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J S Coselli

Publications and source records attributed to J S Coselli.

At least 37 records · Page 2Linked to original sources
PubMed1997

Acquired supranuclear ocular motor paresis following cardiovascular surgery.

Acquired supranuclear ocular motor paresis is a rare disorder characterized by impaired saccadic and smooth pursuit eye movements in one or more directions of gaze. Vestibularly induced eye movements, however, are preserved. Six adult patients developed an acquired supranuclear ocular motor paresis following cardiopulmonary bypass surgery. Neuroimaging studies were normal in two patients and were consistent with small vessel ischemia in four patients. The mean cardiopulmonary bypass time was 132.3 min, and mean circulatory arrest time was 38.7 min; these were not outside established norms for this type of surgery. Patients undergoing cardiopulmonary bypass procedures with deep hypothermia are at risk for acquired supranuclear ocular motor paresis, but the development of this syndrome may not be predictable by duration of circulatory arrest or cardiopulmonary bypass times.

Aged↗
PubMed1996

Fibrillin-1 (FBN1) mutations in patients with thoracic aortic aneurysms.

BACKGROUND: Mutations in the FBN1 gene are the cause of the Marfan syndrome, an autosomal dominant disorder with skeletal, ocular, and cardiovascular complications. Aneurysms or dissections of the ascending thoracic aorta are the major cardiovascular complications of the disorder. We tested the hypothesis that FBN1 mutations cause thoracic aortic aneurysms or dissections in patients who do not have the Marfan syndrome. METHODS AND RESULTS: The FBN1 gene was screened for mutations by use of genomic DNA from two patients with thoracic aortic aneurysms who did not have the Marfan syndrome. Individual FBN1 exons were amplified with intron-based exon-specific primers; the DNA fragments were screened for mutations using single-stranded conformational polymorphism analysis; and aberrantly migrating bands were sequenced directly. We identified a missense mutation in one patient, D1155N in exon 27. Dermal fibroblasts from the affected individual were used to study the effect of the missense mutation D1155N on fibrillin-1 cellular processing. The mutation decreased the amount of fibrillin-1 deposited into the pericellular matrix. A second putative FBN1 mutation was identified in the second patient, P1837S in exon 44. Although this alteration was not observed in 234 chromosomes from unrelated individuals, the alteration may represent a rare polymorphism. CONCLUSIONS: Results of these studies support the hypothesis that FBN1 mutations cause thoracic aortic aneurysms in patients who do not have the Marfan syndrome. This information is important for understanding the pathogenesis of aortic aneurysms and identification of individuals at risk for developing thoracic aortic aneurysms or dissections.

Adult↗
PubMed1996

Results of contemporary surgical treatment of descending thoracic aortic aneurysms: experience in 198 patients.

Between April 1987 and March 1995, 198 patients (133 males [67.17%] and 65 female [32.83%]; mean age 63.85 years) underwent descending thoracic aortic aneurysm repair. Of these, 142 patients (71.71%) had symptoms. In most patients (n = 123 [62%]) the aneurysmal disease was extensive, involving at least two thirds of the descending aorta. In 153 patients (77.27%), the repair was completed with the simple clamp technique (mean clamping time 24.6 minutes). Left atrium-to-femoral bypass was used in 26 patients (13.13%) at high risk (mean clamping time 37.4 minutes). Profound hypothermia and circulatory arrest were necessary in 19 patients (9.6%) with extensive aneurysms that involved the arch and ascending aorta (mean circulatory arrest time 46 minutes). Operative mortality was 5.1% (n = 10). The causes of death were cardiac in three patients (1.5%), pulmonary in four (2.0%), and renal in three (1.5%). Postoperative paraplegia occurred in three patients (1.5%). Important predictors (p < 0.05) of mortality at regression analysis included renal failure, pulmonary complications, and paraplegia. The only independent predictor of paraplegia was clamping time. In conclusion, the simple clamp procedure remains the technique of choice in the majority of patients with descending aortic aneurysms. Atriofemoral bypass is an important adjunct in patients at high risk.

Adolescent↗
PubMed1996

Deep hypothermic circulatory arrest with and without retrograde cerebral perfusion.

Our study indicated that RCP provided significant protection against both postoperative strokes and early death. However, in the subjects studied, the combined detrimental effects of postoperative stroke, COPD, cardiac complications, and procedures requiring composite valve replacement outweighed the protective benefit afforded by RCP in the prevention of early death. RCP's protective benefit was also diminished in the presence of pre-existing cerebrovascular disease. Although the major factors leading to the incidence of postoperative stroke and early mortality were the etiologies and pathologies brought to the operating theater by the patient, RCP when used in conjunction with DHCA significantly diminished the likelihood of either outcome. Therefore, given its simplicity of application in the surgical repair of aortic arch abnormalities, its indication seems warranted.

Aorta, Thoracic↗
PubMed1995

Aortic arch operation: current treatment and results.

Between January 13, 1987, and December 31, 1993, 227 patients were treated surgically for aortic disease involving the transverse aortic arch. Forty-eight patients (21.14%) had acute aortic dissection (group A), 69 (30.40%) had chronic dissection (group B), and 110 (48.46%) had nondissecting fusiform or saccular aneurysms (group C). The replacement of the transverse arch involved 194 graft replacements, 27 elephant trunk procedures, and 6 patch graft repairs. Concomitantly, 22 patients had aortic valve resuspension, 18 patients had composite valve graft insertions, and 75 had separate aortic valve replacement. The frequency of prior cardiac operation was 20.83% (10 patients) in group A, 69.57% (48 patients) in group B, and 15.45% (17 patients) in group C. Profound hypothermic circulatory arrest was used in all patients during their transverse arch procedures. The mean circulatory arrest times (in minutes) were 29.18 +/- 1.39, 36.62 +/- 1.91, and 29.25 +/- 1.46 for groups A, B, and C, respectively. Retrograde cerebral perfusion through the superior vena cava cannula was used in 111 (48.9%) patients during the circulatory arrest period. In-hospital mortality was 6.17% (14 deaths). Long-term follow-up was 100% complete. There were 20 late deaths, with a long-term mortality rate of 9.26% (20/216).

Adult↗
PubMed1995

Rupture of a dissecting thoracic aortic aneurysm into the pulmonary artery: successful surgical repair.

A rare complication of dissecting thoracic aortic aneurysms is rupture into a cardiac chamber or great vessel with fistula formation. A case of congestive heart failure caused by a chronic DeBakey type I dissecting aortic aneurysm that ruptured into the pulmonary artery is reported. Surgical repair involved closure of the fistula followed by graft replacement of the ascending aorta and transverse aortic arch. A review of the literature revealed no previous reports describing successful repair of this lesion. A clinical picture consistent with concomitant aortic dissection and biventricular heart failure, especially when a continuous cardiac murmur is present, suggests the diagnosis of an aortopulmonary arterial fistula caused by a ruptured dissecting thoracic aortic aneurysm. Various imaging studies confirm the diagnosis.

Aortic Dissection↗
PubMed1995

Subsequent proximal aortic operations in 123 patients with previous infrarenal abdominal aortic aneurysm surgery.

PURPOSE: Previous studies have reported that 3% to 8% of patients who have had resection of an infrarenal abdominal aortic aneurysm will subsequently have development of a new aortic aneurysm proximal to the repair. The actual incidence, pathogenesis, and natural history of these aneurysms are unclear. The purpose of this study is to better characterize subsequent proximal aortic aneurysms and to evaluate the outcome of their operative repair. METHOD: We retrospectively reviewed our recent experience with surgery for new proximal aortic aneurysms in 123 patients who had had a prior abdominal aortic aneurysmectomy. Seventy-two patients (58.5%) were admitted with chest or abdominal pain, six (4.9%) were admitted with ruptured aneurysms, and 41 (33.3%) were symptom free. Most subsequent aneurysms involved the thoracoabdominal aorta (n = 94; 76.4%); others involved the juxtarenal abdominal aorta, descending thoracic aorta, or transverse aortic arch. The new aneurysm was in continuity with the existing prosthetic graft in 101 cases (82.1%). Resection and graft replacement of the aneurysmal segment was performed on an emergency basis in patients with evidence of impending rupture and electively when aneurysmal diameter exceeded 5.5 cm. The average time interval between the two operations was 8.2 +/- 5.4 years. Mean aortic clamp and visceral ischemic times were 39.7 +/- 14.7 and 33.5 +/- 12.8 minutes, respectively. RESULTS: The in-hospital mortality rate was 12.2%. Complications included oliguric kidney failure in 11.4% and paraplegia in 4.1%. These results compare favorably with previous studies. CONCLUSION: On the basis of the significant prevalence of subsequent proximal aortic aneurysms and the high mortality rate associated with their rupture, we recommend resection of the entire infrarenal aorta during abdominal aortic aneurysm replacement, followed by long-term surveillance with biannual computed tomography or magnetic resonance imaging scanning of the chest and abdomen. Early diagnosis is facilitated by a high index of suspicion and allows surgical intervention to occur before life-threatening rupture. Both emergency and elective proximal aortic surgery in these patients can be performed with acceptable levels of morbidity and mortality.

Adult↗
PubMed1995

Marfan syndrome: the variability and outcome of operative management.

PURPOSE: This study reviews the contemporary surgical outcome of 69 patients with Marfan syndrome who underwent one or more aortic operations between July 18, 1989, and April 14, 1994. METHODS: During this 5-year period, 79 operations were performed including composite valve graft replacement (n = 28) and graft replacement of the thoracoabdominal aorta (n = 29). Fifty-seven additional operations had been performed before referral, for a total of 136 aortic operations in this group. Forty-two patients (60.9%) required multiple operations; 16 patients (23.2%) underwent three or more procedures. RESULTS: Follow-up was complete on all patients. The 30-day and long-term survival rates were 98.7% and 96.2%, respectively. Distal aortic replacement resulted in paraparesis in only one (2.6%) of 38 patients; no patient had development of paraplegia. No patient had a stroke after the use of profound hypothermic circulatory arrest. CONCLUSION: Aortic surgery prolongs survival in patients with Marfan syndrome and currently has low associated morbidity and mortality rates. Treatment often requires multiple staged operations. The variety and multiplicity of aortic manifestations in these patients demonstrate the necessity for lifelong cardiovascular surveillance to detect new or recurrent disease.

Acute Disease↗
PubMed1995

Retrograde cerebral perfusion: overview, techniques and results.

Cardiovascular surgical repair of arch aneurysms is taking a step forward by going backwards by utilizing retrograde cerebral perfusion. Drs ME DeBakey, ES Crawford, DA Cooley and GC Morris first reported successful resection and repair of a fusiform aneurysm of the aortic arch with replacement graft in 1957. Since then, Crawford and Coselli have pursued materials and techniques which have made this procedure, one which generally resulted in high morbidity and mortality, more viable with decreased morbidity and mortality. Increased numbers of patients are now having this repair and are resuming normal healthy lives after the operation. From February 1992 to October 1993, 88 patients were surgically treated by Coselli who utilized retrograde cerebral perfusion with profound hypothermia and circulatory arrest, thus allowing for repairs that under any other conditions probably could not have been achieved successfully. It is evident that a major determinant for the successful clinical results, in addition to surgical technique and skill, was the employment of profound hypothermia and circulatory arrest. This article will review the techniques and results of aortic arch repair utilizing retrograde cerebral perfusion during circulatory arrest with profound hypothermia to lessen the chance of neurological morbidity following surgical replacement of the transverse aortic arch.

Adult↗
PubMed1994

Influence of segmental arteries, extent, and atriofemoral bypass on postoperative paraplegia after thoracoabdominal aortic operations.

PURPOSE: The purpose of this article was to study the influence of either reattachment or oversewing of patient segmental intercostal or lumbar arteries, extent of aneurysm, and atriofemoral bypass on the incidence of postoperative paraplegia/paraparesis in patients at high risk with type I or II thoracoabdominal aneurysms. METHODS: Data were prospectively collected on 99 patients undergoing type I or II thoracoabdominal aneurysm repairs, including exact extent of repair and whether atriofemoral bypass ws used. Patency of intercostal arteries from T3 to T12 and lumbar arteries from L1 to L4 were checked by intraoperative inspection. If the arteries were patent, note was taken of whether they were reattached to the new aortic prosthesis. Postoperative neurologic motor function was graded daily for the first 5 days, and the worst score in the first 30 postoperative days (POD) was used for analysis. RESULTS: Ninety-five of 99 (96%) patients were 30-day survivors. By POD 30, 31 of 98 (32%) patients had had a neurologic deficit. There was no difference in the incidence of deficits according to whether lumbar or intercostal arteries were reattached, ignoring the effect of patency of the arteries. Of greater importance, however, was whether patent segmental arteries were oversewn at specific levels. Thus, for patients who had one or more arteries at T11, T12, or L1 oversewn (often because they could not be reattached), a deficit developed in 11 of 23 (48%) patients versus 20 of 75 (27%) patients who did not have patent arteries or had all patient arteries reattached (p = 0.05, odds ratio = 2.5). More specifically, if all arteries at this level were oversewn, a neurologic deficit developed in 63% of patients versus 23% if all their arteries were reattached (p = 0.01). Reattachment of patent arteries at individual levels from T7 to L4 showed a trend toward a lower risk of deficits but did not reach statistical significance. On multivariate analysis, atriofemoral bypass was associated with a lower risk of paralysis (p = 0.068), and significantly so when controlled for age (p = 0.0329, odds ratio 0.287). Subgrouping of extent type I thoracoabdominal aneurysms resulted in an incidence of paralysis of 14% (3/22) for subgroup A and 23% (5 of 22) for subgroup B compared with 43% (23 of 55) for type II thoracoabdominal aneurysms (type I [8 of 44 18%], versus type II [p = 0.0097]). CONCLUSION: Patients with no or few patent segmental arteries in the aortic segment being replaced have a lower risk of neurologic deficits, compared with those with patent arteries. Every effort should be made to reattach all arteries at T11, T12, and L1 and, when possible within the constraints of technical feasibility and time, also those from T7 to L4. Preoperative angiography or intraoperative hydrogen testing may better identify the arteries that need to be reattached. When feasible, atriofemoral bypass appears to be protective, particularly when sequential clamping and segmental repairs can be performed.

Adult↗
PubMed1994

Thoracoabdominal aortic aneurysms: experience with 372 patients.

The purpose of this study was to review retrospectively recent results in 372 patients with thoracoabdominal aneurysm treated by a single surgeon and to identify variables associated with early death, renal failure, and postoperative neurological deficits in patients undergoing thoracoabdominal aortic resection. Between January 11, 1986 and March 1, 1994, 203 males (55%) and 169 females (45%) (mean age 65 years) were treated. Aortic dissection was present in 93 patients (25%). The extent of repair included type I (137 patients), type II (95 patients), type III (73 patients), and type IV (67 patients). The overall 30-day survival rate was 95% (352/372 patients). The overall risk of postoperative neurological deficit was 6.4% (24/372 patients). In 309 patients treated without atriofemoral bypass, paraplegia or paraparesis developed in 23 (7.4%). In 63 patients in whom atriofemoral bypass was utilized, the overall risk of paraplegia or paraparesis was 1.6% (1/63). The use of atriofemoral bypass has had a favorable impact on postoperative neurological complications in selected patients.

Adult↗
PubMed1993

Deep hypothermia with circulatory arrest. Determinants of stroke and early mortality in 656 patients.

We have retrospectively evaluated our results after aortic surgery in adults using deep hypothermia with circulatory arrest to determine the patient predictors of early death and postoperative stroke by logistic regression analysis. Of the 656 patients operated on between July 7, 1979, and January 30, 1991, 43% (n = 283) were female, the median age of the patients was 64 years (range 10 to 88 years), 12% (n = 77) had acute dissection, 26% (n = 173) had previously undergone either cardiac or ascending aortic operations, and 13% (n = 85) had a history of cerebrovascular disease. Eighty-four patients underwent elephant trunk procedures. The median circulatory arrest time was 31 minutes (range 7 to 120 minutes). The univariable predictors of transient or permanent stroke, defined as clinical evidence of neurologic injury, either global or hemiparetic, which occurred in 44 patients (7%), were as follows (p < 0.05): increased age; a history of cerebrovascular disease; circulatory arrest time (7 to 29 minutes = 12/298 [4%], 30 to 44 minutes = 15/201 [7.5%], 45 to 59 minutes 9/84 [10.7%], 60 to 120 minutes 7/48 [14.6%]; cardiopulmonary bypass time; and concurrent descending thoracic aorta repair. The multivariably determined predictors were as follows (p < 0.05): a history of cerebrovascular disease; previous aortic surgery distal to the left subclavian artery; and cardiopulmonary bypass time. A history of aortic valve incompetence, however, was associated with a lower risk of stroke (adjusted odds ratio 0.42, p = 0.015). The multivariably determined predictors for increased risk of early death (p < 0.05), which occurred in 66 (10%) patients, were as follows: increased age; Marfan syndrome; concurrent distal aortic aneurysm; previous ascending aortic operation; cardiopulmonary bypass time; cardiac complications; renal complications; and stroke. In this study, the occurrence of stroke was observed to increase after 40 minutes of circulatory arrest; furthermore, the mortality rate increased markedly after 65 minutes of circulatory arrest. Thus the "safe" period for strokes not developing appeared to be limited to approximately 40 minutes. We conclude that deep hypothermia with circulatory arrest is a safe technique for the repair of complex aortic problems provided both the circulatory arrest and the cardiopulmonary bypass times are not excessive. In addition, the clinical characteristics of the patients are important determinants of stroke and death.

Actuarial Analysis↗
PubMed1993

Experience with 1509 patients undergoing thoracoabdominal aortic operations.

PURPOSE: The purpose of this study was to retrospectively identify variables associated with early death and postoperative complications in patients undergoing thoracoabdominal aortic operations. METHODS: The data on 1509 patients who underwent 1679 thoracoabdominal aortic repairs between 1960 and 1991 were retrospectively reviewed. The median age was 66 years (range 1.5 years to 86 years), and aortic dissection was present in 276 (18%) patients. The extent of the first repair performed included 378 (25%) type I (proximal descending to upper abdominal aorta), 442 (29%) type II (proximal descending aorta to below the renal arteries), 343 (23%) type III (distal descending and abdominal aorta), and 346 (23%) type IV (most of the abdominal aorta). The median total aortic clamp time was 43 minutes. RESULTS: The 30-day survival rate was 92% (1386/1509) for the 30-year period. On multivariate analysis the preoperative and operative variables associated with death included (p < 0.05) increasing age, preoperative creatinine level, concurrent proximal aortic aneurysms, coronary artery disease, chronic lung disease, and total aortic clamp time. When the postoperative variables were also included in the stepwise logistic regression model, then in addition, cardiac complications, stroke, kidney failure, and gastrointestinal hemorrhage became significant (p < 0.05). The overall incidence of paraplegia or paraparesis was 16% (234/1509). By use of stepwise logistic regression analysis, the significant predictors (p < 0.05) of paraplegia or paraparesis developing were total aortic clamp time, extent of aorta repaired, aortic rupture, patient age, proximal aortic aneurysm, and history of renal dysfunction. Kidney failure (postoperative creatinine level > 3 mg/dl or dialysis) occurred in 18% (269/1509) of patients; dialysis was required in 9% (136/1509). Gastrointestinal complications manifested in 7% (101/1509) of patients. CONCLUSION: Although the survival rate has improved, paraplegia/paraparesis and kidney failure continue to be vexing problems that require further research.

Adolescent↗