Search PubMed⌕ Search

Biomedical subjects

J L Monro

Publications and source records attributed to J L Monro.

At least 55 records · Page 3Linked to original sources
PubMed1998

Surgery for congenital heart disease in Europe 1995.

OBJECTIVE: An attempt was made to find out how many operations were performed in Europe in 1995 for congenital heart disease. METHODS: Representatives from the 20 most active European countries which could supply reliable information were contacted. They were asked to contact all surgeons performing significant numbers of operations for congenital heart disease in their country. The numbers of operations on children under and over 1 year operated on with and without cardiopulmonary bypass were collected. No attempt was made to collect more detailed information such as operative mortality as it was felt that many surgeons would be reluctant to give their results and the data would be incomplete. RESULTS: A total of 27,976 operations were recorded, of which 20,318 were performed with cardiopulmonary bypass and 7658 without. The total population of the 20 European countries was 448 million and the mean number of operations performed with cardiopulmonary bypass per million was 45.4. However, the rate varied from 9.1 to 70.1. The percentage of operations on cardiopulmonary bypass performed in the first year of life varied from 9.4% to 44.4%. CONCLUSIONS: The total of nearly 28,000 operations in 1995 is probably an underestimate, but it has been difficult to collect this data at all. Obviously many smaller countries have not been included, and some older patients undergoing operations such as atrial septal defect closure in adult units have been missed. The number of open heart operations per million vary in different countries and this presumably represents differing referral patterns. If their numbers are low in some countries, these results may be helpful in persuading their governments that more resources are needed for congenital heart surgery. It is also interesting to see the variation in the number of operations performed in the first year of life. Those countries with a lower rate may have a backlog of older patients who were previously palliated, or their surgeons may still prefer initial palliation and later correction in some conditions rather than early correction. It is hoped that with better prospective data collection, an assessment can be repeated in 2000.

Cardiac Surgical Procedures↗
PubMed1998

Postinfarction ventricular septal rupture: the Wessex experience.

Surgical repair of a postinfarct ventricular septal defect (VSD) remains a difficult surgical challenge associated with a significant operative mortality. Between 1972 and 1995, 179 patients with a postinfarct VSD have undergone operation in this institution. There were 118 males and 61 females, with a mean age of 66 years (range 43 to 80). Operative mortality was 26.7%. Surgery was deferred until 1 month after the septal rupture in 29 patients, with these labeled as having a chronic VSD. The remaining 150 underwent operation on within 1 month of infarction and are described as having an acute VSD. For those with an acute VSD, factors significantly associated with an increased risk of 30-day mortality included preoperative New York Heart Association status (P = .04), site of myocardial infarction (inferior worse than anterior) (P = .004), cross-clamp time (P = .05) and cardiopulmonary bypass time (P = .0001) (logistic regression). On multiple logistic regression, only cardiopulmonary bypass time remained significant. Survival including in-hospital mortality at 5 and 10 years was 49% +/- 4% and 31% +/- 5% and excluding in-hospital mortality was 72% +/- 5% and 45% +/- 6%, respectively. Those patients who survived attained a good quality of life. No factors were significantly associated with prolonged survival.

Adult↗
PubMed1998

Induced hypothermia in the postoperative management of refractory cardiac failure following paediatric cardiac surgery.

Postoperative low cardiac output states are a major cause of postoperative mortality in infants and children following corrective cardiac surgery for congenital heart defects. In this unit, whole body hypothermia has been used since 1979 in the management of these low output states when they are refractory to conventional modes of therapy. Twenty cases treated in this way between July 1986 and June 1990 were reviewed in 1992. The current report reviews the 50 further cases treated with moderate hypothermia between July 1990 and December 1995. The median (range) age of patients was 8 months (0 days-16 years) with a median weight of 4.1 kg (2.5-33 kg). Following cooling, there was a decrease in heart rate (p < 0.001), an increase in mean arterial pressure (p < 0.001) and a decrease in mean atrial pressure (p < 0.001). Significant increases in pH and urine output were also noticed, the increase in urine output being greater in the surviving group (p = 0.02). A decrease in platelet count occurred (p < 0.001) but white blood cell count remained unchanged (p = 0.18). Twenty-five of the 50 patients survived to leave hospital. Induced hypothermia does not appear to be associated with any complications and after the failure of all conventional treatment, it seems likely that the technique may have been beneficial to outcome in some patients.

Adolescent↗
PubMed1997

Aortic valve repair of congenital stenosis with bovine pericardium.

BACKGROUND: Conservative surgical options in the treatment of congenital aortic stenosis are limited. To relieve the obstruction necessitates full incision of the raphe of the larger valve leaflet, but this inevitably causes prolapse. METHODS: We performed aortic valve repair in 6 children, aged 14 months to 17 years, with congenital aortic stenosis, 2 having had aortic valvotomy as infants. The repair consisted of suturing the base of a triangular piece of bovine pericardium, with a simple vertical fold, to the free edges of the incised raphe. The pericardial fold was then sutured vertically to the aortic wall. RESULTS: At follow-up of 2 to 60 months, the mean peak systolic Doppler gradients had decreased from 80 +/- 15 mm Hg to 26 +/- 9 mm Hg. The effective valvular orifice area increased from 33% +/- 6% to 64% +/- 3%, allowing blood flow to increase by a factor of 3.76. Two patients have mild and 2 have mild-to-moderate aortic regurgitation. CONCLUSIONS: The described conservative repair renders the valve tricuspid and trisinusoidal, and the deficient interleaflet triangle is recreated, preventing cusp prolapse. Longer follow-up is required to assess the durability of unstented pericardium in the aortic position, but the early results are encouraging.

Adolescent↗
PubMed1997

Surgical treatment of acquired ventricular septal defects in the elderly.

OBJECTIVE: As the population continues to age, older patients are being referred for repair of acquired ventricular septal defect (VSD) following myocardial infarction (MI). The purpose of this study was to assess the effect of age (> or = 70 years) on operative risk and long term survival following repair of an acquired VSD. METHODS: Between January 1972 and December 1995, 179 patients have undergone repair of acquired VSDs following MI in our unit. There were 118 males and 61 females (age range 43-80 years) of whom 60 were aged 70 years or above. RESULTS: The overall early mortality was 27%. On univariate analysis risk factors for early death included shorter time from both MI and detection of murmur to operation (P < 0.01, P = 0.04), site of MI (P < 0.01), higher NYHA class (P < 0.01), lower preoperative blood pressure (P < 0.01) and longer cardiopulmonary bypass and cross clamp times (P < 0.01, P = 0.03). Non significant variables included age, sex, concomitant CABG and preoperative renal function. Early mortality was 28.6% (34/119) in patients under 70 and 25.0% (15/60) in those over 70. This difference was not significant. The only significant differences between the age groups were sex distribution (females > males, P < 0.01), in the older group, and shorter time from both MI and detection of murmur to operation (P = 0.04, P = 0.02). Cardiopulmonary bypass was the only statistically significant variable on multivariate analysis (P = 0.01). CONCLUSIONS: There was no significant difference in early mortality between the two age groups. As shorter times from both MI and detection of murmur to operation adversely affect early mortality, age over 70 years should not be used to determine suitability for surgery.

Adult↗
PubMed1997

Migration of pectus excavatum correction bar into the left ventricle.

We present the case of a 19-year-old student who underwent correction of a pectus excavatum deformity using a pectus bar. At least 6 months following surgery, one end of the bar had migrated into his right ventricle, across the interventricular septum, to lie with its free end in the left ventricular cavity. This acted as a source of thrombus formation and lead to several systemic embolic events. The patient made a full recovery after removal of the bar. A review of the literature demonstrates that this has not been reported before.

Adult↗
PubMed1997

Prospective study of the value of necropsy examination in early death after cardiac surgery.

OBJECTIVE: To assess the value of necropsy examination in patients dying soon after cardiac surgery, particularly the proportion of clinical questions answered by the necropsy, the frequency of major unexpected findings, and the limitations of the procedure. DESIGN: A three year prospective study of necropsy examinations in adult patients dying before discharge or within 30 days of cardiac surgery performed under cardiopulmonary bypass in one hospital. SETTING: Tertiary referral centre. RESULTS: 123 of 2781 patients (4.4%) died in the early postoperative period, and necropsy examination was performed in 108 of these (88%). The mortality after emergency procedures (18%) was much higher than after routine operations (2.6%). The main causes of death were cardiac failure (52%), haemorrhage (14%), cerebral disease (6%), and pulmonary emboli (5%). The necropsy changed the stated cause of death in 16 patients (15%), and answered clinical questions in 24 of 38 patients. In 15 patients necropsy examination did not provide a full explanation of death. Most of these patients died of cardiac failure soon after surgery or were sudden unexpected deaths. CONCLUSIONS: Necropsy examination in patients dying early after cardiac surgery is valuable as it answers the majority of clinical questions, and shows unexpected findings in a significant proportion of cases.

Adult↗
PubMed1996

Technique for extraanatomic bypass in complex aortic coarctation.

A variety of approaches and surgical techniques have been described for the management of recurrent coarctation. When there is an additional intracardiac defect that requires surgical correction it is preferable to correct both lesions simultaneously and through the same incision. This article reports two new techniques of connecting ascending to descending aorta using an intrathoracic conduit and performed through a median sternotomy.

Aorta↗
PubMed1996

Growth potential in the new aortic arch after non-end-to-end repair of aortic arch interruption in infancy.

BACKGROUND: Complete repair of infants with interrupted arch and ventricular septal defect through a midline incision has been the preferred method for more than 20 years. End-to-end anastomosis can result in restenosis if there is excess tension. Two methods of reducing this tension have been described, and the subsequent growth of the new aortic arch is demonstrated. METHODS: In 2 infants (5 and 9 months old) the duct was used to create a new aortic arch. In 3 other younger infants the left carotid artery was divided, turned down, and anastomosed to the descending aorta to form the new arch. These operations were performed through the midline at the same time as the ventricular septal defect was closed. RESULTS: All 5 patients are well now 8 to 19 years postoperatively. One patient required reoperation for stenosis at the anastomotic site, but all have subsequently shown good growth on follow-up angiographic and magnetic resonance imaging studies. CONCLUSIONS: Although end-to-end repair is best, these alternative methods have shown very satisfactory aortic growth into adult life.

Anastomosis, Surgical↗
PubMed1996

Long-term results of valve replacement using antibiotic-sterilised homografts in the aortic position.

OBJECTIVE: Antibiotic-sterilised homograft valves stored at 4 degrees C have been implanted in the subcoronary position in this unit since 1973. This study was undertaken in order to assess the long-term function of these valves. METHODS: All 249 patients undergoing homograft aortic valve replacement (AVR) at the Wessex Cardiothoracic Centre between April 1973 and December 1994 were studied. Homograft valve sizes ranged from 15 mm to 28 mm internal diameter, 202 (81.1%) varying between 18 mm and 22 mm. The mean patient follow-up was 12.4 years with a total follow-up of 3096 patient-years. There were six early deaths (2.4%). RESULTS: On actuarial analysis, survival was 78.5+/-2.7% (1SE) at 10 years, 65.7+/-3.3% at 15 years and 55.0+/-3.9% at 20 years. The freedom from redo AVR was 87.9+/-2.4% at 10 years, 71.7 +/-3.8% at 15 years and 49.7+/-5.6% at 20 years. The freedom from structural degeneration was 85.6+/-2.5% at 10 years, 63.6+/-4.0% at 15 years and 41.9+/-6.4% at 20 years. On multivariate analysis the risk of valve failure was significantly higher in younger patients (P<0.0001) and in those who underwent aortic root tailoring (P = 0.024). The freedom from endocarditis was 98.4+/-0.9% at 10 years, 96.2+/-1.6% at 15 years and 95.1+/-1.9% at 20 years. Of the 249 patients, 218 had an isolated homograft AVR and were not anticoagulated. In this group there were two possible thromboembolic events. CONCLUSION: As well as the established haemodynamic benefits, this study has shown that homograft AVR with antibiotic-sterilised 4 degrees C stored homograft valves implanted in the subcoronary position, offers good long-term results.

Adolescent↗
PubMed1996

Bidirectional superior cavopulmonary anastomosis: how young is too young?

OBJECTIVE: To define the lowest age at which the bidirectional superior cavopulmonary anastomosis can safely be used in infants with complex congenital heart defects. DESIGN: A retrospective analysis of clinical, echocardiographic, haemodynamic, and angiographic data in four consecutive patients undergoing bidirectional superior cavopulmonary anastomosis below the age of 2 months. PATIENTS: Between November 1990 and September 1993, four infants less than 8 weeks of age (3, 4, 6, and 7 weeks) underwent bidirectional superior cavopulmonary anastomosis as a primary palliation for complex heart disease. The indication for early surgical intervention was progression of cyanosis (n = 3) and high pulmonary blood flow causing heart failure (n = 1). In two infants with tricuspid atresia, surgery was performed through a right thoracotomy without the use of cardiopulmonary bypass. In one infant with double inlet left ventricle and discordant ventriculoarterial connection, cavopulmonary anastomosis was combined with an arterial switch procedure. The final infant had double inlet left ventricle with pulmonary atresia; the central pulmonary arteries were virtually discontinuous and each branch was supplied by a separate arterial duct. The central pulmonary arteries were reconstructed using the subaortic innominate vein. Temporary prostacyclin infusion was used in three patients in the immediate postoperative period. RESULTS: Early postoperative extubation (5, 7, and 48 h) was successful in three patients. The youngest child required ligation of the ductus arteriosus four days later because of severe upper body oedema. The postoperative course was complicated by prolonged effusions in two patients. All were alive and well 14-48 months postoperatively, with satisfactory systemic saturations (80-87%) and haemodynamic indices. CONCLUSIONS: This limited experience challenges the widely held belief that the bidirectional superior cavopulmonary anastomosis cannot be used as a primary palliation for complex heart disease in early infancy. A wider experience is required to determine the safety and indications for this approach.

Age Factors↗
PubMed1995

Influence of bidirectional superior cavopulmonary anastomosis on pulmonary arterial growth.

Right-sided BSCA provides for satisfactory pulmonary arterial growth in infants and children with complex congenital heart defects, and it could enhance the growth of a small right pulmonary artery. The growth of the left pulmonary artery, particularly in younger patients, needs close attention to confirm the safe role of BSCA in long-term palliation.

Anastomosis, Surgical↗
PubMed1995

Influence of competitive pulmonary blood flow on the bidirectional superior cavopulmonary shunt. A multi-institutional study.

BACKGROUND: It is common practice to interrupt all alternative sources of pulmonary blood flow ("competitive flow") at the time of a bidirectional superior cavopulmonary anastomosis (BCPA), although the merits of this have not been systematically studied. METHODS AND RESULTS: We reviewed the early and medium-term clinical and hemodynamic findings in 108 consecutive patients 3 weeks to 25 years old (median, 1.9 years) undergoing BCPA at one of three institutions. Preoperatively, pulmonary blood flow was dependent on antegrade ventricular flow (n = 50), systemic-to-pulmonary shunts (n = 33), or mixed sources (n = 25). Postoperatively, competitive sources of pulmonary blood flow were left patent in 43 of 108 patients (40%). There were four early (3.7%) and four late deaths, none related to persistence of competitive flow. After BCPA, patients with competitive flow had significantly higher systemic oxygen saturations at 1 hour (85% versus 79%), 24 hours (84% versus 78%), and at hospital discharge (84% versus 78%) and required a shorter period of artificial ventilation (median, 9 versus 24 hours) and intensive care (median, 2 versus 4 days). Oxygen saturations at late follow-up (median, 2.8 years; range, 1 to 7) did not differ (83% versus 82%). No patient developed pulmonary arteriovenous malformations. CONCLUSIONS: Competitive flow is well tolerated in the short and medium term after BCPA, and early postoperative systemic oxygen saturations are improved. The long-term influence of competitive flow on pulmonary arterial growth, arteriovenous malformation development, and ventricular function warrants investigation.

Adolescent↗
PubMed1995

Biological valves beyond fifteen years: the Wessex experience.

Between 1975 and 1979, 443 biological valves (298 Carpentier-Edwards, 134 homograft, and 11 Hancock valves) were implanted in 415 patients (age, 16 to 77 years; mean, 59 years) with an operative mortality of 2.9%. Total follow-up was 4,248 patient-years. Overall event-free survival was 60% +/- 1.5% (standard deviation) at 10 years and 29% +/- 1.4% at 15 years. Ten-year and 15-year event-free survival were 72% +/- 3.4% and 41% +/- 3.3% for aortic homografts, 62% +/- 3% and 33% +/- 2.8% for isolated aortic xenografts, and 43% +/- 3.5% and 14% +/- 3.0% for isolated mitral xenografts. Freedom from structural valve degeneration was 87% +/- 1.3% and 63% +/- 2.5% for all patients at 10 and 15 years, respectively, 86% +/- 2.7% and 58% +/- 4.1% for aortic homografts, 93% +/- 1.8% and 76% +/- 5.1% for aortic xenografts, and 75% +/- 4.0% and 47% +/- 7.4% for mitral xenografts. Of the 110 remaining patients, echocardiography was performed in 61 patients (23 aortic xenograft, 24 aortic homograft, 9 mitral xenograft, and 5 tricuspid xenograft) between 14 and 17 years after implantation. An early diastolic murmur was heard in 57% of all aortic valve replacements (AVRs) 62.5% of homograft AVRs, and 52% of xenograft AVRs. Echocardiographically, aortic regurgitation was detected in 79%, 83%, and 74% of all AVRs, homografts, and xenografts, respectively. Aortic stenosis was present clinically in 11% of all AVRs, 4% of homograft AVRs, and 17% of xenograft AVRs.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMed1995

Pulmonary artery banding is not contraindicated in double inlet left ventricle with transposition and aortic arch obstruction.

It has been widely stated that pulmonary artery banding (PAB) is contraindicated in the setting of double inlet left ventricle with transposition of the great vessels (DILV/TGA), especially if aortic arch obstruction is present. We postulated that the poor results for this condition reflect the tendency to leave the band in place long-term without early recognition and relief of subaortic stenosis (SAS). Short-term PAB with early relief of SAS remains an attractive option compared to a neonatal "Norwood" strategy. We reviewed our results applying this approach to 18 consecutive infants presenting since 1980 with DILV/TGA and an obstructive anomaly of the aortic arch (coarctation 16, interruption or atresia 2). Four of the infants (22%) were considered to have important SAS at presentation. One underwent neonatal aortopulmonary connection and died. The remaining 17 patients underwent arch repair with PAB (median age 1.4 weeks; range 2 days-22 weeks) with one early death. The 16 survivors have been followed for 5.6 +/- 3.7 years. All but one ultimately developed SAS. Relief of SAS was performed in 15 patients (median age 8 months) using a proximal aortopulmonary anastomosis. There were two early deaths, and one late death. Thirteen of the 18 patients (72%) are alive and well, and 12 have achieved Fontan repair or bidirectional superior cavopulmonary anastomosis (BCPA) with persistent relief of SAS. Most patients with DILV/TGA and aortic arch obstruction will tolerate temporary PAB with adequate protection of the pulmonary vascular bed. Our current approach (in the absence of severe SAS at presentation) is PAB at the time of arch repair, followed by careful surveillance for, and early relief of, SAS combined with BCPA in infancy.

Anastomosis, Surgical↗
PubMed1994

Transaortic repair of ruptured aneurysm of sinus of Valsalva. Fifteen-year experience.

Between 1978 and 1993 a total of 25 cases of ruptured aneurysm of the sinus of Valsalva underwent transaortic repair at the Railway Hospital and the Institute of Cardiovascular Diseases at Madras, India. The aneurysms ruptured into the right ventricle in 20 patients, into the right atrium in 2, into the left ventricle in 1, and into the interventricular septum in 2. They originated from the right coronary sinus in 22 patients and from the noncoronary sinus in 3. Associated congenital anomalies included ventricular septal defect in 21, tetralogy of Fallot in 1, and pulmonary stenosis in 1. All 25 patients underwent transaortic repair of the ruptured sinus of Valsalva, and in patients with a ventricular septal defect the defect also was closed via this route. The patient with associated pulmonary stenosis had a pulmonary valvotomy. The patient with tetralogy of Fallot had infundibular resection, ventricular septal defect closure via a transatrial route, and a right ventricular outflow patch. No intraoperative deaths occurred, but one early death resulted from septicemia and multiorgan failure after rupture of the aneurysm into the interventricular septum with consequent development of extensive intramyocardial and epicardial abscesses. One late death occurred as a result of recurrent subacute bacterial endocarditis and septicemia. Transaortic repair of ruptured aneurysm of the sinus of Valsalva can be accomplished with a low risk of mortality and has the advantage that an associated ventricular septal defect, which frequently accompanies this condition, can be conveniently closed via the same route.

Adolescent↗