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Biomedical subjects

K Turley

Publications and source records attributed to K Turley.

At least 19 recordsLinked to original sources
PubMed2000

Less invasive Thoratec LVAD insertion: a surgical technique.

Left Ventricular Assist Device (LVAD) implantation is historically a complicated, invasive operation performed on critically ill patients and is often associated with bleeding and multiorgan morbidity. The purpose of this investigation was to devise an LVAD insertion technique, utilizing the concepts of less invasive cardiac surgery, that would be a less complicated operation, with low morbidity, and still meet all the goals of the standard procedure. We describe the technical details of a "less invasive" LVAD implantation.

Adult↗
PubMed1999

Prescription and administration of around the clock analgesics in postoperative pediatric cardiovascular surgery patients.

Despite an increased awareness of postoperative pain management in infants and children, they are still often undermedicated. The importance of providing maximum comfort to children following cardiac surgery is accentuated with shortened hospital stays that require early ambulation to achieve early discharge. The purposes of this study were to evaluate the administration of prescribed around the clock (ATC) pain medication and documentation of pain assessment when administering pro re nata (prn) analgesics. A descriptive design was used to study 114 consecutive patients who underwent surgery for congenital heart disease. Administration of ordered ATC medications was best in the sternotomyl > 24 months of age group and poorest in the thoracotomyl < 24 months of age group. The use of the Wong-Baker FACES Pain Rating Scale in patients who were > 36 months of age (n = 71) was 38% for predose evaluation and only 15% for postdose evaluation. Findings suggest that the postoperative pain of infants and young children demands better attention. The administration of prescribed ATC medications is imperative in providing maximal postoperative pain relief in the pediatric cardiovascular surgery patient.

Adolescent↗
PubMed1996

Cardiovascular-radical outcome method is effective in complex congenital cardiac lesions.

BACKGROUND: The cardiovascular-radical outcome method is a proactive process of patient care that uses standard critical pathway methodology to reduce negative variation while encouraging positive variation to accelerate recovery. Its effectiveness in patients with complex congenital heart disease is explored. METHODS: Two hundred fourteen consecutive patients with congenital heart disease were cared for using the cardiovascular radical outcome method. Age ranged from 2 days to 19 years (median age, 3 years). Cardiovascular radical outcome method data were compared with the pathway plan data for each patient. RESULTS: Survival was 99% (211 patients) with an overall reduction in stay of 156 days (0.74 day/patient) (p < 0.0001). Only 10 patients (5%) exceeded the pathway plan; 201 (95%) reached the planned length of stay (critical pathway method), and 127 patients (60%) had a shorter length of stay than expected by the critical pathway method. One hundred forty-eight patients (70%), including 95 (64%) with more complex conditions, had a length of stay of 3 days and 18% achieved a 2-day length of stay, the maximal response. The process was most effective in the most complex groups, although preoperative comorbidities influenced outcomes. Outcome assessment demonstrated minimal morbidity and excellent family satisfaction. CONCLUSIONS: The radical outcome method is effective in reducing the length of stay of patients with complex congenital heart disease. The power is in the process rather than the plan, and the method provides optimal patient care and family satisfaction.

Adolescent↗
PubMed1995

Radical outcome method. A new approach to critical pathways in congenital heart disease.

BACKGROUND: Treatment of congenital heart disease has entered a new era of healthcare delivery and cost containment. Critical pathway method (CPM) has been previously demonstrated by us to produce a significant reduction in average length of stay (ALOS) in hospital of -44%. A new approach, radical outcome method (ROM), has produced comparable results that appear to improve over time. The dynamic nature is examined. METHODS AND RESULTS: Two hundred consecutive patients with congenital heart disease were treated by a single surgeon at a single health maintenance organization (HMO) facility. ROM was used in all patients. This method uses seven critical moments at which shortening rather than confirmation of the ALOS is possible. This process is completed by the second post-operative day. Overall mortality was 1%. The 200 patients were divided into two consecutive groups of 100 patients to determine the effectiveness of ROM over time. Fifty sets were matched. ALOS hospital decreased by 29 days (mean, 0.6 d/set), P < .003. Thirty sets who underwent cardiopulmonary bypass had a 16% decrease (P < .03), and 20 sets in whom nonbypass procedures were performed had a decrease of 16% (P < .02). ALOS in hospital for the 50 sets decreased from 3.7 to 3.1 days (-16%, P < .003). Outcome data demonstrated no significant difference. CONCLUSIONS: ROM, a proactive approach to hospital stay, is a dynamic process that reduces ALOS in hospital. This is achieved by both reducing negative variation in the standard CPM and allowing for positive variation. Outcome data confirm that this approach can reduce ALOS in hospital while providing optimal patient care and family satisfaction, a standard for the new era of healthcare delivery.

Cardiopulmonary Bypass↗
PubMed1995

Intermediate results from the period of the Congenital Heart Surgeons Transposition Study: 1985 to 1989. Congenital Heart Surgeons Society Database.

BACKGROUND: The period of the Congenital Heart Surgeons Society (CHSS) study (1985 to 1989) provided a transition in the treatment of d-transposition of the great arteries. During this unusual time frame neonatal arterial switch (AS) and neonatal or late atrial baffle repair (Senning) were used in near equal proportion at one reporting institution. All the procedures were performed at this single institution, avoiding the variability intrinsic to a multicenter study. Intermediate follow-up of the results is presented. METHODS: During the period of the CHSS study, January 1985 to March 1989, 46 patients were enrolled in the CHSS study at one institution. Forty-four underwent either neonatal arterial (n = 14, 32%) or neonatal atrial (n = 19, 43%) or late atrial (n = 11, 25%) repair of d-transposition of the great arteries. Ages ranged from 4 to 80 days. Overall survival for the entire series was 91% (40/44). The survival of the AS group operate on in the neonatal period was 93% (13/14). The survival of the Senning group was 90% (27/30); late Sennings, 91% (10/11); and neonatal Sennings, 92% (12/13). Six neonatal Sennings were crossovers from the AS group with an 83% survival (5/6). RESULTS: Intermediate follow-up of 5.2 to 9.2 years revealed no late deaths. In the AS group there was no ventricular failure, no arrhythmias, and one reoperation for supravalvar pulmonic stenosis. In the Senning group, there was no ventricular failure, but significant complications developed in 10 patients: cardiac arrhythmias in 7, tachyarrhythmias requiring pharmacologic therapy in 4, and bradyarrhythmias in 3, 2 requiring permanent pacemaker insertion. Left ventricular outflow tract (subpulmonic) stenosis developed in 3 patients, 1 requiring a left ventricular to pulmonary artery conduit and permanent pacemaker. Systemic atrioventricular valve insufficiency has developed in 3 patients. CONCLUSIONS: Results at one reporting institution from the CHSS study during this period of transition from late atrial repair (Senning) to neonatal atrial or arterial repair show comparable early mortality in all groups. However, the intermediate results at a mean of 6.7 years reveal fewer arrhythmic and functional complications in the AS group. The possibility of neonatal repair combined with low early and intermediate morbidity and mortality confirm AS as the treatment of choice for d-transposition of the great arteries.

Arrhythmias, Cardiac↗
PubMed1995

Aortic implantation is possible in all cases of anomalous origin of the left coronary artery from the pulmonary artery.

BACKGROUND: Anomalous origin of the left coronary artery from the pulmonary artery (PA) optimally is treated by creation of a multiple coronary system. This study explores the use of aortic implantation employing alternative methods to achieve coronary transfer in all patients, regardless of the site of origin of the anomalous coronary artery, avoiding the problems of bypass grafts and tunnel procedures. METHODS: During the period 1986 to 1994, 11 patients aged 6 months to 8 years (mean age, 2.6 years) underwent repair. Coronary artery origin from the PA included left sinus in 3, posterior in 2, right sinus in 2, intramural aorta with its orifice at the bifurcation of the main and right PA in 1, high left main PA in 1, high at the bifurcation of main and right PA in 1, and anterior in 1. Findings included angina in 4, prior infarctions in 3, ischemia in 7, left ventricular dysfunction in 6, mitral regurgitation in 5, atrial septal defect in 2, and echocardiograms suggestive of endocardial fibrosis in 4. One patient had prior ligation with ventricular dysfunction and collateralization and recanalization. A single patient was asymptomatic. Repair was accomplished by direct transfer using the PA sinus of Valsalva as a button in only 6; tubular reconstruction was used in 4 when the distance was too great to avoid tension; 2 short tubes were constructed with PA wall in 2 of the 3 left sinus origins, whereas 2 long tubes of PA wall were used (1 high on the left side of the main PA and 1 with left anterior descending origin from the anterior sinus of Valsalva in a patient with malrotation [end neo-artery to side aortic reconstruction]); finally, in situ transfer and intraaortic reconstruction (unroofing and anastomosis) was performed in 1 intramural coronary artery. Division of the PA, mobilization of the distal PA, division of the ductus, and direct reanastomosis of the PA was performed in 3 tubular reconstructions, as well as all 6 direct coronary transfers. RESULTS: There were no operative or late deaths. Follow-up of 2 to 100 months (mean, 46 months) revealed no new angina or infarctions, improved function and decreased mitral regurgitation. Echocardiographic and angiographic studies demonstrated patency and prograde flow in the new coronary systems. CONCLUSIONS: Aortic implantation is the treatment of choice for anomalous origin of the left coronary artery. Methods such as direct transfer, tubular reconstruction, and in situ transfer make such implantation possible in all patients regardless of the site of coronary origin, distance from the aorta, or coronary artery configuration.

Anastomosis, Surgical↗
PubMed1994

Critical pathway methodology: effectiveness in congenital heart surgery.

Critical pathway methodology has been demonstrated to provide producible reduction in average length of stay (ALOS) in adults in certain diagnostic-related groups and operations such as coronary artery bypass grafting. The efficacy of this approach in congenital heart surgery was explored. Two hundred eighty-six consecutive patients from a health maintenance organization treated by a single surgeon since the institution of diagnostic-related group coding at that health maintenance organization constituted the study group. One hundred fourteen patients were treated at a university hospital without critical pathway methodology (group 1) and 172, subsequently at the health maintenance organization institution using the methodology (group 2). Operation/lesion, age, and diagnostic-related group matching was possible in 61 pairs. Examination of the ALOS Hospital (operative and postoperative days) for the entire cohort revealed a 43.8% reduction in ALOS Hospital (p < 0.0001) and a 39.0% reduction in ALOS Intensive Care Unit (p < 0.0001). There was also significant reduction in ALOS Hospital and ALOS Intensive Care Unit in the operation/lesion-matched subsets. Outcome measures including operative and late mortality, readmission, unscheduled emergency room and clinic visits, and health maintenance organization family assessment survey demonstrated no improvement in outcome with increased hospital stay. Thus, critical pathway methodology when used in patients undergoing a congenital heart operation produces a significant reduction in hospital stay and intensive care unit stay as well as quality patient care with uniformity of outcome.

Adolescent↗
PubMed1994

Maximal vascular conductance in right ventricular myocardial circulation.

With acutely increasing right ventricular (RV) hypertension, failure eventually occurs because of RV ischemia. This study examines the effects of RV hypertension on the diastolic right coronary circulation. Conscious dogs instrumented to measure right coronary artery pressure and blood flow were studied after maximal coronary vasodilation with chromonar. Diastolic coronary pressure-flow relations, described by slope (conductance) and zero-flow, pressure axis intercept (Pf = 0), were generated before and during RV hypertension. Diastolic Pf = 0 increased from 11.8 +/- 6.5 to 17.1 +/- 7.1 (means +/- SD, P < 0.01) Torr, with no change in conductance. During RV hypertension, RV diastolic pressure increased. To examine possible mechanisms for the increase in Pf = 0, pressure-flow relations were generated before and after volume loading, without systolic hypertension. Diastolic Pf = 0 increased from 15.5 +/- 3.1 to 20.8 +/- 4.1 Torr, suggesting that changes in Pf = 0 with RV hypertension were mediated by increased filling pressures. Pressure flow relations were derived from mean right coronary flow and RV driving pressure before and during RV hypertension. Under these conditions, Pf = 0 is close to zero; the use of RV driving pressure provides a method for calculating maximal right coronary conductance.

Animals↗
PubMed1993

Reconstruction of hypoplastic aortic arch and coarctation in a 720-gram premature infant.

The case of a 720-g infant born at 29 weeks of gestation who underwent successful surgical correction of a hypoplastic aortic arch and aortic coarctation is presented. The infant was initially brought to surgery with an echocardiographic diagnosis of patent ductus arteriosus with left to right shunt unresponsive to indomethacin therapy. The correct diagnosis of hypoplastic aortic arch and severe coarctation with ductal dependent blood flow to the lower body was made intraoperatively. This case illustrates the danger of limited diagnostic testing in premature infants assumed to have isolated patent ductus arteriosus, and also that these small infants can undergo successful surgical repair of complex aortic arch lesions.

Aorta, Thoracic↗
PubMed1992

Intraoperative echocardiography for evaluation of congenital heart defects in infants and children.

To determine the accuracy, utility, and limitations of intraoperative transesophageal echocardiography (TEE) in infants and children, we performed prebypass and postbypass TEE in 90 children undergoing surgical repair of congenital heart lesions, comparing the results to those obtained using intraoperative epicardial echocardiography and pre- and postoperative precordial echocardiography. Patients ranged in age from 4 days to 21 yr (mean 4.1 yr) and in weight from 3 to 68 kg (mean 15.4 kg). Prebypass, we obtained high-quality, two-dimensional TEE images in 86 patients, with correction of the preoperative precordial diagnosis in 3 and confirmation of the preoperative diagnosis in the rest. Adequate epicardial images were obtained in 78 patients, with confirmation of the preoperative diagnosis in all. Shunt lesions that were well delineated prebypass by both TEE and epicardial imaging included interatrial, interventricular, and atrioventricular septal defect lesions. TEE failed to detect the exact size and location of lesions involving the right ventricular outflow tract, i.e., doubly committed subarterial (supracristal) ventricular septal defects. Regurgitant lesions (n = 30) were identified and their severity evaluated in all patients by both TEE and epicardial imaging. Obstructive lesions (n = 33), excluding those involving the right ventricular outflow tract, were well defined by both echocardiographic approaches. Postbypass, we obtained high-quality, two-dimensional, color and Doppler TEE images in 86 patients and epicardial images in 78 patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1992

Current method of repair of truncus arteriosus.

Surgical treatment of truncus arteriosus has been demonstrated to be optimized when approached in early infancy. In the past, the materials available, namely the 12-mm porcine valve Dacron conduit, restricted the size of the patient in whom early repair could be performed with increasing risk associated with decreasing age and size. The availability of homografts for reconstruction of right ventricular pulmonary artery continuity has allowed repair even in the neonatal period. Two hundred forty-four patients with truncus arteriosus have been operated on at the University of California San Francisco since 1975. In the past 5 years, 49 have been repaired using homograft reconstruction. The method of repair differs markedly from that of Dacron conduits, and specific points concerning homograft insertion including orientation, method of proximal anastomosis, and sizing are discussed in detail and the difference in insertion from the Dacron bovine heterograft conduit are discussed.

Age Factors↗
PubMed1991

Growth of the hypoplastic ascending aorta after radical palliation.

Surgical treatment of hypoplasia of the ascending aorta is a difficult problem. An approach using proximal pulmonary artery to distal aorta bypass with distal pulmonary artery banding was employed in 19 patients with an ascending aorta less than 6 mm in diameter but a patent aortic outflow. There were 11 male and 8 female neonates and infants, and weight ranged from 2 to 4.5 kg (median weight, 3.5 kg). Four patients had transposition of the great arteries, 12 had subaortic stenosis, and 5 had interrupted aortic arch. There was one operative death. Cerebral cyanosis developed in 3 of the 4 patients with transposition of the great arteries and necessitated additional operations within the first year postoperatively. Therefore, palliation with a pulmonary artery to descending aorta conduit and banding was abandoned in such patients. All 14 surviving patients with normally related great arteries had successful palliation and growth of left heart structures. Subsequent procedures included a Fontan/Damus procedure in 1 patient, patch aortoplasty and pulmonary arterioplasty in 5 patients, arch reconstruction with aortic valvulotomy and pulmonary arterioplasty in 2, double arch reconstruction in 2, and simple patch aortoplasty with plans for subsequent pulmonary arterioplasty and ventricular septal defect closure in 1. Results demonstrate that in patients with a hypoplastic ascending aorta, this radical method of palliation can result in growth of right and left heart structures and thus provides the possibility of biventricular repair.

Anastomosis, Surgical↗
PubMed1991

Intraoperative transesophageal echocardiography of atrioventricular septal defect.

To determine the accuracy and utility of single-plane transesophageal echocardiography in analyzing atrioventricular (AV) septal defect, intraoperative transesophageal echocardiography was performed before and after institution of cardiopulmonary bypass in 16 patients (age 24 days to 14 years, weight 3 to 47 kg). Prebypass transesophageal echocardiography (including two-dimensional echocardiography, Doppler color flow mapping and pulsed wave Doppler ultrasound) correctly diagnosed divided AV valve, common AV valve and unbalanced AV valve, as well as atrial or ventricular septal defect, or both, in all cases. It correctly analyzed AV valve regurgitation in all 10 patients with right and all 14 with left AV valve regurgitation and correctly analyzed 30 of 33 additional cardiac anomalies. Transesophageal echocardiography was able to detect the absence of normal pulmonary venous connections but failed to demonstrate all of the complex anomalous pulmonary venous connections in three patients with atrial isomerism. Postbypass transesophageal echocardiography documented the absence of a significant residual shunt in 11 of 11 patients undergoing corrective surgery and verified residual AV valve regurgitation in 7 of 9 patients with tricuspid regurgitation and 11 of 13 with mitral regurgitation. Transesophageal echocardiographic information that altered or refined the surgical treatment was obtained in 5 (31%) of 16 patients. Epicardial and transesophageal echocardiography results were concordant in all 13 patients in whom both were performed. Transesophageal echocardiography provides useful and accurate imaging of the important two-dimensional, pulsed wave Doppler ultrasound and Doppler color flow mapping features in AV septal defect.

Adolescent↗
PubMed1991

Intraoperative transesophageal echocardiography of ventricular septal defect.

The accuracy and limitations of intraoperative two-dimensional (2-D) and color Doppler flow mapping transesophageal echocardiography (TEE) of ventricular septal defect (VSD), before and after cardiopulmonary bypass, were analyzed in 62 children. Twenty-one patients had an isolated VSD, and 41 had a VSD plus additional cardiac anomalies. Two-dimensional and color Doppler flow mapping TEE were performed with a miniaturized 5-MHz single (transverse) plane transducer in the 51 of 62 patients weighing less than 20 kg. The remaining 11 were monitored using a single plane adult probe (n = 4) and a biplane (transverse plus longitudinal) probe (N = 7). Prebypass TEE provided a correct diagnosis in 57 of 62 cases (92%) and corrected an erroneous preoperative transthoracic echocardiographic diagnosis in three of 62 cases (5%). Single plane TEE diagnosis was erroneous in five patients: four with doubly-committed subarterial VSD and one with multiple small apical muscular defects and pulmonary hypertension. Biplane TEE (transverse longitudinal) provided clear and complete imaging of the right ventricular outflow tract in all seven cases in whom it was used. Postbypass TEE showed absence of a hemodynamically significant residual VSD in 30 of 40 patients (95%) who underwent VSD patch closure, prospectively identified two of 40 with significant residual VSD, and accurately measured the color Doppler jet width of all residual VSDs. We conclude that hemodynamically significant VSDs can be identified immediately after cardiopulmonary bypass based on the width of the residual VSD color Doppler flow map jet. Therefore, 2-D and color Doppler flow mapping TEE provide an accurate diagnosis in most cases of VSD but may miss doubly-committed subarterial and apical muscular VSD unless biplane TEE is used.

Adolescent↗