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Biomedical subjects

M Goormastic

Publications and source records attributed to M Goormastic.

At least 55 records · Page 3Linked to original sources
PubMed1986

Reoperations for valve surgery: perioperative mortality and determinants of risk for 1,000 patients, 1958-1984.

One thousand consecutive cardiac reoperations for valve surgery in 897 patients were reviewed to determine in-hospital mortality and indicators of risk. Subgroups based on the number of previous cardiac procedures and the valve or valves replaced or repaired at reoperation (aortic valve, mitral valve, tricuspid valve, or multiple valves and mortality [deaths/number of procedures (% mortality)]) for those subgroups are as follows: (Table: see text) Predictors of increased risk for a first aortic valve reoperation were advanced age (p = .0002), endocarditis (p = .0018), female sex (p = .014), impaired left ventricular function (p = .039), and number of coronary vessels obstructed by 70% or more (p = .055). For a first mitral valve reoperation, the predictors were advanced age (p less than .0001), preoperative shock or cardiac arrest (p = .01), previous aortic or tricuspid valve operations (p = .02), type of mitral valve procedure (risk for repair of periprosthetic leak was greater than mitral valve replacement which was greater than mitral valve-conserving operation [p = .05]), and impaired left ventricular function (p = .059). For a first multiple valve reoperation, the predictors were diabetes (p = .04) and ascites (p = .02), whereas patients undergoing mitral valve replacement and tricuspid valve operations were at decreased risk (p = .01). Comparison of second reoperations with first reoperations indicates risk increases for multiple operations (p = .01) but not for aortic or mitral valve procedures. Rereplacement of a prosthesis (p = .007), coronary bypass grafting at reoperation (p = .006), and advanced age (p = .06) increased the risk for second reoperations. Age is the most consistent predictor of risk for patients undergoing valve reoperations.

Aortic Valve↗
PubMed1986

Detrimental effect of cyclosporine on initial function of cadaver renal allografts following extended preservation. Results of a randomized prospective study.

We report herein the results of a randomized prospective trial comparing maintenance cyclosporine (CsA)-prednisone immunosuppression to a regimen of azathioprine-prednisone-antilymphocyte globulin (ALG) in cadaver renal transplant recipients. Fifty-six patients were entered into this study with 31 assigned to the ALG group and 25 to the CsA group. These two groups were well matched for most major determinants of graft outcome and the mean renal preservation time was 37 hr in each group. The incidence of acute tubular necrosis (ATN) was high in both groups (58% ALG, 72% CsA, NS). There were five cases of primary nonfunction in the CsA group and only one in the ALG group (P = .05). Of the kidneys that functioned, the mean serum creatinine nadir (1.5 vs. 2.2 mg/dl, P = .06) and the mean number of days to reach the serum creatinine nadir (24.2 vs. 43.3 days, P = .03) were both less in the ALG group. The actuarial one-year graft survival rate in the ALG and CsA groups is 78% and 48%, respectively (P less than .05). This difference is mainly due to the large number of primary nonfunctioning grafts in the latter group, which we attribute to the effect of CsA's nephrotoxicity superimposed on renal ischemia incurred prior to transplantation. These data emphasize that, in order to realize the full benefit of CsA in cadaver transplantation, renewed emphasis must be placed on minimizing ischemic renal damage.

Adolescent↗
PubMed1986

Survival of non-surgical patients with mild angina or myocardial infarction without angina.

A group of 408 catheterised patients who had mild angina or myocardial infarction without angina was selected in conformity with the criteria for entry into a previously reported randomised trial. Medical treatment had been chosen initially by the cardiologist, referring physician, or the patient, although 27% had late operation. Five year survival rates were 91% and 72% for mild angina with high or low ejection fractions and 85% for those who had myocardial infarction without subsequent angina. Survival rates were 95%, 88%, and 80% for one, two, and three artery disease respectively. For patients who had ejection fractions of at least 0.50, five year survivals were 95%, 89%, and 83% for one, two, and three artery involvement respectively. Good left ventricular function, single artery disease, and a short history were favourable prognostic variables in multivariate analysis of patients who had angina pectoris. Statistical methods of dealing with patients who had late operation influenced calculated survival, especially for patients at relatively high risk. The lower survival rates for the whole group and most subsets compared with survival rates in the randomised trial may be of clinical importance.

Angina Pectoris↗
PubMed1986

Lumbar herniated disk disease and canal stenosis: prospective evaluation by surface coil MR, CT, and myelography.

Sixty patients with suspected lumbar herniated disk and/or canal stenosis were studied prospectively with surface coil MRI, CT, and/or myelography, and the results were compared with the surgically confirmed abnormality. Forty-eight patients had lumbar surgery at 62 levels. There were no negative explorations. Thirty-nine patients had a myelogram and CT. Thirty of the CTs were performed following the injection of metrizamide for myelography. Nine patients had a CT without intrathecal contrast material 1 to several days before the myelogram. Six patients had myelography only, and three patients had CT only. All studies were evaluated for the location and type of disease in a forced choice fashion. Independent of the surgically correlated levels, there was 86.8% agreement between the MR and CT studies in all patients at 151 levels and 87.2% agreement between MR and myelography at 218 levels. At the operative levels, there was 82.6% agreement between MR and surgical findings for both type and location of disease; 83% agreement between CT and surgical findings; and 71.8% agreement between myelography and surgical findings. There was 92.5% agreement when MR and CT were used jointly, and 89.4% agreement when CT and myelography were used jointly. The results of this study indicate that a technically adequate MR examination was equivalent to CT and myelography in the diagnosis of lumbar canal stenosis and herniated disk disease. CT and MR can be complementary studies, and surface coil MR can be viewed as an alternative to myelography.

Adult↗
PubMed1986

Perioperative risk of bilateral internal mammary artery grafting: analysis of 500 cases from 1971 to 1984.

The records of the first 500 patients (420 men, 80 women, mean age 55 years, range 24 to 78) undergoing bilateral internal mammary artery (IMA) grafting were reviewed to determine in-hospital morbidity and mortality. Sixty patients (12%) had had previous cardiac operations and 130 (26%) previous saphenous vein removal. From two to seven total grafts (mean 3.2) were performed, including 595 IMA grafts to the anterior descending or diagonal artery, 355 to the circumflex, and 105 to the right coronary system. To assess changing risks, the first 125 patients (group A, 1971 to 1982) were compared with the next 375 (group B, 1982 to 1984). Major complications in groups A and B included stroke, four (3.2%) vs ine (2.4%); wound complications requiring reoperation, three (2.4%) vs five (1.3%); prolonged (greater than 48 hr) respiratory care, seven (5.6%) vs 19 (5.1%); and death, two (1.6%) vs five (1.3%) (no p value less than .05). Complications significantly less frequent in group B were new Q waves in nine (7.2%) vs 10 (2.7%) in group A (p = .02) and reoperation for bleeding in 17 (13.6%) vs 16 (4.3%) in group A (p = .0003). Logistic regression analysis showed that major complications did not correlate with gender, diabetes, number of grafts, or preoperative left ventricular function but were associated with increasing age (p = .0001) and previous cardiac surgery (p = .009) and were decreased by the use of cardioplegia (p = .002). The excellent long-term patency of IMA grafts, combined with low and decreasing perioperative risk, supports the continued use of bilateral IMA grafting.

Adult↗
PubMed1986

A critical look at survival of diabetics with end-stage renal disease. Transplantation versus dialysis therapy.

The survival of 100 consecutive patients with diabetic nephropathy after treatment with hemodialysis, peritoneal dialysis, or renal transplantation was reviewed at our institution from 1976 to 1982. Standard actuarial survival analysis revealed an overall survival of 83% and 61% at one and two years, respectively. Coronary angiography was used as a screening procedure for renal transplantation. In the dialysis group, 27 patients were considered acceptable transplant candidates on the basis of the coronary angiography but were not transplanted for other reasons. When the survival analysis was limited to those "transplant candidates" the survival rates were 78%, 51%, and 8% at 1, 2, and 5 years, respectively. In comparison, survival after transplantation was 81%, 67%, and 45%, at 1, 2, and 5 years, respectively. In order to eliminate bias, survival comparisons were subsequently made using the Cox Proportional Hazard Model to take into account the time the transplant patients spent on dialysis prior to renal transplantation. When this analysis was performed, there was no significant difference in survival between transplantation and dialysis for the first two years, but overall survival after five years was significantly better after renal transplantation even when the comparison was limited to acceptable transplant candidates who remained on dialysis (P = .04). Survival for patients with significant coronary disease (greater than 70% stenosis of a coronary vessel or moderate to severe left ventricular dysfunction) was analyzed according to therapeutic modality. Although overall prognosis was poor in this group as a whole (1, 2, and 5 year survivals were 76%, 45%, and 19%, respectively), the cardiac patients had a trend to better survival after renal transplantation than when maintained on dialysis (P = .22). In addition to other factors such as quality of life, rehabilitation, and progression of other diabetic complications, the benefit of renal transplantation on patient survival must be considered when deciding between renal transplantation and maintenance dialysis therapy for diabetic patients with renal failure.

Adolescent↗
PubMed1986

Results of mitral valve reconstruction.

To evaluate the early results of mitral valve reconstruction for mitral insufficiency, 117 consecutive cases were analyzed. Sixty-four (57.7%) of the patients were men, and the mean age was 60 +/- 13 years (range 18 to 85). Eighty-nine (76%) of the patients were in NYHA functional class III or IV preoperatively. The cause of the mitral disease was degenerative in 94 (80%) and rheumatic in 13 (11%) patients. Isolated mitral valve repair was performed in 56 patients (47.9%); the remainder underwent associated procedures that included myocardial revascularization in 38 (32.5%). Ninety-nine (85%) underwent a ring annuloplasty but in only seven (6%) was this the only repair technique. Resection of the posterior leaflet was performed in 41 (35%). There were five operative deaths (4.3%); one (1.8%) occurred after isolated repair and four (6.5%) after repair with associated procedures. All deaths occurred in patients greater than 65 years of age who were in NYHA functional class III or IV. Mean follow-up was 13.5 months (range 1 to 62). Two year actuarial survival was 90.6%. Three patients required reoperation (incidence of 2.5% per patient-year). Two patients sustained embolic events (incidence of 1.6% per patient-year). There were no anticoagulant-related complications. After surgery, 100 survivors (96.2%) were in NYHA functional class I or II.

Adolescent↗
PubMed1986

Predictors of reoperation after myocardial revascularization.

The first 1,000 patients undergoing primary isolated myocardial revascularization each year from 1971 to 1978 were analyzed to define the incidence of reoperation and to elucidate the determinants of reoperation and reoperation-free survival. Six hundred sixty-six patients (9.7%) underwent reoperation in a mean of 6.9 +/- 3.2 years. Cumulative percent reoperation was 2.7% at 5 years, 11.4% at 10 years, and 17.3% at 12 years. The annual incidence of reoperation was 1.1% at 5 years and increased to 3.9% at 12 years. Twenty-five patient descriptors were analyzed for predictors of reoperation. Young age was found to be the most important predictor of potential for reoperation. Other risk factors in descending order of significance were absence of an internal mammary artery graft, incomplete revascularization, New York Heart Association Functional Class III/IV, and single or double vessel disease. Absence of an internal mammary artery graft was an important predictor for all age groups. In the multivariate analyses for risk factors for reoperation-free survival, absence of an internal mammary artery graft was the most important predictor. Other factors of major significance were smoking, incomplete revascularization, and moderate/severe left ventricular impairment. Internal mammary artery grafting neutralizes hypertension, serum cholesterol level higher than 300 mg/dl, and smoking as risk factors for reoperation-free survival.

Adult↗
PubMed1985

Combined cardiac catheterization and carotid cineangiography: an analysis of complications.

Two hundred fifty-three patients underwent cardiac catheterization with selective cineangiography of the carotid arteries. Diagnostic angiograms of both the right and left carotid arteries were obtained in 240 patients (95%). Of these, 217 patients (90%) were studied without complication, 18 (8%) had minor complications, and five (2%) had major complications. Four of the five major complications occurred in patients with bilateral carotid atherosclerosis obliterans. Variations of catheterization technique used in an effort to reduce risk are discussed.

Adult↗
PubMed1985

Recurrence after surgery in Crohn's disease. Relationship to location of disease (clinical pattern) and surgical indication.

Among 615 patients with Crohn's disease originally diagnosed at the Cleveland Clinic Foundation from 1966 to 1969, 592 have been followed (96%) for a mean of 13 yr. Of these, 438 had undergone operation. The purpose of this study was to determine how many of these patients had developed recurrences requiring another operation and to relate recurrences to the original anatomic location of disease (the clinical pattern) and surgical indication. Those patients with ileocolic disease had the highest recurrence: 53% compared with 45% for colonic and 44% for small intestinal patterns. Second recurrences were ileocolic pattern 35%, colon 34%, small intestine 38%. The estimated median time of recurrence was similar among these three groups. The presence of internal fistula or perianal disease as an indicator for surgery were associated with a higher likelihood of recurrence and a shortened estimated median time to recurrence. This study supports the concept of conservatism with regard to the management of these two complications for patients with Crohn's disease.

Adult↗
PubMed1985

Renal transplantation in the older recipient.

From 1976 to 1983, 13 living related and 54 cadaver renal transplants were done in 62 patients more than 50 years old. Patients with no coronary or myocardial disease upon coronary angiography were selected preferentially for transplantation. Over-all 1-year patient and graft survival rates were 88 and 70 per cent, respectively. Among cadaver recipients graft survival was improved (p less than 0.001) when prophylactic antilymphoblast globulin was used. There were fewer steroid-related complications (p less than 0.001) in recipients managed with a low dose rather than a high dose maintenance prednisone regimen. With careful patient selection and a steroid-sparing immunosuppressive regimen, renal transplantation can be done safely in older recipients with no increased risk of death or graft loss.

Age Factors↗
PubMed1985

Determinants of 10-year survival after primary myocardial revascularization.

The first 1000 patients undergoing primary isolated myocardial revascularization each year from 1971 to 1978 were analyzed to elucidate the determinants of long-term survival. Five-year survival was 93.2%, and 10-year survival was 79.3%. Five-year survivals were 96.1%, 94.2%, 92.1%, and 90.8%, respectively, for single, double, triple, and left main disease. Ten-year survivals for the same subsets were 88.6%, 83.0%, 74.9%, and 70.9%. Five-year survivals were 95.3%, 92.4%, 88.0%, and 81.3% for patients with normal, mild, moderate, and severe impairment of the left ventricle. Ten-year survivals for the same subsets were 84.1%, 76.5%, 65.8% and 53.6%. Patients receiving internal mammary artery grafts had 95.6% and 85.8% 5- and 10-year survivals that were superior to 92.0% and 76.2% in patients with only vein grafts. Patients completely revascularized had 95.0% and 82.5% 5- and 10-year survivals, while incompletely revascularized patients had lower (90.5% and 75.2%) 5- and 10-year survivals. Advancing age was the most important factor influencing late survival. Other risk factors in descending order of significance were impaired left ventricular function, no mammary artery graft, smoking, abnormal EKG, three vessel or left main disease, left ventricular end diastolic pressure (LVEDP) greater than 24, hypertension, 1971 to 1974 surgical era, cholesterol greater than 300, incomplete revascularization, and two vessel disease.

Adult↗
PubMed1985

Mitral valve replacement combined with myocardial revascularization: early and late results for 300 patients, 1970 to 1983.

Of 300 consecutive patients undergoing primary operation for mitral valve replacement combined with coronary bypass grafting, 22 (7.3%) died in-hospital. Multivariate testing of preoperative and operative descriptors identified radiographic cardiac enlargement, preoperative paced rhythm or atrial fibrillation, 70% or more left main coronary obstruction, and serum bilirubin of more than 2 mg% as factors associated with an increase in in-hospital mortality. Follow-up of the 278 hospital survivors (mean interval 48 months, range 2 to 165 months) documented survival of 85%, 66%, and 31% and an event-free survival of 65%, 46%, and 21% at 2, 5, and 10 postoperative years, respectively. Cox proportional-hazard regression models of late risk implicated in-hospital ventricular arrhythmias, left ventricular dysfunction, and rheumatic or ischemic causes of mitral valve disease in decreasing long-term survival. In addition, patients with bioprostheses without warfarin anticoagulation had better survival and event-free survival than those with bioprostheses taking warfarin and those with mechanical prostheses with or without warfarin.

Aged↗
PubMed1985

Interobserver variability in EEG interpretation.

A random sample of 100 active electroencephalographers in the United States evaluated 10-second samples of 12 selected EEGs. The evaluations consisted of multiple-choice questions related to the age of the patient, EEG finding, artifact, and consciousness of the patient. The rate of reporting the "correct" response was examined in terms of various respondent characteristics such as EEG board certification, age, percent of time in clinical EEG work, and number of recordings interpreted annually. This study indicates that, even today, there is considerable variability in EEG interpretation, and that this variability is influenced by specific reader characteristics.

Action Potentials↗
PubMed1985

Does mammary artery grafting increase surgical risk?

From 1980 through 1982, 7105 patients underwent primary isolated myocardial revascularization. Of these, 49.2% received only vein grafts and 50.2% received at least one internal mammary artery graft. The incidence of mammary artery grafting increased from 33.5% in 1980 to 67.1% in 1982. The operative mortality rate was 1.4% in the vein group and 0.2% in the mammary artery group (p less than .0001). A multivariate analysis identified six incremental risk factors for operative mortality. After adjusting for these risk factors, the use of vein grafts only was found to be an incremental risk factor (p less than .0001). In a subset of patients without major risk factors, there was no difference in the incidence of perioperative infarction, respiratory insufficiency, wound complication, stroke, use of intra-aortic balloon, reoperation for bleeding, or blood requirements. We conclude that internal mammary artery grafting is safe and is not associated with increased surgical morbidity or mortality.

Adult↗
PubMed1984

Improved results of cadaver renal transplantation with azathioprine, prednisone and antilymphoblast globulin.

From 1980 to 1982, 100 consecutive cadaver renal transplants were performed. All but 2 recipients received preoperative transfusion and all received an initial 2-week course of antilymphoblast globulin. A prospective controlled evaluation of high versus low maintenance prednisone, and antilymphoblast globulin versus intravenous methylprednisolone for first rejection therapy was done. Over-all 1-year graft and patient survivals were 77 and 96 per cent, respectively. Graft survival was equal in the high and low steroid groups. Antilymphoblast globulin was as effective as intravenous methylprednisolone in reversing first rejections. Graft survival was improved with better donor-recipient matched grafts. We conclude that excellent results can be obtained in transfused cadaver renal allograft recipients managed with azathioprine, prednisone and antilymphoblast globulin. The regimen of prophylactic antilymphoblast globulin, low maintenance prednisone and antilymphoblast globulin alone for first rejections is immunologically effective and steroid sparing.

Antilymphocyte Serum↗
PubMed1984

Young adults with coronary atherosclerosis: 10 year results of surgical myocardial revascularization.

This study reviews data on 107 patients, aged 35 years or younger, who underwent surgical coronary revascularization from 1971 to 1975. Early clinical events included one operative death and five nonfatal perioperative myocardial infarctions. Late follow-up (mean interval after operation 115 months) demonstrated actuarial survival rates of 94% at 5 years and 85% at 10 years. Fifteen late deaths, 23 nonfatal myocardial infarctions, 13 reoperations and return of severe angina in 10 patients were considered late clinical events. Actuarial survival free of early or late clinical events was 77% at 5 years and 53% at 10 postoperative years. Testing of clinical, angiographic and operative variables for influence on survival and event-free survival showed that survival was decreased by multivessel disease and impaired left ventricular function; event-free survival was decreased by a family history of coronary disease and cigarette smoking. Both survival and event-free survival were decreased by diabetes and elevated serum cholesterol. Postoperative cardiac catheterization (64 patients, mean postoperative interval 47 months) demonstrated that mammary artery graft patency (25 of 27, 93%) exceeded vein graft patency (49 of 88, 56%, p less than 0.01). The atherogenic diatheses of young adults may compromise the operative result, whereas use of internal mammary artery grafts may enhance the palliation of bypass surgery.

Adult↗