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Biomedical subjects

J S Coselli

Publications and source records attributed to J S Coselli.

At least 73 records · Page 4Linked to original sources
PubMed1989

Hypothermic-induced electrocerebral silence, prolonged circulatory arrest, and cerebral protection during cardiovascular surgery.

Certain cardiovascular operations require cardiopulmonary bypass and prolonged circulatory arrest to provide an adequate operative field. Profound hypothermia is induced to protect brain function during these periods without cerebral perfusion. Because peripheral body temperatures may not be valid indicators of brain temperature, we conducted this study to establish an alternative, more reliable, method of determining the appropriate level of hypothermia. We measured peripheral body temperatures from 3 sites (rectum, nasopharynx, and esophagus) at the onset of hypothermic-induced electrocerebral silence (ECS) in the intraoperative electroencephalogram (EEG) of 56 adults undergoing cardiovascular procedures. The EEG in most patients showed a characteristic progression of changes from its normal resting state during cooling. Gradual depression and slowing of background rhythms was followed by generalized, periodic, slow-wave transients, prolongation of the intervals between the transients, and then the onset of ECS. In cases in which the slow-wave transients did not appear, the initial depression and slowing of background activity gradually progressed to ECS. No consistent relationship was found between peripheral body temperatures at various sites and the onset of ECS. Using EEG-guided hypothermia, there was low morbidity and mortality. These data suggest that ECS is a safe and reliable guide for determining the appropriate level of hypothermia during cardiovascular procedures.

Adult↗
PubMed1989

Impact of cardiovascular operation on survival in the Marfan patient.

This report is concerned with the surgical treatment of cardiovascular manifestations of Marfan syndrome in 151 patients by 280 operations, 70 before referral, 203 by the authors during a 16-year period, and seven by others in the follow-up interval. This therapy resulted in mitral valve replacement in 13, aortic valve replacement in 135, aortic segment replacement in 151 (including total aortic replacement in 10), nearly total aortic replacement in 26, entire thoracic aortic replacement in seven, and replacement of the entire descending and abdominal aorta in 20 patients. The early (30-day) survival was 94%, and the 5- and 10-year Kaplan-Meier survival was 75% and 56%, respectively. Fusiform aneurysms were present in the ascending aorta, aortic arch, or both in 135, the descending aorta in two, the thoracoabdominal aorta in four, and the abdominal aorta in seven. Aortic dissection occurred in 102 (67%) patients, and 34 (22%) patients with ascending aortic operations required reoperation. This study suggests that the results of current techniques warrant a more aggressive approach to these problems to permit better long-term results.

Adolescent↗
PubMed1989

Appraisal of adjuncts to prevent acute renal failure after surgery on the thoracic or thoracoabdominal aorta.

We evaluated 1525 consecutive patients who had undergone thoracic or thoracoabdominal aortic surgery to ascertain the factors associated with the development of acute renal failure. Complete data were available in 1233 patients who were treated recently, and these were analyzed. Acute renal failure, severe enough to require dialysis, developed in 5.5% of this group (68/1233): 2.3% and 7%, respectively, for descending (9/391) and thoracoabdominal repairs (59/842). Of interest, on multivariate analysis, both renal artery endarterectomy for occlusive disease (p = 0.0006) and chronic dissection (p = 0.03) were associated with significantly less acute renal failure. On multivariate analysis, the significant independent predictors (p less than 0.05) of acute renal failure were preexistent renal dysfunction, evidence of diffuse atherosclerosis, the use of the pump bypass, and markers of hemodynamic instability. Contrary to earlier reports based on a smaller number of patients, we found that neither the use of pump bypass (7% acute renal failure), atriorenal bypass (8% acute renal failure), nor cold Ringer's lactate (3% acute renal failure) appeared to significantly avert the complication of acute renal failure. Indeed, pump bypass appeared to be deleterious (p = 0.0146) and perfusion with cold Ringer's lactate was not without risk. Furthermore, in a prospective evaluation of angiotensin converting enzyme blockers, we were unable to show that they afforded renal protection after transient renal ischemia. This study has clarified the clinical problems associated with acute renal failure and lays the foundation for future research.

Acute Kidney Injury↗
PubMed1989

Surgical treatment of aneurysm and/or dissection of the ascending aorta, transverse aortic arch, and ascending aorta and transverse aortic arch. Factors influencing survival in 717 patients.

Ascending aorta and/or aortic arch reconstruction by composite valve graft (281, 39%), separate valve graft (117, 16%), graft only (256, 36%), and other procedures (63, 9%) was used for aneurysm or dissection caused by trauma (6), infection (20), aortitis (46), dissection (261: acute 72, chronic 189), and medial degeneration (384) in 717 patients during the 9-year period between Jan. 11, 1980, and Jan. 16, 1989. Of these, 150 had 173 previous heart or aortic operations and needed reoperation for progression or recurrence of aneurysm, rupture, valvular insufficiency, aortocutaneous or aorta-heart chamber fistulas, great vein or airway obstruction, and infection. Concurrent distal aneurysmal disease was present or developed in 267 (37%) patients, being most prevalent in patients with arch involvement (211/395, 53%). These patients were treated either simultaneously or later. The ages ranged from 10 to 88 years, median 61. Aneurysm symptoms were mild or absent in 593 (83%) and severe in 124 (17%). The 30-day survival rate was 91%. The independent determinants predictive of 30-day death were increasing age, severe aneurysm symptoms, diabetes, previous proximal aortic operation, need for cardiac support, postoperative tracheostomy, postoperative heart dysfunction, and stroke. Of the 319 patients who had none of the four preoperative factors, 308 (97%) survived. Survival decreased to 74% in those with two or more factors. After a total of 1193 operations, the entire aorta was replaced in 53, near total in 35, total thoracic replacement in 78, and total aorta except arch in 27. Late survival rates (Kaplan-Meier) were 66% and 57% at 5 and 7 years. Independent predictors of death were severe aneurysm symptoms, preoperative angina, extent of proximal replacement, associated residual distal aneurysm, balloon pump, renal dysfunction, cardiac dysfunction, and stroke. Five-year survival rates varied with the incidence of the four preoperative variables and age in a single patient: 78% in 413 patients with up to one variables, 57% in 193 patients with two or three, and 39% in 111 patients with three or four (p less than 0.0001).

Aortic Dissection↗
PubMed1988

Marfan's syndrome: combined composite valve graft replacement of the aortic root and transaortic mitral valve replacement.

Echocardiographic studies in patients with Marfan's syndrome indicate that 95% eventually have aortic root dilatation, mitral valve prolapse, or a combination of these. Both lesions can progress and require operation for aortic root aneurysm, aortic valve insufficiency, and mitral valve insufficiency. This report reviews the simplified treatment of 6 patients by combined composite valve graft replacement of the aortic root and transaortic mitral valve replacement at one operation. All patients survived and are well for periods extending from 1 month to 12 months.

Adult↗
PubMed1988

Calcified mitral valve annulus: prosthesis insertion.

We describe a technique for insertion of a mitral valve prosthesis in the presence of a heavily calcified annulus. The valve leaflets are used for securing the prosthesis, and both the anterior and posterior chordae tendineae and papillary muscle complexes are preserved.

Adult↗
PubMed1988

Determination of brain temperatures for safe circulatory arrest during cardiovascular operation.

Profound hypothermia protects cerebral function during circulatory arrest in the surgical treatment of a variety of cardiac and aortic abnormalities. Despite its importance, techniques to determine the appropriate level of hypothermia vary; studies of temperatures recorded from multiple peripheral body sites show inconsistent findings. The purpose of this study is to establish objective criteria to consistently identify intraoperatively the safe level of hypothermia. Our studies are based on experimental evidence showing a correlation between brain temperature and development of electrocerebral silence (ECS) on the electroencephalogram (EEG), and the recognition that the EEG, as an objective measure of brain function, can easily be recorded intraoperatively. We studied 56 patients who required circulatory arrest during operation for replacement of the ascending aorta or aortic arch (N = 55) or aortic valve replacement (N = 1). Peripheral body temperatures from the nasopharynx, esophagus, and rectum and the EEG were continuously recorded during body cooling. Circulatory arrest time ranged from 14 to 109 minutes. No peripheral body temperature from a single site or from a combination of sites consistently predicted ECS. There was a wide variation in temperature among body sites when ECS occurred: nasopharyngeal, 10.1 degrees to 24.1 degrees C; esophageal, 7.2 degrees to 23.1 degrees C; rectal, 12.8 degrees to 28.6 degrees C. Fifty-one (91%) of the 56 patients survived. Three had neurological deficits, none clearly related to hypothermia. Two patients (3.6%) required reexploration for postoperative bleeding. We conclude that monitoring the EEG to identify ECS is a safe, consistent, and objective method of determining the appropriate level of hypothermia.

Aorta↗
PubMed1988

The impact of renal fusion and ectopia on aortic surgery.

This article is concerned with observations in 17 patients with renal fusion and ectopic abnormalities: horseshoe kidney in 13 patients, crossed ectopia with fusion in two, pancake kidney in one, and pelvic kidney in one. Three patients had occlusive disease, one may have had renal artery occlusion, and 13 had aneurysms--three thoracoabdominal and 10 infrarenal. Rupture of aneurysm had occurred in one patient at each level and six patients had had one or more previous attempts at aneurysmal removal. Diagnosis and evaluation were made with the aid of intravenous pyelography, retrograde pyelography, CT scanning, and at operation (three patients). Three patients had two normally located right and left renal arteries. Twelve patients had one to three additional aberrant arteries arising from the aorta and iliac arteries. One patient's renal blood supply arose from multiple aberrant arteries. Ureters crossed the midline in two patients. Treatment of occlusive disease consisted of endarterectomy in one patient and percutaneous transluminal angioplasty in two. Aneurysms were treated by graft replacement with retroperitoneal exposure in seven patients and transabdominal exposure in six. One patient was treated medically. Renal isthmus division was employed in only two patients and involved accessory arteries were reattached to the grafts in all cases. Death from myocardial infarction occurred in two patients (12%). Eleven patients subjected to operation were alive 6 months to 14 years later.

Aged↗
PubMed1988

Aortic dissection and dissecting aortic aneurysms.

Operation was employed in the treatment of 546 patients for complications of aortic dissection during the 32-year period of 1956-1988. Current concepts and operative techniques evolved during this period. Fortunately, about half the patients were treated during the latter 4 years, as modern therapy became standardized. The cumulative survival rate was 86% for all patients and 94% for those treated during recent years. Pathologic processes and requirements of operation became clearer by treating 174 patients who had had 198 previous operations by the time of referral. Reoperation was required for complications of operations now considered outdated, heart operations in patients with ascending aortic dilatation, and progressive dilatation of residual segments of the aorta. The 546 patients were followed, and a total of 838 operations were finally employed, resulting in total aortic replacement in 18, near total replacement in 41, entire thoracic aorta in 22, near total thoracic aorta in 33, and the entire thoracoabdominal aorta in 148 patients. Long-term survival in 439 patients after final operation was 66% and 44% at 5 and 10 years, respectively, despite the fact that the median age at first admission was 59. Operative treatment appears to be well-established for this disease.

Adolescent↗
PubMed1988

The impact of distal aortic perfusion and somatosensory evoked potential monitoring on prevention of paraplegia after aortic aneurysm operation.

Temporary distal aortic perfusion and somatosensory evoked potential monitoring were attempted prospectively in 198 patients to prevent neurologic complications from occurring after operation for descending thoracic and thoracoabdominal aortic aneurysm. These 198 patients were divided into two groups. Group 1 consisted of 99 (50%) patients in whom adequate (60 mm Hg) distal bypass was achieved and combined with somatosensory evoked potential monitoring. Group 2 consisted of 99 (50%) in whom this could not be achieved. Of the latter, four patients were excluded because of operative death in one and preexisting neurologic deficits in three. The rates of early and delayed neurologic complications were 8% and 12%, respectively, in the former and 7% and 8%, respectively, in the latter. Using the logistic regression method of statistical analysis, adjusting for the difference in patient mix, we found no statistical difference in the incidence of neurologic complications in the two groups. The incidence of false negative somatosensory evoked potential response was 13% and false positive response 67%. Localization of critical spinal arteries for reattachment was not possible. Thus, the method had no significant impact upon the prevention of neurologic deficits, which varied from mild or transient to severe and which either occurred during the operation or were delayed from 12 hours to 21 days.

Aorta, Thoracic↗
PubMed1987

Femoral artery perfusion for cardiopulmonary bypass in patients with aortoiliac artery obstruction.

A patient with type I aortic dissection, ascending aortic aneurysm, and infrarenal aortic occlusion was managed by inserting an infrarenal bifurcation graft and using one limb as arterial access for cardiopulmonary bypass. Following ascending aorta and aortic arch repair, the aorto-bi-common femoral artery bypass was completed. In patients with severe aortoiliac occlusive disease, graft replacement can provide access for both cardiopulmonary bypass and intraaortic balloon pump insertion.

Adult↗
PubMed1987

Surgical treatment of aneurysms of the intrathoracic segment of the subclavian artery.

From June 1969 to May 1986, 16 patients underwent 17 operations to treat 18 aneurysms of the intrathoracic segment of the subclavian artery. Surgical treatment in 12 cases involved Dacron tube graft replacement; in the remainder, patch graft angioplasty or exclusion with and without extra-anatomic revascularization were utilized. Twelve patients required simultaneous graft replacement of aortic aneurysms. Five procedures were performed through a median sternotomy and 12 through a left posterior lateral thoracotomy. Deep hypothermia and circulatory arrest was used on three occasions. All but one patient were early survivors, and there were no related cerebrovascular accidents. There were five late deaths unrelated to operative treatment. Surgical treatment of aneurysms of the intrathoracic segment of the subclavian artery is both well tolerated and durable.

Adult↗
PubMed1987

Graft reconstruction to treat disease of the abdominal aorta in patients with colostomies, ileostomies, and abdominal wall urinary stomata.

Abdominal aortic reconstruction combined with colon or urinary tract operations is generally not acceptable because of a supposed greater incidence of graft infection. Similar fears exist regarding aortic reconstruction in the presence of colostomies, ileostomies, and permanent urinary diversion stomata. In fact, the presence of a colostomy has been reported to be a contraindication for abdominal aortic reconstruction. This report is concerned with vascular operations in 13 such patients with aortic disease referred to us for fear of these complications. Eleven patients had abdominal aortic aneurysms and two had atherosclerotic occlusion of the aorta and iliac arteries. Twelve patients had colostomies, ileostomies, or both and one patient had permanent tube cystostomy. All had good renal function and the disease for which the diversion procedure was performed was either cured or under good control. All patients survived the vascular reconstructive procedures without significant complications and long-term follow-up revealed that late graft infection did not occur.

Abdominal Muscles↗
PubMed1987

Partial cardiopulmonary bypass, hypothermic circulatory arrest, and posterolateral exposure for thoracic aortic aneurysm operation.

Partial cardiopulmonary bypass, profound hypothermia, and circulatory arrest were used in the treatment of 25 patients with thoracic aortic aneurysms exposed through left posterolateral incisions. Indications included aortic clamp laceration (4 patients), pulmonary artery tear (1), treatment of ruptured aneurysm without clamping (5), right-sided arch (2), exposure of proximal aorta in a patient with a large aneurysm (1), inability to expose the proximal aorta for clamping (3), to permit removal of both arch and distal aorta (4), and to avoid distal arch clamping because of atheromatous disease (5). Aortic segments ranging from the upper descending thoracic aorta to most of the aorta were replaced, with early survival in 21 patients. Cerebral protection was satisfactory.

Adolescent↗
PubMed1986

Thoracoabdominal aortic aneurysms: preoperative and intraoperative factors determining immediate and long-term results of operations in 605 patients.

Graft inclusion and vessel reattachment to openings made in the graft were employed in the treatment of 605 patients with thoracoabdominal aortic aneurysms. These patients were divided into four groups on the basis of the extent of aneurysm. Group I consisted of those patients with involvement of most of the descending thoracic and upper abdominal aorta; group II involved most of the descending thoracic aorta and most or all of the abdominal aorta; group III involved the distal descending thoracic aorta and varying segments of abdominal aorta; and group IV involved most or all of the abdominal aorta including the segment from which the visceral vessels arose. The cause of aneurysm formation was medial degenerative disease in 80%, and dissection in 17%; other causes were responsible in the remaining 3%. The median age was 65 years and associated diseases including aneurysms involving other segments, atherosclerotic occlusive disease, heart disease, chronic obstructive pulmonary disease (COPD), hypertension, and renal insufficiency were frequent. The aneurysm was symptomatic in 70% of cases and rupture had occurred in 4% of cases. There were 54 (8.9%) early (30-day) deaths and 151 late deaths; 400 (66%) patients were still alive 3 months to 20 years after operation, including 60% at 5 years. Statistically significant pre- and intraoperative variables by univariate analysis that were predictive of increased risk of early death were advancing age, associated diseases that included COPD, renal artery occlusive disease, atherosclerotic heart disease, renal insufficiency, and long aortic clamp time. Three of these (age, clamp time, and the presence of COPD) retained significance by multivariate analysis. Variables predictive of risk of late death were age, dissection, extent of aneurysm, rupture, heart disease, cerebrovascular disease, COPD, hypertension, and poor renal function. Age, rupture, renal dysfunction, extent of aneurysm, and dissection retained their significance by multivariate analysis. Variables predictive of neurologic disturbances of the lower extremities included rupture, reattachment of intercostal and lumbar arteries, clamp time, dissection, extent and age. Rupture, reattachment of vessels, dissection, and extent of aneurysm retained significance by multivariate analysis. Thus, the risk of this complication was greatest in patients with extensive lesions (group II) with aortic dissection. The greatest risk of renal failure after operation that required dialysis was in patients who had impaired renal function before operation. Methods employed did not prevent these complications.

Adolescent↗
PubMed1986

Aortic valve replacement in the patient with extensive calcification of the ascending aorta (the porcelain aorta).

The best management for patients requiring cardiac procedures with superimposed severe intimal atheromatous disease or medial calcification of the ascending aorta and transverse arch has yet to be established. Clamping such an aorta can produce embolization, dissection, mural laceration, and hemorrhage. Successful surgical treatment of two patients with a porcelain aorta requiring aortic valve replacement is reported. Traditional aortic cross-clamping was avoided with femoral artery cannulation, profound hypothermia, and circulatory arrest.

Aged↗
PubMed1985

Redo operations for recurrent aneurysmal disease of the ascending aorta and transverse aortic arch.

Sixty-seven operations were performed in 59 patients for aneurysmal disease occurring after previous operations involving the ascending aorta and transverse aortic arch. The initial aortic pathological condition included the following: fusiform aneurysm due to medial degenerative disease in 34 patients, 12 of whom had Marfan's syndrome; aortic dissection in a previously undilated aorta in 23; and aneurysm persisting or occurring after brachiocephalic bypass in 2. One of the latter had an aneurysm because of aortitis. Various operations initially performed did not completely treat the disease, and certain complications occurred spontaneously, including infection and dissection. The residual pathological condition led to the development of aortic insufficiency, aortic dissection, coronary artery insufficiency, and progressive aneurysmal dilatation. These complications were treated by composite valve graft replacement of the aortic valve and ascending aorta or the transverse aortic arch or both, simple aortic valve replacement, graft replacement of the ascending aorta or arch or both, and suture of false aneurysm with viable tissue wrap. Twenty patients (34%) had an aneurysm of the distal aorta. The entire aorta was replaced in 3, thoracoabdominal segments in 9, and the abdominal aorta in 1. Of the 59 patients, 49 (83%) were early survivors and 40 (68%) were alive on January 1, 1985. Principles of therapy that may have prevented the complications leading to reoperation include aneurysm replacement at the time of aortic valve replacement and coronary artery bypass; total replacement of the ascending aorta and aortic valve in patients with Marfan's syndrome; the same procedure or aortic valve replacement and separate graft replacement in patients with non-Marfan's medial degenerative disease; ascending aortic replacement in all patients with dissection combined with valve resuspension, aortic valve replacement, or composite valve graft depending on the involvement of the aortic sinuses and the presence of aortic insufficiency.

Adult↗