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Biomedical subjects

J W Kirklin

Publications and source records attributed to J W Kirklin.

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

Summary of a consensus concerning death and ischemic events after coronary artery bypass grafting.

The early and long-term results of myocardial revascularization are reviewed for four unidentified community hospitals, for Katholieke Universiteit (Leuven, Belgium), and for the University of Alabama at Birmingham at two different times. After operation, approximately 77% of patients are free from all ischemic events at 5 years and nearly 50% are free at 10 years. Over 90% of patients survive 5 years, and approximately 80% survive 10 years. Some of the incremental risk factors for early death after operation include older age; degree of left ventricular dysfunction; hemodynamic instability at the time of operation; recent myocardial infarction; number of diseased coronary vessels; associated mitral incompetence, ventricular aneurysm, or ventricular tachycardia; longer aortic cross-clamp time; and non-use of the internal mammary artery for revascularization. The number of diseased coronary arteries and the aggressiveness of the atherosclerotic process, degree of left ventricular dysfunction, older age, and non-use of the internal mammary artery are risk factors for reduced long-term survival.

Actuarial Analysis↗
PubMed1989

Risk factors for mortality after primary combined valvular and coronary artery surgery.

Risk factors for death after combined valvular and coronary artery bypass graft surgery (CABG) were examined in 141 patients undergoing isolated mitral valve (MV) surgery and CABG (n = 47) or isolated aortic valve (AV) surgery and CABG (n = 94) between January 1, 1986, and January 1, 1988. Actuarial survival was 92% at 1 month and 79% at 1 year. The hazard function for death was highest immediately after operation, had a single phase of decline, and reached a low level only after about 4 months. Risk factors for death included older age at operation, preoperative hemodynamic instability, left main coronary artery disease, ischemic mitral valve disease, important tricuspid valve incompetence, and longer ischemic time. The adverse effect of hemodynamic instability at time of surgery was most pronounced in the elderly (age 70 years or more, 20% 30-day mortality). A favorable risk group includes patients under 70 years of age without left main stenosis, hemodynamic instability, or ischemic mitral valve disease; the 30-day mortality for this subset undergoing isolated valve surgery and CABG is less than 5%. A proper comparison of surgical therapy in differing patient subsets with combined valvular and coronary artery disease should include multivariate analysis in which nondichotomous variables are examined in a continuous manner rather than establishing arbitrary stratifications.

Actuarial Analysis↗
PubMed1989

The size of the pulmonary arteries and the results of the Fontan operation.

All patients (n = 334) undergoing the Fontan operation at the University of Bordeaux, France, and the University of Alabama Medical Center, Birmingham, were entered into a single data base to examine the relation, if any, between size of the pulmonary arteries and outcome. Recent follow-up was made of all patients. The time-related freedom from death or takedown of the Fontan operation was 78% at 1 month, 73% at 6 months, and 72%, 68%, 61%, and 50% at 1, 5, 10, and 15 years after the operation. The hazard function (instantaneous risk of the combined event at each moment in time after the operation) had a rapidly declining early phase that gave way at about 6 months to a late phase of hazard, which began slowly to rise about 8 years after the operation. One of the most powerful risk factors for death or takedown of the Fontan operation was the dimensions of the right and left pulmonary arteries, expressed as a McGoon ratio. By multivariate analysis, the risk of the combined event increased sharply when the McGoon ratio was less than about 1.8, and when the ratio was as low as 1.2 the probability of death or takedown within 30 days of the operation was predicted to be 55% when the right atrium was connected to the pulmonary artery and 34% when connected to the right ventricle. Other risk factors identified were age at operation, the presence of mitral atresia, the degree of main chamber hypertrophy, elevated pulmonary artery pressure, non-use of cardioplegia, global myocardial ischemic time, and attachment of the right atrium to the pulmonary artery rather than to the right ventricle.

Blood Vessel Prosthesis↗
PubMed1988

The relief of pulmonary stenosis by a transatrial versus a transventricular approach to the repair of tetralogy of Fallot.

The ratio of peak pressure in the right ventricle to that in the left ventricle (PRV/LV) in the operating room thirty minutes after repair of tetralogy of Fallot by an atrial approach, with or without a concomitant transatrial approach, was 0.58 +/- 0.217. It was 0.52 +/- 0.158 when repair was through a right ventricular approach (p for difference = 0.16). This ratio 18 to 24 hours postoperatively was 0.49 +/- 0.148 and 0.45 +/- 0.121 for the right atrial and right ventricular approaches, respectively. The reduction in PRV/LV between the two observations was -0.09 +/- 0.147 for the right atrial and -0.07 +/- 0.110 for the right ventricular approach (p for difference = 0.4). Therefore, the predictive rules for placing a transannular patch, rules derived from patients in whom the right ventricular approach was used and depending in part on the fall in PRV/LV during the first 24 hours after operation, are also applicable to patients in whom an atrial approach, with or without a transpulmonary approach, is used.

Blood Pressure↗
PubMed1988

Coronary and systemic vascular resistance during reperfusion after global myocardial ischemia.

During controlled aortic root reperfusion after global myocardial ischemia for the performance of coronary artery bypass grafting (N = 16), coronary blood flow was the highest during the first 1 minute to 2 minutes even though the aortic root pressure was controlled at about 40 mm Hg. Even during the period of controlled low pressure, flow began to decline, and the decline continued during the period in which the pressure was controlled at 75 mm Hg. Calculated coronary vascular resistance rose steadily from an initially low value to one well above the normal value for beating hearts. A transient fall in resistance resulted from the administration of a bolus of nitroglycerin into the aortic root. When the initial reperfusate was normokalemic, coronary flow was less and coronary vascular resistance higher during the initial phase of reperfusion. The systemic arterial pressure and resistance fell during the first 1 minute to 3 minutes of reperfusion and in 25% of patients, remained low. The greater the potassium load delivered during the initially hyperkalemic phase, the longer the interval between the beginning of reperfusion and the resumption of cardiac systole.

Blood Pressure↗
PubMed1988

Corrective repair of complete atrioventricular canal defects and major associated cardiac anomalies.

Twenty-nine patients with balanced forms of complete atrioventricular (AV) canal defects and tetralogy of Fallot in 12, double-outlet right ventricle (DORV) in 10, and additional anomalies associated with atrial isomerism in 7 underwent corrective repair. Age ranged from 39 days to 24 years (median, 3.7 years). Repair included reconstruction of the common AV valve in 25 patients and prosthetic valve replacement in 4. Construction of an intraventricular tunnel connecting the left ventricle with the aorta was accomplished in 23 of 25 patients with ventriculoarterial concordant or double-outlet connections. In 2 patients with situs inversus and associated DORV and in 4 patients in the isomerism group who had ventriculoarterial discordant connections, repair included intraatrial venous diversion by a modified Senning procedure in 2, a modified Mustard venous switch in 1, and a tailored atrial baffle in 3. A valved extracardiac conduit was required for repair in 4 patients. Partial anomalous systemic venous connection was repaired in 7 patients and total anomalous pulmonary venous connection, in 5. There was 1 hospital death (3%) and 3 late deaths (11%). There was 1 (3.6%) reoperation to replace an incompetent right (systemic) AV valve 17 months postoperatively, and each of the 25 surviving patients was in New York Heart Association Functional Class I (80%) or II (20%) at follow-up.

Adolescent↗
PubMed1988

Aortic valve endocarditis with aortic root abscess cavity: surgical treatment with aortic valve homograft.

Aortic valve endocarditis with an aortic root abscess cavity was treated by a modification of the standard technique of aortic homograft implantation in 3 patients. At a mean follow-up of 35 months, all 3 patients were well without reoperation or signs of aortic incompetence. This technique may, in some cases, be an alternative to the more complex procedure of homograft aortic root replacement with coronary reimplantation.

Abscess↗
PubMed1988

Long-term outcome of patients undergoing surgical repair of isolated pulmonary valve stenosis. Follow-up at 20-30 years.

In a group of 191 consecutive patients who underwent operation at the Mayo Clinic for isolated pulmonary valve stenosis between 1956 and 1967, late results were excellent. In patients surviving operation before the age of 21 years, long-term survival was similar to that in an age- and sex-matched control population. In the other patients, late survival and functional status were good, but survival was poorer than in the control population. This late attrition, most likely due to the sequelae of long-standing right ventricular hypertrophy, suggests the need for continued surveillance. Late sudden death occurred in only three patients, between 10 and 21 years postoperatively. The finding of normal life expectancy for such patients who survive operation before age 21 is important for actuarial purposes and for the patients' career and employment plans.

Adolescent↗
PubMed1988

Intermediate results of the arterial switch repair. A 20-institution study.

A total of 466 neonates with transposition of the great arteries, all less than 15 days of age, have been entered into a 20-institution study between Jan. 1, 1985, and June 1, 1987. Seventy-three percent were less than 48 hours old when entered into the study. Two hundred twelve of these underwent an arterial switch repair, and the 1-week, 1-year, and 2 1/2-year survival rates were 82%, 79%, and 78%, respectively. The usual coronary anatomy was present in 67% of the patients. The arterial switch repair was performed in 16 of the institutions. Six among these were shown to be "low-risk" institutions, with the prevalence of the demographic and surgical variables seeming to be the same in these as in the other institutions. The 1-week, 1-year, and 2 1/2-year survival rates after the arterial switch repair in low-risk institutions for simple transposition were 96%, 91%, and 90%, respectively; for transposition with ventricular septal defect they were 84%, 83%, and 83%. Only older age at operation (over 14 days of age), in the case of simple transposition, and transposition with ventricular septal defect were risk factors for death in these six institutions. Among the patients as a whole, freedom from reoperation for pulmonary outflow obstruction at 1 week and 1 year was 99% and 89%, respectively. A previous pulmonary artery banding and, possibly, one institution were identified as risk factors for reoperation. Inferences: In low-risk institutions, the arterial switch repair can be accomplished with good early results, which suggests the possibility that the late results will be better than after the atrial switch repair. Since young age was not a risk factor for the arterial switch repair of transposition and ventricular septal defect, this type of repair for this anomaly, as well as for simple transposition, may be more advantageously performed early in life than at 2 to 3 months of age.

Age Factors↗
PubMed1988

The results of a surgical program for interrupted aortic arch.

Seventy-one patients with interrupted arch entered the Boston Children's Hospital between Jan. 1, 1974, and Jan. 1, 1987, of whom 63 underwent an operation. Type B was the most prevalent form of interrupted arch, and ventricular septal defect alone was the commonest coexisting cardiac anomaly. Among the 63, the 30-day and the 1-, 5-, and 10-year survival rates were 61%, 52%, 48%, and 47%, respectively. The mortality rate declined strikingly during the experience, and by multivariate analysis in patients with coexisting ventricular septal defect operated on in 1986, the probability of death within 2 weeks of repair was only 7%. Also, preoperative therapy became progressively more intense and more prolonged. The complication of left ventricular outflow tract obstruction developed in eight of the 33 patients undergoing repair of interrupted arch and of isolated ventricular septal defect. The time-related freedom from this complication was 97%, 78%, and 58% at 1 month, 1 year, and 3 years, respectively. Seven of the eight patients underwent a surgical procedure directed against the left ventricular outflow tract obstruction, and all have survived. Recurrent or persistent aortic arch obstruction became evident after repair in 15 patients and appeared more frequently and earlier after direct anastomosis than after tube graft repair. All patients had either reoperation or balloon dilation, but all were alive at follow-up. Most surviving patients are active and without symptoms. Inferences: An aggressive surgical program can result in survival and a good clinical state for at least 10 years after birth of over 40% of patients born with interrupted arch. Multiple anatomic bases account for the development of left ventricular outflow tract obstruction in about 50% of the patients undergoing repair of interrupted arch with coexisting ventricular septal defect. Repair by direct anastomosis combined with repair of the coexisting defect whenever possible is optimal therapy.

Aorta, Thoracic↗
PubMed1988

The early results of treatment of simple transposition in the current era.

A total of 187 neonates with simple transposition of the great arteries (TGA) have been entered into a twenty institution cooperative study between Jan. 1, 1985, and June 1, 1986. Eighty-two percent entered within the first 2 days of life. Seventy-six of the 187 patients were initially entered into a treatment protocol leading to an arterial switch repair, 45 into one leading to an atrial switch (Mustard) repair, and 49 into one leading to a Senning repair. Five (7%) of the patients entered initially into an arterial switch protocol later were crossed over to an atrial switch protocol, and 7% of those entered into an atrial switch (Mustard) protocol were crossed over to an arterial switch protocol. Formal follow-up information is available on all patients. Only 5% of patients entered into an arterial switch protocol were without repair 2 weeks after entry, whereas 96% and 100%, respectively, of those entered into a Mustard or Senning atrial switch protocol were without repair at that time. Ninety-seven percent of the first group had no preliminary procedures other than balloon atrial septostomy, which was true of only 76% and 90%, respectively, of the last two groups. No deaths before repair occurred in the first group, whereas five occurred in the latter two groups (P = 0.06). Overall survival rate among the 187 patients was 81% at 1 year. The only risk factors for death were birth weight, date of entry into the study, and an arterial switch protocol in the group of institutions at high risk for arterial switch repair; neither an arterial nor an atrial switch protocol was a risk factor per se. According to the multivariate equation, the 12-month predicted survival rate of a patient with a birth weight of 3.4 kg, entered currently into atrial or arterial switch protocols (except in the high risk for arterial switch group of institutions) is 92%.

Humans↗
PubMed1988

Early and late results of a protocol for simple transposition leading to an atrial switch (Mustard) repair.

Inferences: A treatment protocol for patients with simple transposition, consisting of initial balloon atrial septostomy and leading to a delayed atrial switch repair of the Mustard type, in good circumstances, results in survivorship at 1 month, 1 year, 10 years, and 20 years of 95% (95% confidence limits [CL] 90% to 97%), 90% (95% CL 84% to 94%), 83% (95% CL 74% to 90%), and 80% (95% CL 70% to 88%), respectively. Low birth weight adversely affects survivorship. Hypoxia or heart failure accounts for most deaths within the first month and before the atrial switch (Mustard) repair. Most of the few deaths late postoperatively are sudden and they appear to occur particularly in patients who have junctional rhythm. A progressive increase in the prevalence of junctional rhythm has been a risk of the atrial switch repair, and only 76%, 65%, 59%, 56%, and 53% of patients can be expected to be free of this by 1, 5, 10, 15, and 20 years after repair. Important right ventricular dysfunction late after an atrial switch repair, with its adverse affect on the patients' functional capacity, appears to be present in up to 10% of patients after the atrial switch repair, but may not be an immutable risk of this type of repair. About 90% of patients, essentially all of those who do not have right ventricular dysfunction, can be expected to be in New York Heart Association class I or II late postoperatively.

Adult↗