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Biomedical subjects

J A Kisslo

Publications and source records attributed to J A Kisslo.

At least 19 recordsLinked to original sources
PubMed1992

Diagnosis and management (by subxiphoid pericardiotomy) of large pericardial effusions causing cardiac tamponade.

To determine the clinical features, course and outcome of patients with cardiac tamponade, 57 consecutive patients with new, large pericardial effusions were prospectively studied. Twenty-five patients (44%) developed cardiac tamponade with venous hypertension and a pulsus paradoxus greater than 10 mm Hg. Electrocardiography, radiographic studies and echocardiography did not differentiate patients with and without tamponade. All 57 patients underwent thorough diagnostic evaluation followed by subxiphoid pericardial biopsy and drainage. A diagnosis was obtained in 53 patients (93%). Collagen vascular disease was significantly more frequent in the 25 patients with than in the 32 without cardiac tamponade (24 vs 3%; p less than 0.05). The frequency of malignant and uremic effusions was equal in both groups, whereas radiation-induced effusions seldom produced tamponade. At 1-year follow-up, 3 patients (12%) with tamponade had recurrent effusions, and 1 needed reoperation. This was not significantly different from the 32 patients without tamponade. Twelve-month mortality was also similar in both groups (36 vs 44%). This prospective series disclosed several unexpected findings: (1) Cardiac tamponade occurred in almost 50% of patients with new large pericardial effusions; (2) both malignancy and collagen vascular disease occurred with equal frequency as etiologies, whereas radiation-induced tamponade was unusual; (3) thorough clinical evaluation resulted in few idiopathic etiologies; and (4) subxiphoid pericardiotomy was effective for both diagnosis and therapy of tamponade.

Cardiac Tamponade↗
PubMed1992

The learning curve for intraoperative echocardiography during congenital heart surgery.

Our group has previously reported a large prospective experience with the use of intraoperative echocardiography with Doppler color-flow imaging (IE-DCFI) during the repair of congenital heart defects. We have now performed IE-DCFI in 621 patients and have observed a major change in the impact of this technology, which has stabilized during our most recent experience (the last 207 patients). To evaluate the surgical learning curve with IE-DCFI, we divided patients into three groups: group 1, patients 1 through 207; group 2, patients 208 through 414; and group 3, patients 415 through 621. There were no major differences between groups with respect to age or disease entities. The average time needed to perform an IE-DCFI examination decreased from 3.75 +/- 1.77 minutes in group 1 to 3.35 +/- 1.52 minutes in group 2 and has remained stable. The number of patients requiring revisions in the operating room (based on IE-DCFI findings) decreased from 17 (8%) in group 1 to 7 (3%) in group 2 to 5 (2%) in group 3. Furthermore, revisions were 100% successful in correcting the problem in groups 2 and 3, whereas 18% of group 1 patients left the operating room with persistent residual defects by IE-DCFI. Surgeons can acquire the ability to interpret the results of IE-DCFI themselves and use it to enhance their operative repair of congenital heart defects, but this requires an experience of at least 200 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac Surgical Procedures↗
PubMed1992

Subxiphoid pericardiotomy in the diagnosis and management of large pericardial effusions associated with malignancy.

To determine the safety, diagnostic value, and clinical outcome of patients with malignancy undergoing subxiphoid pericardiotomy for large pericardial effusions, we prospectively studied 25 consecutive patients with malignancy and new, large pericardial effusions diagnosed by echocardiography. Twenty-two of the 25 operations were done under local anesthesia, and no patient died at surgery. Pericardial fluid cytology revealed malignant cells in 11 patients (44 percent), while tumor was seen in only five (45 percent) of these 11 patients on pathologic examination. The remaining 14 patients showed no evidence of pericardial invasion with tumor. Evidence of intrathoracic disease by CT or MRI scanning, tamponade, a sanguineous pericardial fluid character, and an elevated serum and pericardial fluid lactate dehydrogenase level all were suggestive of malignant invasion of the pericardium. All 25 patients were followed at least 12 months postoperatively. Effusions recurred in three patients (12 percent), and one patient required reoperation. Overall mortality was 72 percent with a 91 percent (10 of 11) mortality for those with malignant effusions and a 57 percent (8 of 14) mortality for those with nonmalignant effusions. Diagnostically, subxiphoid pericardiotomy has little advantage over examination of pericardial fluid alone in this group of patients. Therapeutically, however, it is a low morbidity procedure which is safe and effective in treating patients with malignancy and large pericardial effusions.

Cardiac Tamponade↗
PubMed1991

Safety and efficacy of sonicated albumin microspheres in perfusion and vein graft patency assessments.

This study was designed to identify a concentration of sonicated albumin microspheres that is safe, useful in determining graft patency, and provides an estimate of regional myocardial perfusion. The study included 8 patients between 50 and 72 years of age who were undergoing coronary artery bypass grafting. All patients were hemodynamically stable with left ventricular ejection fractions greater than or equal to 0.35. None had congestive heart failure or myocardial infarction within 4 months prior to the study. All had normal baseline neurologic and renal functions, and none had experienced allergic reactions to blood products or contrast dyes. A standard median sternotomy was performed for exposure of the heart at surgery, and saphenous veins were harvested and used for grafting. Intraoperative epicardial echocardiography (EE), always in the left ventricle short-axis at midpapillary level, was performed before and after grafting to determine regional myocardial wall motion. Sonicated albumin microspheres were prepared and injected into a single vein graft using an 18-gauge needle; 20 x 10(6), 100 x 10(6), and 200 x 10(6) microspheres were injected into the first graft sequentially. All other vein grafts were injected once with the dose that gave optimal contrast enhancement in the initial graft studied. In each patient, a minimum of 3 and maximum of 5 injections were performed, and graft perfusion was studied using EE. Graft flow, blood pressure, and electrocardiographic (ECG) measurements were continuously monitored, with a final EE performed after weaning the patient off cardiopulmonary bypass to assess wall motion. Preliminary results showed that no patient had adverse effects during or after the study and all remained hemodynamically stable.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1990

Routine use of intraoperative epicardial echocardiography and Doppler color flow imaging to guide and evaluate repair of congenital heart lesions. A prospective study.

Routine epicardial two-dimensional echocardiography, Doppler, and Doppler color flow imaging studies were performed before and after cardiopulmonary bypass in 328 patients undergoing operations for congenital heart disease. Ages ranged from 1 day to 59 years (mean 5.9 years); the smallest patient was 1.8 kg. Complete examinations were conducted in 3.6 +/- 1.7 minutes. Prebypass examinations demonstrated previously unappreciated details of anatomy in 60 patients (18%), which did not relate to whether catheterization had been performed, and they were believed to play a role in surgical planning in 143 patients (44%). Discovery of previously unrecognized features of anatomy increased the impact of echo-Doppler color flow imaging on operative planning by 2.5 times. After bypass, echo-Doppler color flow imaging disclosed unsuspected residual defects in 22 patients (7%) who were doing well clinically and enabled an attempt at immediate revision of the procedure. When ultimate clinical outcome was compared to postbypass findings of echo-Doppler color flow imaging, the presence of a residual defect, right or left ventricular dysfunction, or any concern with the heart by echo-Doppler color flow imaging appeared to serve as a predictor of unfavorable outcome (p less than 0.001 for each when compared with absence of these difficulties). Thus routine intraoperative echo-Doppler color flow imaging is useful in aiding the planning, conduct, and assessment of results in operations for congenital heart disease.

Cardiopulmonary Bypass↗
PubMed1989

Patent foramen ovale and decompression sickness in divers.

30 patients with a history of decompression sickness were examined for the presence of patent foramen ovale by bubble contrast, two-dimensional echocardiography and colour flow doppler imaging. With bubble contrast, 11 (37%) of the patients had right-to-left shunting through a patent foramen ovale during spontaneous breathing. 61% of a subset of 18 patients with serious signs and symptoms had shunting. This number was significantly higher than the 5% prevalence seen with the same diagnostic technique in 176 healthy volunteers. The presence of patent foramen ovale seems to be a risk factor for the development of decompression sickness in divers.

Acute Disease↗
PubMed1989

The use of intraoperative echo with Doppler color flow imaging to predict outcome after repair of congenital cardiac defects.

Surgical repair of congenital cardiac defects (CCD) has undergone a remarkable evolution in the past decade. Major defects are now often completely corrected in early infancy with continually improving rates of survival. It has become clear that the next major focus will be improvements in the long-term quality of life and this has promoted many innovations in surgical technique and approach. One advance is the use of intraoperative echo with Doppler color flow imaging (echo-DCFI) to evaluate the exactness of operative repair. Aside from anecdotal reports, very little information is available regarding the interpretation of images produced by this technology in the operating room. Furthermore there have been no studies addressing the predictive value of intraoperative echo-DCFI findings with respect to outcome for patients undergoing repair of CCD. The prospective data obtained by following the course of 273 patients receiving intraoperative echo-DCFI has been reviewed after repair of a variety of CCD (age range, 1 to 53 years; mean 5.3 years; smallest patient, 1.8 kg). Forty-seven patients (17%) had initially unacceptable results, by echo, at the completion of their repair. Eighteen of these patients (7% of entire series) had no clinical problems and the defects were discernible only by echo. Twenty-six patients with initially unacceptable results had their repairs revised in the operating room and left with an acceptable result by echo. Twenty-one patients were allowed to leave the operating room with echo-discernible defects. Follow-up of these patients demonstrated a significantly higher (p less than 0.006) rate of reoperation (42% vs. 3%) and of early death (29% vs. 10%) for those patients whose defects were left unrepaired compared to those whose problems were corrected before leaving the operating room. Sixty-eight patients (25%) had some alteration of ventricular function (compared to their prebypass evaluation) at the completion of their repair. Regardless of whether the dysfunction was limited to the right ventricle, left ventricle, or was biventricular, patients in this group had a significantly higher incidence (p less than 0.004) of early, but not late, death compared to patients without alteration of ventricular function (35% vs. 4%). Patients who left the operating room with no problems of concern by echo-DCFI had a greater than 90% likelihood of a long-term acceptable outcome compared to patients who had any problem of concern (residual defect, anatomic or technical imperfection, ventricular dysfunction, and so on) whose long-term likelihood of an acceptable outcome approached 50% (p less than 0.0125).(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1989

Intraoperative prebypass and postbypass epicardial color flow imaging in the repair of atrioventricular septal defects.

The use of intraoperative epicardial Doppler echocardiography with color flow imaging both before and after cardiopulmonary bypass to assist repair of congenital heart defects in infants and small children has not been reported. To demonstrate its simplicity and utility, we obtained immediately prebypass and postbypass examinations from 18 consecutive patients undergoing repair of atrioventricular septal defects between March 1987 and March 1988 (aged newborn to 3 years, smallest 2.4 kg, 11 patients less than 1 year old). Direct application of a sterile transducer to the epicardial surface eliminates any restriction imposed by the transesophageal approach, and the routine use of color flow imaging enables the operating surgeon to directly evaluate intracardiac anatomy and flows in a variety of orientations. Average examination time was 3.95 +/- 1.96 minutes. Prebypass studies disclosed that a short-axis inspection through the common atrioventricular valve orifice produced a unique visualization of the dynamic commitments of atrioventricular valve tissue throughout systole and diastole that was helpful in planning valve allocation during repair. In addition, echocardiography demonstrated features not previously appreciated in seven of 18 patients (39%). In all, image quality and resolution were vastly superior to preoperative chest wall studies. Postbypass studies revealed significant residual interventricular shunts in two of 18 patients (11%). Views obtained from various orientations directed specific and efficient repair immediately so that all patients left the operating room with documented, surgically acceptable results. Comparison of ventricular function between prebypass and postbypass studies enabled appropriate application of pharmacologic agents in the operating room if necessary. All patients survived their operation. There have been two late deaths, and 16 patients are alive and doing well (follow-up: 9 to 21 months). These experiences indicate that intraoperative epicardial Doppler color flow imaging (1) can be easily learned and applied by the surgeon, (2) enhances the repair of atrioventricular septal defect by providing unique spatial, anatomic, and flow information in the beating heart at the time of repair, (3) increases confidence of a surgically acceptable repair before the patients leave the operating room, (4) guides specific surgical or anesthetic adjustments to optimize results, and (5) works as a valuable aid that may help reduce poor results in the repair of complex congenital cardiac lesions.

Abnormalities, Multiple↗
PubMed1988

In vivo estimation of left ventricular wall volume in volume-overloaded canine hearts.

Several geometric algorithms have been applied to estimate left ventricular wall volume (Vwall) from two-dimensional echocardiograms but have not been validated in eccentrically hypertrophied hearts. These algorithms can be fitted to the general formula: Vwall = k.Ao.Lo = k.Ai.Li, where Ao and Ai are the outer (epicardial) and inner (endocardial) short-axis areas, Lo and Li are the corresponding long-axis lengths, and k is a constant. The simplifying assumption that Lo and Li are equal yields Vwall = k.Awall.Lo, where Awall = Ao - Ai. In 20 unsedated dogs (10-30 kg), including 10 with aortic regurgitation of 1-18 wk duration, the relationship between actual Vwall (determined postmortem) and Awall.Lo was not significantly different from the line of identity (Vwall = 1.01 Awall.Lo + 0.5 ml, r = 0.98, SEE = 3.5 ml), indicating k was not significantly different from 1. There was no significant difference between predicted and actual Vwall over a range of 31-105 ml, and interobserver variability was 4.1%. The simple area-length product, Awall.Lo, accurately predicts Vwall of both normal and volume-overloaded hypertrophied canine left ventricles and is thus suitable for serial observations of hypertrophic adaptation to volume overload.

Algorithms↗
PubMed1987

Validation of in vivo two-dimensional echocardiographic dimension measurements using myocardial mass estimates in dogs.

The accuracy of in vivo measurements of left ventricular wall thickness and chamber size by means of two-dimensional echocardiography was investigated by comparing left ventricular mass estimates obtained at end diastole in 15 closed-chest dogs with a wide range of left ventricular weights. The systolic and diastolic echocardiographic mass estimates were compared with the actual weights of the freshly excised, stripped left ventricles immediately following death. The mean +/- SD of the weighed mass of the excised ventricles was 104 +/- 25 gm. The mean predicted left ventricular mass with the use of the cylinder-ellipse geometric model and gross anatomic sections corresponding to the echocardiographic imaging planes was 106 +/- 26 gm (r = 0.97 compared to the actual weight). The mean echocardiographic estimate of left ventricular mass at end diastolic was 107 +/- 24 gm (r = 0.98 compared to the weight) and 105 +/- 26 gm at end systole (r = 0.95 compared to the weight). The correlation between the echocardiographic mass estimate at end diastole and the echo mass estimate at end systole was 0.95. Regression analysis failed to demonstrate a significant over- or underestimation of the actual weight by the calculated mass with the use of either the gross anatomic or the in vivo echocardiographic dimension measurements.

Animals↗
PubMed1987

Sequence of mitral valve motion and transmitral blood flow during manual cardiopulmonary resuscitation in dogs.

According to the thoracic pump model of cardiopulmonary resuscitation (CPR), the heart serves as a passive conduit for blood flow from the pulmonary to the systemic vasculature, necessitating an open mitral valve and anterograde transmitral blood flow during chest compression. To assess the applicability of this model to manual CPR techniques, two-dimensional echocardiograms were recorded from the right chest wall and/or the esophagus in nine dogs (18 to 26 kg) during manual CPR. The aortic valve opened with chest compression and closed with release, while the pulmonary and tricuspid valve leaflets closed with compression and opened during release. The mitral valve remained open during ventilation alone and during abdominal compressions. With the onset of brief, high-velocity (high-impulse) chest compressions, the mitral valve closed rapidly and the left ventricle was deformed, whether compressions were applied to the sternum or the left mid-chest wall. The mitral valve reopened with release of each compression. Left atrial echocardiographic contrast injections confirmed the absence of anterograde transmitral blood flow during high-impulse compression and its presence during release. Failure of mitral leaflet approximation during chest compression was observed only when a very low-velocity, prolonged (low-impulse) compression technique was used, or when regions that did not directly overlie the heart were compressed. Consistent with these observations, simultaneous recordings of the left ventricular and left atrial pressures during high-impulse sternal compressions in five dogs (19 to 25 kg) demonstrated peak and mean left ventriculoatrial pressure gradients of 38.5 +/- 4.0 and 13.5 +/- 2.9 mm Hg, respectively, and these pressure gradients declined with less impulsive compressions. The observations made during all but low-impulse chest compressions are inconsistent with the thoracic pump model, and support direct cardiac compression as the primary mechanism of forward blood flow with more impulsive manual chest compression techniques.

Animals↗
PubMed1987

Intraoperative transesophageal color flow mapping: initial experience.

Transesophageal Doppler color flow mapping (TEDCFM) is a new ultrasound modality now being developed. It provides a convenient, noninvasive way to image cardiac anatomy and intracardiac blood flow that is applicable to intraoperative use. We describe its use in one normal subject and seven cardiac surgical patients. Blood flow characteristics as visualized by TEDCFM are described for these patients. Transesophageal Doppler color flow mapping provided specific information about the presence, site, and severity of mitral regurgitation, aortic regurgitation, and interatrial shunting. Paravalvular leak was detected in one patient after mitral valve replacement. The intimal tear of a type I aortic dissection was located with positive identification of the true and false lumina. A high incidence of mild asymptomatic mitral regurgitation was found in patients undergoing coronary artery bypass grafting (CABG).

Cardiac Surgical Procedures↗
PubMed1985

Cardiac involvement in myotonic muscular dystrophy.

Cardiac illness in myotonic muscular dystrophy (MyD) is infrequent, but subclinical cardiac involvement in MyD is very common (found in 42 of 46 subjects) and may be responsible for sudden death. In this series, we found ECG abnormalities in 72%, left ventricular dysfunction in 70%, mitral valve prolapse in 37%, and sudden death in 4%. Four deaths during the study period were due to acute left ventricular failure, one to sepsis and respiratory insufficiency, and one was unexplained. We did not find ominous bradyarrhythmias or atrioventricular block, evidence of congestive heart failure, noninvasive evidence of coronary artery disease, or any correlation of type or amount of cardiac involvement with any clinical parameter such as age, sex, or severity of systemic dystrophy. We feel tachyarrhythmias may play as important a role in sudden death of myotonic muscular dystrophy subjects as bradyarrhythmias, and coronary artery disease in addition to cardiac dystrophy may produce arrhythmias and myocardial dysfunction in myotonic muscular dystrophy. In addition, some subjects have an unusual form of resting left ventricular dysfunction which improves with exercise. The most important problem in the clinical management of myotonic muscular dystrophy subjects is sudden death, and the solution does not appear to be empiric ventricular pacing. Our recommendations for prophylaxis of sudden death in myotonic muscular dystrophy are noninvasive investigation of coronary artery disease in subjects with significant risk factors, with angiography and surgery if indicated: detailed evaluation of syncopal and presyncopal events, including electrophysiologic testing, with pacemaker or antiarrhythmic drug therapy if indicated; and consideration of ventricular pacing of asymptomatic subjects if severe bradycardia or marked intraventricular conduction delay develops during follow-up, serial 12-lead ECGs. The documentation of tachyarrhythmias during sudden death and syncopal episodes in myotonic muscular dystrophy subjects makes ventricular pacing alone an uncertain modality for prevention of sudden death in subjects with only mildly lengthened PR or QRS intervals, and suggests a combination of pacemaker and antiarrhythmic drug therapy for the myotonic muscular dystrophy subject with syncope of no apparent cause.

Adult↗
PubMed1985

Right ventricular isolation procedures for nonischemic ventricular tachycardia.

Nonischemic ventricular tachycardia most commonly arises in the right ventricular free wall and is frequently refractory to medical therapy. Many different types of surgical procedures have been employed to treat medically refractory nonischemic ventricular tachycardia arising in the right ventricle, but the results of these procedures have been less than optimal. The majority of these surgical procedures have been directed toward ablation of the site (or sites) of origin of the tachyarrhythmia and have failed because of the frequent occurrence of multifocal or polymorphic ventricular tachycardia in these patients. We first employed localized surgical isolation procedures to control nonischemic ventricular tachycardia arising in the right ventricular free wall in 1979. These localized procedures evolved into the development of a technique for isolating the entire right ventricular free wall from the remainder of the heart to control ventricular tachyarrhythmias arising from multiple sites in the right ventricle. Case histories are reported of two patients who underwent localized isolation procedures in 1979 as well as two patients who underwent total disconnection of the right ventricle in 1982. The follow-up period in these four patients ranges from 2 to 5 years and the control of their tachyarrhythmias has been uniformly successful. However, surgical isolation of the entire right ventricular free wall has resulted in progressive dilatation of the right ventricle as documented by serial echocardiography. The pathophysiology of the progressive right ventricular dilatation postoperatively is discussed in terms of etiology and prevention, and the indications for application of localized and total isolation procedures for nonischemic right ventricular tachycardia are outlined.

Adolescent↗