperfusion. Complement depletion decreased injury at both 30 minutes and 4 hours of reperfusion. Requirements for tumor necrosis factor-alpha, interferon-gamma, and monocyte chemoattractant protein-1 for early injury were shown whereas only tumor necrosis factor-alpha was involved at 4 hours. We propose that acute (30-minute) lung injury is determined in large part by products of activated lung macrophages whereas the delayed (4-hour) injury is mediated by products of activated and recruited neutrophils.

Animals↗
PubMed1996

Mitral valve reconstruction for active and healed endocarditis.

BACKGROUND: Mitral valve reconstruction rather than replacement for mitral insufficiency offers a number of well-accepted benefits. However, the feasibility and results of reconstruction for endocarditis remain largely unknown. METHODS AND RESULTS: We reviewed 22 consecutive patients referred to the Thoracic Surgical Service at the University of Michigan from January 1, 1991, through October 1, 1995, who underwent mitral valve reconstruction for mitral insufficiency caused by isolated mitral valve endocarditis. Mean age, preoperative ejection fraction, and New York Heart Association (NYHA) functional class were 53 +/- 15 years, 54 +/- 12%, and 3.2 +/- 0.8, respectively. Seven patients had early operation because of septic embolization, persistent infection, or refractory heart failure. Fifteen were cured of infection and were operated on for progressive symptomatic heart failure and left ventricular dilation. Preoperative transesophageal echocardiograms demonstrated severe mitral insufficiency in 20 patients. Valvular pathology noted at operation included annular (6 patients) or leaflet calcification (2), chordal rupture (13), leaflet vegetations (11), annular abscess (3), annular dilation (18), flail leaflet (12), leaflet prolapse (17), chordal shortening (1), and mitral stenosis (1). Mitral valve reconstruction included debridement of infected tissue and implantation of an annuloplasty ring (20 of 22 patients), as well as other complex techniques. Postrepair transesophageal echocardiograms demonstrated mild mitral insufficiency in 6 patients and none in 16 patients. There were no operative or in hospital deaths. Mean follow-up was 20 +/- 14 months. One late death occurred at 30 months. At follow-up, 90% of surviving patients were in NYHA functional class I or II. CONCLUSIONS: Mitral valve reconstruction for active or healed endocarditis can be performed with low operative morbidity and mortality and yields excellent functional results. Although longer-term follow-up is mandatory, these data support strong consideration of mitral valve reconstruction rather than mitral valve replacement for mitral insufficiency secondary to endocarditis.

Adult↗
PubMed1996

Restricted V beta usage by T cells infiltrating rejecting human lung allografts.

TCR expression was evaluated in lung transplant patients to determine whether T cells infiltrating rejecting lung allografts employed restricted V beta elements. Serial bronchoalveolar lavage (BAL) specimens were obtained from six lung transplant recipients at approximately 3 wk, 6 wk, and 3 mo post-transplant. T cell lines were established by culturing lavage cells with irradiated donor splenocytes in the presence of low dose IL-2 for 3 wk, and TCR V beta usage was determined by quantitative reverse transcriptase-PCR. Patients were grouped into three categories based on TCR V beta profiles and the clinical status of the allograft. 1) In one patient, BAL-derived T cells expressed heterogeneous V beta repertoires at all time points evaluated. This patient did not experience graft rejection during the 16-mo period of observation, though respiratory infections were diagnosed. 2) In three patients, V beta usage by BAL-derived T cells was restricted during allograft rejection episodes, but was heterogeneous in the absence of rejection and during respiratory infections. In one of these patients, similar V beta repertoires were employed by BAL cells during multiple rejection episodes. 3) In two patients, restricted V beta usage by BAL-derived T cells was observed before and during rejection episodes. Collectively, these data illustrate that human lung allograft rejection, but not pulmonary infection, is associated with T cells expressing a limited number of V beta families. Restricted V beta usage by graft-reactive T cells may allow for the selective elimination of these cells using TCR-specific reagents, thereby promoting allograft-specific tolerance.

Bronchoalveolar Lavage Fluid↗
PubMed1996

Regulatory effects of interleukin-10 on lung ischemia-reperfusion injury.

OBJECTIVE: Interleukin-10, a cytokine with antiinflammatory activities, was studied to determine its effects on development of early lung reperfusion injury. METHODS: Adult male rats underwent 90 minutes of left lung ischemia followed by 4 hours of reperfusion. Time-matched sham-operated control rats underwent hilar dissection but not lung ischemia. Lung injury was measured by vascular permeability to bovine serum albumin tagged with iodine 125. To evaluate the effect of exogenous interleukin-10, additional animals received interleukin-10 intravenously before ischemia. To assess the role of endogenous interleukin-10, animals received rabbit antimouse interleukin-10 immunoglobin G (or preimmune rabbit immunoglobin G) before ischemia. RESULTS: Compared with sham control rats, ischemia-reperfusion control rats demonstrated significantly more lung injury. Animals receiving interleukin-10 had significantly less lung injury than did ischemia-reperfusion control rats. Animals receiving antiinterleukin-10 had significantly more lung injury than did animals receiving preimmune immunoglobin G. Alveolar macrophages from animals after 90 minutes of lung ischemia produced more tumor necrosis factor-alpha in culture than did unstimulated macrophages; this production was reduced significantly by the addition of interleukin-10 to the culture medium. CONCLUSION: Endogenous interleukin-10 has a protective effect against early lung reperfusion injury, and interleukin-10 administration can reduce lung reperfusion injury, perhaps in part through its ability to reduce production by alveolar macrophages of tumor necrosis factor-alpha, a known proinflammatory cytokine.

Animals↗
PubMed1996

Evaluation of thoracic aortic disease with the use of helical CT and multiplanar reconstructions: comparison with surgical findings.

PURPOSE: To assess the accuracy of helical computed tomography (CT) in differentiating different types of thoracic aortic disease, to determine the incremental value of multiplanar reconstructions, and to determine if helical CT could help to reliably predict the need for intraoperative hypothermic circulatory arrest. MATERIALS AND METHODS: Forty-nine patients underwent pre-operative helical CT with multiplanar reconstructions. Images were reviewed for type and location of pathologic lesions and for features that indicated the need for hypothermic circulatory arrest. The incremental yield of multiplanar reconstructions compared with that of axial images was assessed. Imaging findings were compared with surgical findings. RESULTS: The types of lesions present in the patients included 36 aneurysms (three were ruptured), six penetrating ulcers, five dissections, and two pseudoaneurysms. The accuracy of diagnosis was 92% (45 of 49 patients) with the use of CT (both with and without multiplanar reconstruction). The necessity of hypothermic circulatory arrest was successfully predicted in 94% (45 of 48 patients) of cases. CONCLUSION: Helical CT, both with and without the use of multiplanar reconstruction, enabled highly accurate differentiation among diseases of the thoracic aorta and prediction of the need for hypothermic circulatory arrest.

Aorta, Thoracic↗
PubMed1996

Mitral valve reconstruction in elderly, ischemic patients.

The role of mitral valve reconstruction is controversial in elderly patients with concurrent ischemic heart disease owing to technical difficulty, prolonged operative times, high mortality, and possible residual mitral regurgitation. However, mitral reconstruction could be most beneficial in this age group due to preservation of left ventricular function, avoidance of anticoagulation, or repeat operation for bioprosthetic degeneration. We studied the outcome of mitral valve reconstruction in 100 consecutive elderly ischemic patients 65 years or older (mean = 73 years; range, 65 to 86 years) operated on between October 1990 and May 1995. Preoperatively all patients were New York Heart Association (NYHA) class III or IV with an ejection fraction of 32 +/- 2%. All patients underwent primary coronary bypass grafting (2.7 +/- 0.2 grafts) and had a flexible mitral annuloplasty ring inserted. Additionally, 54 patients required further complex mitral repairs. All patients had 4+ mitral regurgitation by transesophageal echocardiography prior to operation. After mitral reconstruction, no patient had more than 1+ regurgitation, while most had none and no systolic anterior leaflet motion was noted. There were 4 early (30 day) deaths (4%) and 6 late deaths (6%) at a mean follow-up of 25 months. Patient morbidity has included episodes of mild congestive heart failure (nine), transient ischemic attack (one), endocarditis (one), and respiratory failure (five). There have been one early and two late reoperations for mitral valve replacement. All remaining patients are in NYHA class I or II. While longer-term follow-up is mandatory, coronary bypass grafting and mitral valve reconstruction in the elderly can be accomplished with acceptable surgical mortality and morbidity, yielding reliable improvement in symptoms and quality of life.

Aged↗