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J M Craver

Publications and source records attributed to J M Craver.

At least 37 records · Page 2Linked to original sources
PubMed1995

In-hospital and long-term outcome after reoperative coronary artery bypass graft surgery.

BACKGROUND: Increasingly over the past several years, patients have returned after coronary surgery for reoperative procedures, and the experience has become substantial. In this report, we describe immediate- and long-term outcomes after reoperative coronary artery bypass graft surgery. METHODS AND RESULTS: The source of data was the clinical database at Emory University. The surgical procedure and statistical methods were standard. Data were collected prospectively and entered into a computerized database. Follow-up was by letter, telephone, or hospital records documenting additional events resulting in readmission. In-hospital correlates of survival were determined by logistic regression, and long-term correlates were determined by Cox model analysis. There were 2030 patients with a mean age of 61 and a mean of 7.8 +/- 4.1 years since the first surgery. The mean ejection fraction was close to 50%, and the majority had three-vessel or left main disease. Urgent or emergency surgery was required in 16.6%. The internal mammary was used in 60.1%. Q-wave myocardial infarctions occurred in just over 5%. Neurological events increased from 1.2% at less than age 50 to 4.1% at more than age 70. The hospital mortality increased from 5.7% at less than age 50 to 10% at more than age 70, with an overall rate of 7.0%. Mortality was 5.7% for elective, 10.9% for urgent, and 16.4% for emergency cases. Angina was noted at follow-up in 41.3%. Urgent or emergency surgery, reduced ejection fraction, hypertension, older age, and female sex were univariate and multivariate correlates of in-hospital death. Diabetes was a univariate correlate only. Five- and 10-year survival rates were 76% and 55%, respectively. Five- and 10-year myocardial infarction-free survival rates were 63% and 40%, respectively. By 12 years, few patients were free of cardiac events. The univariate and multivariate correlates of long-term mortality were older age, reduced ejection fraction, hypertension, diseased vessels, presence of diabetes, congestive failure, and emergency surgery, with a strong trend for female sex. The use of the internal mammary artery was not a correlate for long-term mortality. CONCLUSIONS: Patients undergoing reoperative procedures have higher mortality initially and at long term than patients undergoing a first procedure. Expected mortality based on covariates may help in the decision of whether to perform reoperative coronary artery bypass graft surgery.

Age Factors↗
PubMed1995

Neurologic events after coronary bypass grafting: further observations with warm cardioplegia.

Warm heart surgery has documented myocardial protection benefit, but with an added neurologic threat. It is hypothesized that moderately hypothermic aerobic heart surgery will maintain the myocardial protection and reduce neurologic risk. This study compared 493 patients undergoing coronary artery bypass graft operations with normothermic (35 degrees to 37% degrees C) continuous blood cardioplegia and normothermic perfusion to 379 coronary artery bypass grafting patients with hypothermic (33 degrees to 29 degrees C) continuous blood cardioplegia and hypothermic perfusion to test this hypothesis. There was no difference in age, sex, prior myocardial infarction, hypertension, prior neurologic event, congestive failure, or diabetes. The hypothermic group had more reoperations (24% versus 14%; p = 0.0002), class III/IV angina (83% versus 71%; p = 0.002), a trend to more triple-vessel (54% versus 47%; p = 0.10) and left main disease (18% versus 14%; p = 0.10), lower ejection fractions (0.52 +/- 0.15 versus 0.55 +/- 0.13), more grafts placed (3.6 +/- 1.1 versus 3.4 +/- 1.1; p = 0.04), but fewer internal mammary arteries (62% versus 78%; p < 0.0001). Postoperative myocardial infarction rate was 1.2% in the hypothermic group and 1.3% in the normothermic group (p = not significant). Intraaortic balloon pump requirement was 3.4% with hypothermic and 1.4% with normothermic groups (p = 0.05). The incidence of postoperative neurologic events was significantly higher in the normothermic group (4.7% versus 1.8%; p = 0.038). The multivariate correlates of stroke were older age and normothermic cardioplegia, whereas the only multivariate correlate of death was older age.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed1995

Coronary artery bypass grafting in patients after failure of intracoronary stenting.

BACKGROUND: Intracoronary stents are being used to treat acute and threatened closure after percutaneous transluminal coronary angioplasty and to prevent restenosis. METHODS: The outcomes of 68 patients having coronary artery bypass grafting after stent placement were reviewed. The mean age was 60.5 +/- 9.7 years, and 71% were male. Thirty-seven percent had hypertension, 13% had diabetes, 62% had class III or IV angina, 60% had multivessel disease, and 40% had sustained a prior myocardial infarction. Fifty-three patients underwent emergency operation, 22 with hemodynamic collapse immediately after percutaneous transluminal coronary angioplasty, and 7 others required urgent revascularization within 24 hours of angioplasty. Seventeen underwent coronary artery bypass grafting for acute closure of the stented vessel several days after the angioplasty procedure. RESULTS: There was no correlation between urgency of the procedure, previous infarction, or previous coronary artery bypass grafting with successful procedure. The in-hospital mortality was 4.4%, 21% had a Q-wave myocardial infarction, and 1.5% sustained a stroke. Ejection fraction was the only correlate of long-term mortality. CONCLUSIONS: Coronary artery injury for which stents are placed for acute or threatened occlusion or to prevent restenosis but then fail, thus necessitating coronary artery bypass grafting, can be treated successfully. Although the rate of Q-wave myocardial infarction is substantial and related to the initial ischemic insult, the long-term survival and event rates are excellent with prompt surgical revascularization.

Aged↗
PubMed1994

Frequency of repeat coronary bypass or coronary angioplasty after coronary artery bypass surgery using saphenous venous grafts.

This study examines the long-term frequency of reoperative coronary artery bypass grafting (CABG) and percutaneous transluminal coronary angioplasty (PTCA) after CABG. The source of data was the clinical database at Emory University Hospitals. The population comprised 3,480 patients undergoing a first CABG between 1978 and 1981. Event-free survival was determined using the Kaplan-Meier method and determinants of survival with the Cox proportional-hazards model. The in-hospital mortality was 1.0% and 5-, 10- and 12-year survival was 91, 78 and 70%. The 5-, 10- and 12-year freedom from reoperative CABG was 98, 88 and 80%. The 5-, 10- and 12-year freedom from PTCA was 98, 91 and 85%. The 5-, 10- and 12-year freedom from either CABG or PTCA was 96, 81 and 69%. Younger patients had much higher incidences of repeat procedures. The yearly incidence of repeat procedures accelerated over time. These data reveal the ultimately palliative nature of revascularization for coronary artery disease.

Aged↗
PubMed1994

Prospective, randomized trial of retrograde warm blood cardioplegia: myocardial benefit and neurologic threat.

From March 1991 through July 1992, 1,001 patients having elective coronary artery bypass grafting were randomized to receive either continuous warm (> or = 35 degrees C) blood cardioplegia with systemic normothermia (> or = 35 degrees C) or intermittent cold (< or = 8 degrees C) oxygenated crystalloid cardioplegia and moderate systemic hypothermia (< or = 28 degrees C). Preoperative variables including age, sex, prior coronary bypass grafting, hypertension, prior myocardial infarction, diabetes, angina class, and preoperative heart failure class were similar in both groups, as were the intraoperative variables of number of coronary grafts, mammary artery use, and cardiopulmonary bypass time. Aortic cross-clamp time was significantly longer in the warm group (46 +/- 23 minutes versus 40 +/- 21 minutes). Most postoperative variables including mortality (warm, 1.0%, and cold, 1.6%), Q wave infarction (warm, 1.4%, and cold, 0.8%), and need of an intraaortic balloon pump (warm, 1.4%, and cold, 2.0%) were similar between groups. Total neurologic events (warm, 4.5%, and cold, 1.4%; p < 0.005) and perioperative strokes (warm, 3.1%, and cold, 1.0%; p < or = 0.02) were significantly higher in the warm group. Neurologic events included perioperative stroke (warm, 15 patients, and cold, 5 patients; p < 0.02), perioperative encephalopathy (warm, 2 patients, and cold, 1 patient), and delayed (> or = 3 in-hospital days) stroke (warm, 5 patients, and cold, 1 patient). All patients experiencing a stroke had a persistent neurologic deficit at the time of discharge. Encephalopathy resolved completely in all instances.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1994

Interaction of age and coronary disease after valve replacement: implications for valve selection.

The interaction of patient age and the presence of coronary artery disease (CAD) and its influence on survival were examined in 3,644 patients undergoing either aortic (AVR) or mitral (MVR) valve replacement with or without coronary artery bypass grafting (CABG) between 1974 and 1991. Emergency procedures were performed much more frequently in those undergoing MVR and CABG than in those undergoing AVR and CABG (18.8% and 6.7%, respectively). The adverse effect of CAD on median survival for patients of all ages undergoing either AVR or MVR was statistically significant (AVR without CAD 11.8 versus 8.7 years with CAD; MVR without CAD 12.7 versus 7.3 years with CAD; p < 0.0001). Survival in patients younger than 70 years without CABG who underwent either AVR or MVR was quite good (< 60 years: AVR, > 14 years; MVR, 15.4 years; 60 to 69 years: AVR, 10.4 years; MVR, 11.4 years). The most profound effect of CAD on patient survival after valve replacement was observed in patients 60 to 69 years of age who underwent MVR, in whom the median survival without CABG was 11.4 years versus 5.5 years with CABG (p < 0.0001). An emergency operative status was associated with a reduced early and late survival for those patients undergoing MVR, particularly those with CAD. By relating the Cox proportional hazard models for valve survival to patient survival, we found that, in those patients 70 years and older with and without CAD who underwent either AVR or MVR, the median patient survival was reduced sufficiently (5.5 versus 8.1 years) to justify use of a bioprosthetic valve.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed1993

Coronary surgery and coronary angioplasty in patients with two-vessel coronary artery disease.

There is uncertainty regarding the selection between coronary artery surgery and angioplasty in many patients with coronary artery disease, especially in those with 2-vessel disease. Whereas randomized trials will provide the best possible and most detailed data comparing therapy in these patients, clinical data bases may be used to provide a current perspective. The purpose of this study was to compare the long-term outcome of patients with 2-vessel coronary artery disease undergoing coronary surgery or angioplasty at Emory University hospitals in the years 1984 and 1985. Data on all patients with 2-vessel disease diagnosed at Emory University who underwent elective angioplasty or coronary surgery in the years 1984 and 1985 were compared. Categoric variables were analyzed by chi-square and continuous variables by unpaired t test. Survival was determined by the Kaplan-Meier method and differences in survival by the Mantel-Cox method. Determinants of survival were determined by Cox model analysis. There were 415 angioplasty patients and 454 surgical patients. Surgical patients were older and had more frequent systemic hypertension, diabetes mellitus, prior myocardial infarction, severe angina and congestive failure, and more significant narrowing in the left anterior descending coronary artery, totally occluded vessels and left ventricular dysfunction than did angioplasty patients. Complete revascularization was achieved more often in surgical patients. There was no difference in Q-wave myocardial infarction in the hospital. No angioplasty patient died compared with 1.1% of surgical patients (p = 0.03). Whereas 5-year survival was 93% in angioplasty patients and 89% in surgical patients (p = 0.11), there was no difference in risk-adjusted survival.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1993

Bilateral mammary artery grafting: avoidance of complications with extended use.

This study was undertaken to more clearly define the operative risks and appropriate strategies for the selection of patients who might be candidates for bilateral internal mammary artery grafting. A review of the 674 patients who underwent this procedure was performed over a 10-year period from January 1982 through 1991. These patients represented 5% of the 12,824 patients who underwent bypass grafting during this period. The mean patient age was 54 +/- 9.4 years, and 92% of the patient were male. Diabetes was present in 17.5%, with 24% of this group insulin dependent. The ejection fraction was less than 0.50 in 26.7% and 14% had had previous bypass procedures. Hospital mortality was 1.9% (n = 13). Hospital morbidity included wound infection in 3.6%, reoperation for bleeding in 2.1%, and stroke in 1.6%. Postoperative intraaortic balloon pump support was necessary in 2.8%. Univariate and multivariate analysis revealed that advanced age, an emergent operative status, and the number of diseased vessels (especially left main obstruction) were predictors of hospital death. Except for wound infection (9.3% versus 2.5%) and length of hospital stay (10.8 +/- 11.8 days versus 8.8 +/- 7.6 days), the complications in diabetics were similar to those in patients without diabetes, respectively. At 5 years, freedom from death, death or infarctions, and death, myocardial infarction, or coronary reoperation was 90%, 70%, and 62%, respectively. The only significant multivariate correlates of long-term survival were diabetes and reoperative surgery.

Aged↗
PubMed1993

Changing clinical characteristics of coronary surgery patients. Differences between men and women.

BACKGROUND: There is uncertainty as to the relative efficacy of coronary artery bypass graft surgery (CABG) in men and women. Differences between sexes may be of greater importance than heretofore because of increased frequency of risk factors for adverse outcome. It is the purpose of this study to examine the changing clinical characteristics of patients undergoing CABG and to determine the influence of these changes on the results of CABG in men and in women. METHODS AND RESULTS: The source of data was the clinical database at Emory University Hospitals. The population comprised 13,368 patients (2648 women, 10,720 men) who had cardiac catheterization followed by CABG between 1974 and 1991. The patients were divided into the time periods 1974 through 1979 (532 women, 2792 men), 1980 through 1983 (727 women, 3151 men), 1984 through 1987 (695 women, 2619 men), and 1988 through 1991 (694 women, 2158 men). Data were collected prospectively and entered into a computerized database. The women were older (63 +/- 10 versus 58 +/- 10 years, P < .0001) and more frequently had diabetes (26.0% versus 15.4%, P < .0001). The in-hospital mortality was 3.8% in women and 1.6% in men. The multivariate correlates of death were older age, emergent surgery, reduced ejection fraction, female sex, diabetes, and more severe distribution of coronary arterial narrowings. Each of these risk factors for death became more prevalent, such that the mortality in men increased from 1.0% in 1974 through 1979 to 2.7% in 1988 through 1991, whereas the mortality in women increased from 1.3% in 1974 through 1979 to 5.4% in 1988 through 1991. CONCLUSIONS: The population undergoing CABG has aged, with correlates of in-hospital death becoming more common. The higher mortality in women could only partially be explained by other clinical variables. In addition, the risk of death after CABG has increased in women more than in men because women have consistently been older, have more emergent surgery and diabetes, and in recent years more women undergoing CABG have three-vessel or left main disease.

Age Factors↗
PubMed1992

Emergency coronary artery bypass surgery for failed percutaneous coronary angioplasty. A 10-year experience.

Six hundred ninety-nine patients have required emergency coronary artery bypass after failed elective percutaneous coronary angioplasty during the decade September 1980 through December 1990. This represents 4% of 9860 patients having 12,146 elective percutaneous coronary angioplasty procedures during this interval. Emergency coronary artery bypass was required for acute refractory myocardial ischemia in 82%. Hospital mortality rate for all patients was 3.1%; 3.7% in patients with refractory myocardial ischemia but 0.8% in patients without refractory myocardial ischemia, p = 0.08. Postprocedural Q-wave myocardial infarctions were observed in 21% versus 2.4%, p less than 0.0001, and intra-aortic balloon pumping was required in 19% with versus 0.8% without refractory myocardial ischemia, p less than 0.0001. Multivessel disease, p = 0.004, age older than 65 years, p = 0.005, and refractory myocardial ischemia, p = 0.08, interacted to produce the highest risk of in-hospital death. Follow-up shows that there have been 28 additional late deaths, including 23 of cardiac causes for a 91% survival at 5 years. Freedom from both late death and Q-wave myocardial infarction at 5 years was 61%. In the group going to emergency coronary artery bypass with refractory myocardial ischemia, the late cardiac survival was 90%, and in those without ischemia, 92% at 5 years, p = not significant. The MI--free survival in the group with refractory ischemia, however, was 56% versus 83% in the group without ischemia, p less than 0.0001. Multivariate analysis showed the highest late event rates for patients with Q-wave myocardial infarction at the initial emergency coronary artery bypass, age older than 65 years, angina class III or IV, and prior coronary bypass surgery. In spite of a continuing high incidence of early acute myocardial infarction and an increasing operative mortality rate (7%) in the latest 3 years cohort of patients, excellent late survival and low subsequent cardiac event rates demonstrate the lasting effectiveness of prompt, successful emergency coronary bypass surgery for failed percutaneous coronary angioplasty.

Actuarial Analysis↗
PubMed1991

Late follow-up after repair of left ventricular aneurysm and (usually) associated coronary bypass grafting.

This study assesses clinical and operative data (LV) aneurysm was repaired to determine factors that might predict in-hospital and long-term outcome. Long-term follow-up study was obtained in 296 of 298 patients undergoing LV aneurysm repair with or without coronary artery bypass grafting between 1974 and 1986. No patient had sustained a myocardial infarction within 2 weeks of surgery or was undergoing other concurrent cardiac surgery. The average age of the study patients was 57 +/- 9 years and the average ejection fraction was 35 +/- 13%. Ninety percent of the patients underwent concurrent bypass grafting, with an average of 2.2 +/- 1.3 grafts placed. Fourteen (5%) patients died in the hospital, with most deaths attributable to LV dysfunction. Advanced age and less extensive revascularization were correlates of in-hospital mortality. The 10-year survival was 57%, myocardial infarction-free survival 43%, and freedom from death, myocardial infarction and reoperative coronary surgery 41%. Advanced age, systemic hypertension, significant left main coronary artery narrowing and emergent operative status were multivariate correlates of long-term mortality. A low-risk population was defined by the absence of these risk factors, and high-risk by the presence of greater than or equal to 1 risk factors. The 10-year survival was 71% in the low-risk and 41% in the high-risk groups (p = .0006). The 10-year myocardial infarction free survival was 55% in the low-risk and 31% in the high-risk groups (p = 0.0017). LV aneurysm repair may be performed with acceptable in-hospital mortality, and the long-term risk may be stratified.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1991

Multiple reoperative coronary artery bypass grafting.

Initial reoperative coronary artery bypass grafting is being performed commonly, and an increasing number of patients are being referred for subsequent reoperative coronary artery bypass grafting. From January 1980 through June 1990, 53 patients (52 male, 1 female) underwent a third or fourth coronary artery bypass operation and were retrospectively reviewed. This represented 0.3% (53/17,102) of the coronary artery bypass procedures done during that time period. The mean age was 59 +/- 8 years. The number of grafts placed ranged from one to four with an average of 2.6 per patient. Internal mammary artery grafts were used in 30 patients (57%). The mean left ventricular ejection fraction was 0.52 +/- 0.13. Intraaortic balloon pump support was necessary in 10 patients postoperatively. There were no intraoperative deaths, although 4 patients died in the postoperative hospitalization period. Perioperative myocardial infarctions were diagnosed in 6 patients, 13 patients had perioperative dysrhythmias, and 2 patients sustained a stroke. Superficial wound infections occurred in 5 patients. Late follow-up in 49 patients revealed that 2 other patients have since died, and no further myocardial infarctions have been reported in the survivors. Postoperative 3-year survival is 85%, whereas 3-year myocardial infarction-free survival is 70%. Although there is increased risk of operative complications and early death after multiple reoperative coronary artery bypass grafting, both in-hospital and long-term results suggest that it is an appropriate therapeutic strategy.

Coronary Artery Bypass↗
PubMed1991

Coronary bypass surgery: is the operation different today?

Patients undergoing coronary bypass grafting have undergone an evolution in recent years. To document this change, we analyzed two groups of patients in 1981 (n = 1586) and 1987 (n = 1513) to document preoperative and postoperative variables important in determining immediate morbidity and mortality after isolated coronary bypass. Between 1981 and 1987, patients were found to be older (greater than or equal to 70 years, 8.7% versus 21.8%, p less than 0.0001), more often diabetic (15% versus 24%, p less than 0.0001), have a greater prevalence of triple vessel disease (14.5% versus 46.1%, p less than 0.0001), and have more left ventricular dysfunction (ejection fraction 0.60 +/- 14 versus 0.54 +/- 13, p less than 0.0001). To facilitate analysis and because of overlap between subgroups, we subdivided patients into three subgroups for statistical comparison of the years 1981 and 1987: subgroup I, no prior procedure (n = 1546 in 1981 and 1396 in 1987); subgroup II, optimal group (n = 503 in 1981 and 292 in 1987, and defined as no prior procedure, ejection fraction greater than or equal to 0.50 and age less than 65 years); subgroup III, patients having reoperations (n = 40 in 1981 and 117 in 1987). Internal mammary artery grafting was infrequently used in 1981 but was used in 72.1% in 1987. Major postoperative morbidity between the 2 years for the total population increased significantly: need for intraaortic balloon pumping, 1.4% versus 4.7%, p less than 0.0001; myocardial infarction 3.5% versus 5.5%, p less than 0.008; stroke, 1.4% versus 2.8%, p less than 0.008; and wound infection, 1.0% versus 3.0%, p less than 0.001. Wound infection (all types) in 1987 was increased sevenfold in patients having a perioperative myocardial infarction (0.7% versus 5%, p less than 0.0001). For young patients with good left ventricular function (subgroup II), there was no increase in these morbid events between 1981 and 1987. Hospital mortality in the total population increased significantly between 1981 and 1987 from 1.2% to 3.1% (p less than 0.0002), respectively. It was lowest for the patients in optimal condition (subgroup II) in both years, 0.8% versus 1.1%, and highest for reoperative patients, 5.3% versus 4.3%. In 1981, 58% of patients (503/870) were in the optimal group compared with 35% (292/828) in 1987 (p less than 0.0001). The last six years have seen a progressive trend in surgically treating older, sicker patients who have more complex disease, with a significant reduction in the best candidate group.(ABSTRACT TRUNCATED AT 400 WORDS)

Age Factors↗
PubMed1991

Influence of age on results of coronary artery surgery.

Coronary surgery is being used increasingly in older and more seriously ill patients. To evaluate the importance of age in predicting complications and mortality after coronary surgery, the results in 13,625 patients undergoing coronary surgery were evaluated. There were 321 patients under the age of 40, 1,758 were 40-49, 4,167 were 50-59, 5,049 were 60-69, 2,184 were 70-79, and 146 were over 80. As patients aged the proportion of women increased, the prevalence of severe angina and congestive heart failure increased, and the severity of the distributions of the coronary stenoses increased. The incidence of the complications of neurological events, wound infections, and death rose in every decade after the age of 40 years. The incidence of death was 0.6% for patients aged 40-49, 1.5% for those aged 50-59, 1.9% for those aged 60-69, 5.0% for those aged 70-79, and 8.3% for those aged 80-89. Advanced age was the most significant independent correlate of neurological events, wound infections, and death. The other multivariate correlates of neurological events were diabetes, hypertension, and, surprisingly, angina class. Again surprisingly, the only other multivariate correlate of wound infections was angina class. The other multivariate correlates of death were emergent surgery, female gender, ejection fraction, severity of coronary disease, diabetes, and a history of congestive heart failure. Of interest, periprocedural Q wave myocardial infarction was independent of age. The most predictive and significant correlate of periprocedural myocardial infarction was emergent surgery; hypertension, absence of a previous myocardial infarction, and a normal ejection fraction were weaker correlates. The ability to predict any complication was relatively weak compared with the ability to predict death. The relative infrequency of coronary surgery over the age of 80 years suggests that there is already strong selection against surgery in octogenarians. In addition, the risk of death, and to some extent other complications, may be predicted in advance based on extensive patient experience.

Adult↗