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Biomedical subjects

J M Piehler

Publications and source records attributed to J M Piehler.

At least 37 records · Page 2Linked to original sources
PubMed1986

Mechanical decalcification of the aortic valve.

Thromboembolism and anticoagulant-related complications secondary to prosthetic aortic valve replacement constitute a significant risk (28% at 5 years). From 1978 through 1984, decalcification of the aortic valve was performed in 8 patients who were undergoing coronary artery revascularization. Preoperative gradients of between 30 and 80 mm Hg (mean, 50 mm Hg) were abolished after operation. To determine the viability of decalcification, the records of 84 additional patients who had undergone this procedure between 1959 and 1978 were reviewed (86% before 1965). There were 60 male and 32 female patients ranging from 14 to 74 years old (mean, 49 years). The cause of the calcification was a bicuspid valve in 32 patients (35%), senile calcification in 9 (10%), and rheumatic fever in 50 (54%); the cause in 1 patient was unknown. Thirty-day mortality was 13%. Follow-up was 98% complete and ranged from 6 months to 22 years (mean, 7 years). Aortic valve replacement was subsequently required in 25 patients. Freedom from reoperation at 1, 5, 10, and 15 years was 98%, 75%, 43%, and 26%, respectively, for patients with rheumatic valves compared with 97%, 76%, 57%, and 51%, respectively, for those with bicuspid valves. Survival for patients with rheumatic valves at 1, 5, 10, 15, and 20 years was 93%, 70%, 48%, 40%, and 35%, respectively, compared with 100%, 66%, 57%, 46%, and 46% for patients with bicuspid valves. At follow-up, 61% of the patients were in New York Heart Association Functional Class I or II. Causes of late death were valve related (30%), congestive heart failure (27%), and myocardial infarction (24%).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1986

Primary chest wall tumors: factors affecting survival.

Between 1955 and 1975, chest wall resection was done in 90 patients for primary chest wall tumors. Ages ranged from 8 to 96 years (mean, 44.3 years). A painful mass was the most common sign and symptom. Eighty-two tumors (91.1%) were located in the lateral chest wall and eight, in the anterior thorax. The tumor was malignant in 71 patients (78.9%) and benign in 19. All patients with benign tumors had complete excision and are currently free from disease. Malignant fibrous histiocytoma, chondrosarcoma, and rhabdomyosarcoma constituted 62% of the malignant neoplasms. Most malignancies were treated by wide resection. There were no thirty-day operative deaths. Overall 1-, 5-, and 10-year survival was 89%, 57%, and 49%, respectively. Recurrent tumor developed in 37 patients (52%); 5-year survival, however, was only 17% after recurrence. Cell type and extent of invasion significantly influenced survival. Both chondrosarcoma and rhabdomyosarcoma had a better prognosis than malignant fibrous histiocytoma (p less than 0.05). We conclude that early resection is the treatment of choice for primary malignant chest wall tumors and that development of recurrent disease is an ominous event.

Adolescent↗
PubMed1986

Current techniques for the surgical management of malignant lesions of the thoracic esophagus and cardia.

Cancers of the esophagus and cardia remain serious conditions that cause many thousands of deaths every year throughout the world. In North America, cancer of the esophagus and gastric cardia is an endemic disease of low order and stable incidence. Nevertheless, it is responsible for many deaths and considerable suffering. With current methods of treatment, substantial palliation and amelioration of patient disability are possible, and some patients gain long-term survival with comfort and even cure. A combination of surgical resection and reconstruction is the chief modern method of management of such cancers. Herein we discuss a variety of standard surgical procedures that are currently available and present detailed illustrations of these procedures. The selection of a specific operation depends largely on the site of the neoplasm. With all these procedures, function is restored and the local and regional neoplastic tissue is removed without compromising the potential for cure. Associated operative mortality is approximately 7%. The late results of the operations illustrated depend primarily on the cell type, grade, and stage of the neoplasm encountered at the time of surgical treatment. For patients who have undergone resection, 5-year survival rates have ranged from 15 to 54%, the results depending on the stage of the cancer. Of equal importance is the fact that oral diet can be maintained in 93% of patients despite recurrence of the neoplasm.

Cardia↗
PubMed1986

Early and late results following repair of dissections of the descending thoracic aorta.

Management of dissections of the descending thoracic aorta remains controversial, especially with regard to timing and method of repair. To clarify these and other issues we have reviewed our total experience with repair of descending aortic dissections between 1962 and 1983. The 44 men and 20 women had a mean (+/- SEM) age of 59 +/- 2 years (range, 19 to 83 years), and in all patients the dissection originated in and was limited to the aorta distal to the left carotid artery (Stanford type B, DeBakey types IIIa and IIIb). Twenty-nine patients underwent operation within 2 weeks of the onset of symptoms (acute), and the remainder had later repair (chronic). During repair, circulation distal to the aortic cross-clamp was supported with cardiopulmonary bypass or shunt in two thirds of patients. Overall, 18 deaths occurred less than or equal to 30 days postoperatively (operative risk 28%), and risk was higher in acute (45%) than in chronic (14%) dissections. Operative risk was not significantly related to protection of the distal circulation. The most serious postoperative complication was spinal cord ischemia manifested by paraplegia in five patients (8%) and transient or permanent paraparesis in six patients (9%). Risk of spinal cord ischemia was significantly lower in patients who had protection of the distal circulation during operative repair (8% vs. 44%, p = 0.003). Late survival, including hospital deaths, was 49% +/- 7% at 5 years after operation; 22 of the 46 patients who survived repair were found to have aneurysms involving the thoracic and/or abdominal segments of the aorta. Our results indicate that repair of chronic dissection of the thoracic aorta has a lower operative risk than repair of acute dissections, and initial medical management of acute dissection may be indicated if no early complications occur. Risk of spinal cord ischemia is significantly reduced by cardiopulmonary bypass or shunt and is preferred over aortic cross-clamping alone. Finally, these patients require careful long-term follow-up because of the high incidence of residual or recurrent aortic aneurysms.

Acute Disease↗
PubMed1986

Coronary artery thrombus as a risk factor for acute vessel occlusion during percutaneous transluminal coronary angioplasty: improving results.

Early experience with percutaneous transluminal coronary angioplasty (from October 1979 to March 1983 inclusive) showed that pre-existing coronary artery thrombus was associated with a significant increase in the incidence of acute coronary occlusion during angioplasty. Acute occlusion occurred in 11 (73%) of 15 patients with pre-existing thrombus compared with 18 (8%) of 223 patients without thrombus. The effect of improved technology (steerable guiding systems) and altered dilatation strategy (full intravenous heparinisation for 24 hours after the procedure and more intensive use of antiplatelet medications) was studied by review of angiograms from 297 consecutive patients without evidence of acute myocardial infarction who underwent angioplasty from April 1983 to March 1985 inclusive. Coronary artery thrombus was present in 34 (11%) patients, eight (24%) of whom had complete occlusion during or immediately after the procedure compared with 34 (13%) of 263 patients without thrombus. Patients with pre-existing coronary artery thrombus continue to be at greater risk of complete occlusion than patients without thrombus, but this risk has declined significantly since the modification of the angioplasty procedure.

Acute Disease↗
PubMed1986

Pulmonary aspergilloma. Results of surgical treatment.

Between 1953 and 1984, 53 patients (40 male and 13 female) underwent thoracotomy for treatment of pulmonary aspergilloma. The median age was 58 years (range 4 to 86 years). Either underlying lung disease or immunologic risk factors were present in 49 patients (92%). Twenty-one patients (31%) had simple aspergilloma and 32 (47%) had complex aspergilloma. The most common indication for operation was an indeterminate mass, hemoptysis, or severe cough. Lobectomy, wedge excision, and pneumonectomy were the most frequent operations. Complications occurred in 78% of patients with complex aspergilloma and in 33% of patients with simple aspergilloma (p = 0.002). Operative mortality was 5% (one death) in patients with simple aspergilloma and 34% (11 deaths) in patients with complex aspergilloma (p = 0.01). Cause of death was respiratory failure in four patients, underlying pulmonary disease in three, aspergillosis in two, and other conditions in three. At follow-up, 84% of operative survivors with simple aspergilloma were alive and well compared with 43% of those with complex aspergilloma. Although operative mortality in patients with complex aspergilloma was high, 67% of the survivors had a good long-term result in terms of absence of symptoms, but they frequently died of underlying disease. In contrast, operation in patients with simple aspergilloma was done with low risk, and approximately 90% of survivors had a good late result. Late appearance of contralateral disease did occur and argues for rigorous postoperative surveillance.

Adolescent↗
PubMed1986

The significance of multiple, recurrent, and "complex" cardiac myxomas.

We reviewed the Mayo Clinic records of 56 patients who underwent operation for cardiac myxoma and 29 cases in which cardiac myxoma was found at autopsy. Five patients had a "complex" of unusual findings including multiple pigmented skin lesions (lentiginosis), myxoid fibroadenomas of the breast, skin myxomas, and primary pigmented nodular adrenocortical disease (a cause of Cushing's syndrome). Four of these five patients had multiple cardiac myxomas. Three of the four patients who underwent surgical excision of the cardiac myxomas had recurrent myxomas (the only recurrences in our series), and one of these patients had a second recurrence. The occurrence of multiple and recurrent myxomas in patients with the complex was significantly (p less than 0.001) higher than in our 80 patients with sporadic myxomas. The world literature was searched for cases of cardiac myxomas with the unusual associations of the complex, and also for familial, multiple, and recurrent myxomas. A group of patients were identified who had unusual biologic behavior including early development of myxomas, atypical myxoma locations, and a high risk for the development of recurrent myxomas. For these patients, we recommend a thorough search for multiple tumors at operation, close postoperative follow-up, and careful screening of family members.

Adenofibroma↗
PubMed1985

Chondrosarcoma of the chest wall: factors affecting survival.

The cases of 96 patients (55 male and 41 female) with primary chondrosarcoma of the chest wall were reviewed. Ages ranged from 17 to 78 years (median, 53.5 years). The tumor involved the rib in 78 patients and the sternum in 18. Seventy-two patients had treatment at the Mayo Clinic, 28 by wide resection, 25 by local excision, and 19 by palliative excision. There was 1 operative death. Follow-up ranged from 1 to 46 years. Recurrent chondrosarcoma developed in 37 patients. All had local recurrence, and 14 also had metastases. Within 10 years, recurrence had developed in 50% of patients who had local excision and in 17% of patients who had wide resection. Ten-year chondrosarcoma survival (Kaplan-Meier) for patients treated by wide resection was 96%; by local excision, 65%; and by palliative excision, 14% (p less than 0.0001). Tumor grade, tumor diameter, tumor location, and date of operation all had a significant influence on survival. This report documents the natural history of chest wall chondrosarcoma and demonstrates that early wide resection is the treatment of choice.

Adolescent↗
PubMed1985

Percutaneous transluminal coronary angioplasty, alone or in combination with streptokinase therapy, during acute myocardial infarction.

The treatment strategy in 66 consecutive patients who underwent invasive therapy for acute myocardial infarction was analyzed, and specific attention was focused on the role of percutaneous transluminal coronary angioplasty. The following four treatment regimens were used: angioplasty alone (11 patients), angioplasty followed immediately by administration of streptokinase (15), streptokinase therapy alone (11), and streptokinase therapy followed by angioplasty (29). Reperfusion was achieved in 91%, 80%, 82%, and 72% of these subgroups, respectively. Angioplasty was particularly helpful in patients with severe residual stenoses after intracoronary administration of streptokinase and in patients in whom streptokinase therapy failed to reopen the occluded artery. Angioplasty further reduced the residual stenosis in 11 of 15 patients (73%) with successful thrombolysis, and it restored blood flow in 10 of 14 patients (71%) in whom thrombolysis had failed to do so. The incidence of reinfarction after therapy was similar in all four treatment groups. Patients in whom angioplasty was used either alone or in combination with streptokinase therapy had a significantly decreased incidence of subsequent revascularization (less than 30% compared with 82%). Angioplasty is of considerable value in patients undergoing invasive therapy for acute infarction. In some patients, it may be used as the only treatment; in others, it may be used to treat severe residual stenosis after initial streptokinase therapy. Finally, angioplasty achieves reperfusion in most patients in whom streptokinase therapy has failed.

Adult↗
PubMed1985

Results of triple valve replacement in 91 patients: perioperative mortality and long-term follow-up.

Between 1961 and 1984, 91 patients underwent simultaneous triple valve replacement at the Mayo Clinic. Of the 273 prosthetic valves used, 77% were Starr-Edwards. Perioperative (30 day) mortality was 24% to 27% between 1962 and 1974 and 7% between 1975 and 1983 (p = .17). In patients with NYHA class IV symptoms, perioperative mortality was 44%, and in those with milder symptoms, it was 8% (p less than .0001). The median follow-up was 7.5 years (range, 6 weeks to 20 years). Cumulative survival, which was calculated taking into consideration perioperative mortality, was 64% at 1 year, 55% at 5 years, 40% at 10 years, and 25% at 15 years. Multivariate analysis identified preoperative functional class and age as predictors of late survival. Among causes of late mortality were sudden death in 32.5%, congestive heart failure in 15%, thromboembolism in 12.5%, prosthetic valve dysfunction in 7.5%, and infective endocarditis in 5%. Late complications included systemic emboli in 42% (embolic rate, 12.3 events per 100 patient-years), bleeding in 22%, myocardial infarction in 16%, and infective endocarditis in 6%. Eight patients required reoperation for prosthetic valve dysfunction, and 12 patients had permanent pacemakers. Of the 29 patients still alive, 79% are in NYHA class I or II. In summary, perioperative mortality after triple valve replacement appears to be declining; long-term survival in 30 day survivors is similar to that after single valve replacement and excellent symptomatic improvement can be obtained, although morbidity is high.

Aortic Valve↗
PubMed1985

Early and late results of pericardiectomy for constrictive pericarditis.

Records of 231 patients (171 males, 60 females; aged 10 months to 83 years [median 45 years]) who underwent operation for constrictive pericarditis at the Mayo Clinic from 1936 through 1982 were reviewed. All had had hemodynamically significant pericardial constriction preoperatively, and pericardial disease was confirmed at operation. Preoperatively, 69% were in New York Heart Association Class III or IV and 81% had peripheral edema or ascites. Pericardiectomy was performed through a left anterolateral thoracotomy (34%), a median sternotomy (27%), a U incision (Harrington) (21%), or a bilateral anterior thoracotomy (18%). Postoperatively, 28% of patients had evidence of low cardiac output; 70% of the 32 deaths within 30 days of operation were due to low cardiac output. Operative risk was significantly (p less than 0.001) related to preoperative disability (1% for Class I or II; 10% for class III; 46% for Class IV). Median postoperative follow-up was 9 years (longest was 43 years). Probability of survival for patients dismissed alive from the hospital was 84% at 5 years, 71% at 15 years, and 52% at 30 years. Long-term survival (excluding operative mortality) was not significantly influenced by the disability class preoperatively, the operative approach, or the development of low cardiac output in the immediate postoperative period. At the end of the follow-up interval, there were 141 patients in whom functional capacity could be assessed; 140 were in Class I or II. We conclude that a poor hemodynamic result after complete pericardiectomy relates to the preoperative degree of constriction and resultant cardiomyopathy. We recommend early pericardiectomy when pericardial constriction is diagnosed, and we continue to use a left anterolateral thoracotomy as the preferred approach for most patients.

Adolescent↗
PubMed1985

Mitral regurgitation due to ruptured chordae tendineae. Early and late results of valve repair.

From 1958 through 1980, 131 patients had repair of ruptured chordae tendineae of the mitral valve; 62% were men. Ages ranged from 5 to 70 years (median 57). Chordae to the anterior mitral leaflet were ruptured in 44 patients (34%), to the posterior mitral leaflet in 85 (65%), and to both leaflets in two patients (1%). The mitral valve was repaired by leaflet plication without resection in 116 patients, plication after wedge resection of the unsupported leaflet in six, Ivalon sponge buttress of the posterior leaflet in three, resuspension of chordae in two, and annuloplasty alone in the remaining four. Mitral valve annuloplasty was performed in addition to leaflet repair in 115 patients (88%). Operative (less than 30 days) mortality was 6.1%. Survival rate of patients dismissed from the hospital was 92% at 5 years and 73% at 10 years. There were no differences in late survival or risk of reoperation for recurrent or residual mitral insufficiency between patients with ruptured chordae to the anterior leaflet and those with ruptured chordae to the posterior leaflet. Survival was significantly better for the group with repair than it was for a group that underwent mitral valve replacement for ruptured chordae during this same time interval (5 year survival rate, 92% versus 72%, p less than 0.003). The incidence of thromboembolism after repair was 1.8 episodes/100 patient-years compared with 8.0 episodes/100 patient-years after replacement. Our data indicate that valvuloplasty is the procedure of choice for most patients with mitral regurgitation owing to ruptured chordae tendineae, including selected patients with ruptured chordae to the anterior leaflet.

Adolescent↗
PubMed1985

Surgical management of effusive pericardial disease. Influence of extent of pericardial resection on clinical course.

Surgical drainage for effusive pericardial disease is usually accompanied by pericardial resection to obtain tissue for analysis and to lessen the chance of recurrent effusion or late constriction. The purpose of this study was to determine the relationship between the extent of resection and the development of late complications. From 1960 through 1983, 145 patients with pure pericardial effusive disease underwent operative drainage. The effusions were malignant in 72 patients (49.7%) and benign in 73 (50.3%). The patients were divided into three groups according to the extent of resection: complete in 72 patients (49.7%), partial in 36 (24.8%), and window in 37 (25.5%). The 30 day mortality was 19.4% for patients with malignant effusions and 5.5% for those with benign effusions (p less than 0.05). All survivors had immediate improvement in symptoms. The actuarial 1 year survival rate was 23.4% (mean 4.2 months) for patients with malignant disease and 85.6% for patients with idiopathic effusions (p less than 0.001). Survival was not influenced by the extent of resection. Fifteen patients (10.3%) had late constriction or recurrent effusion. Six of these required reoperation, all after having had a window procedure. Actuarial probability of reoperation or late complication was greater with window procedures than other resections, both for all patients (p = 0.0001) and for those with benign disease (p = 0.0001). Transthoracic complete pericardiectomy is the procedure of choice for effusive pericardial disease. Subxiphoid drainage has immediate advantages for selected patients but has a statistically greater chance of late complications.

Adolescent↗
PubMed1985

Concomitant cardiac and pulmonary operations.

From 1965 through 1983, 43 patients underwent concomitant cardiac and pulmonary procedures at our institution. Most patients presented with cardiac symptoms and were incidentally found to have a roentgenographically indeterminate lung nodule. The pulmonary diagnosis of 38 patients was unknown preoperatively, and nine of these had a malignant lesion. All 43 cardiac procedures necessitated extracorporeal circulation. Thirty-one patients had benign pulmonary disease, 10 had bronchogenic carcinoma, and two had metastatic carcinoma. Concomitant pulmonary procedures were performed via median sternotomy and included single wedge resections in 32 patients, lobectomy in seven, multiple wedge resections in three, and pneumonectomy in one. Most resections were performed either before or after institution of bypass, without systemic anticoagulation. Of the two operative deaths (4.6%), one was related to intraparenchymal pulmonary hemorrhage after multiple wedge resections during anticoagulation. Thus, pulmonary resections performed during anticoagulation may be associated with increased risk and probably should be avoided. The second death was cardiac in origin and not related to pulmonary resection. The remaining patients recovered uneventfully. Definitive correction of both cardiac and pulmonary disease can be performed at one operation via a single incision with safety and benefit to the carefully selected patient.

Adolescent↗
PubMed1985

Surgical management of broncholithiasis.

Fifty-two patients (31 men and 21 women) were treated for complications of broncholithiasis between 1969 and 1984. Mean age was 50.8 years (range 26 to 74 years). Indications for operation included symptoms in 49 patients and an abnormal chest x-ray film in three. Broncholithectomy was initially attempted by thoracotomy in 40 patients and by bronchoscopy in 12. In the thoracotomy group broncholithectomy was successful in all patients, 32 of whom underwent pulmonary resection. Significant postoperative complications occurred in five patients (12.8%). There was one postoperative death (2.5%). In the bronchoscopy group broncholithectomy was successful in eight patients (67%); significant complications occurred in two and there were no early deaths. Subsequent thoracotomy was done in three of the four patients in whom bronchoscopic removal was unsuccessful. Follow-up averaged 76.5 months (range 6 to 183 months). The 15 year survival rate (Kaplan-Meier) for all patients was 75.1% and did not differ from a control group of patients. No patient in the thoracotomy group had recurrent complications of broncholithiasis. In contrast, complications recurred in three of the eight patients (37.5%) successfully treated by bronchoscopy. We conclude that broncholithectomy via thoracotomy is the preferred treatment, as the risks are low and the long-term results are excellent.

Adult↗
PubMed1984

Percutaneous transluminal coronary angioplasty (PTCA) in the elderly patient: experience in the National Heart, Lung, and Blood Institute PTCA Registry.

Because CABG results in a significantly higher morbidity and prolonged hospitalization in the older patient group, PTCA is an attractive alternative for providing myocardial revascularization in the small group of older patients with appropriate lesions for dilation. This analysis of the results of PTCA in 370 older patients in the NHLBI PTCA Registry reveals that PTCA can be performed with acceptably low mortality and morbidity. Therefore, PTCA may offer an alternative to CABG in the highly selected symptomatic older patient.

Age Factors↗
PubMed1984

Postsurgical stage I bronchogenic carcinoma: morbid implications of recurrent disease.

Three hundred forty-six patients with post-surgical non-small cell Stage I bronchogenic carcinoma were followed from 5.0 to 10.8 years (median, 7.0 years). Recurrent cancer developed in 135 patients (39%). Seventy-five recurrences were nonregional metastases (55.6%); 35 (25.9%), a subsequent primary lung cancer; and 25 (18.5%), local recurrence only. The rate of recurrent lung cancer decreased from 15.0 patients per 100 patient-years the first postoperative year to 2.3 the seventh and subsequent years. The rate of recurrence varied among the three different types of recurrent cancer. Five years after pulmonary resection, 70.0% of patients with T1 N0 neoplasms had no evidence of recurrence compared with 58.2% of patients with T2 N0 tumors (p = 0.012) and only 31.8% of patients with T1 N1 neoplasms (p less than 0.001). There was no significant difference in overall rate of recurrence among the various cell types. Currently, 174 patients are alive. Lung cancer survival (Kaplan-Meier) was 69.1% at 5 years and 61.9% at 9 years. At 2 years following detection of subsequent lung cancer, 51.8% of patients with subsequent primary lung cancer had survived lung cancer compared with 23.4% for those with local recurrence and only 8.9% for those with nonregional metastases.

Adenocarcinoma↗