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Biomedical subjects

M I Turina

Publications and source records attributed to M I Turina.

At least 19 recordsLinked to original sources
PubMed1998

Late outcome of coronary artery bypass grafting in young versus older patients.

BACKGROUND: We compared long-term results of coronary artery bypass grafting between 1976 and 1988 in 176 patients 40 years old or younger with a matched control group of 176 patients 25 to 30 years older. METHODS: Mean age was 37.4 +/- 2.7 years (+/- standard deviation) in the study group and 64.2 +/- 2.9 years in the control group. Matching criteria were age, sex, left ventricular ejection fraction, number of bypass grafts, and year of operation. RESULTS: The study group had more smokers (p = 0.000) and more patients with hypercholesterolemia (p = 0.026), unstable angina (p = 0.003), and preoperative myocardial infarction (p = 0.009); fewer patients had hypertension (p = 0.000) and diabetes (p = 0.005) in this group than in the control group. The internal mammary artery was used in 31% of the study patients and in 30% of the controls. The actuarial survival rates after 5, 10, and 15 years were 92%, 86%, and 72% in the study group and 92%, 86%, and 66% in the control group (p = 0.202). Young age was a predictor of cardiac reoperation. CONCLUSIONS: Late survival is similar for young and older patients, but the reintervention rate is higher in the younger group. The absence of unstable angina, a left ventricular ejection fraction greater than 0.45, and the use of internal mammary artery grafts increase survival in all patients.

Adult↗
PubMed1998

Inflammatory aneurysm of the ascending aorta.

The gold standard to clarify an acute pathology of the ascending aorta is transesophageal echocardiography or contrast-enhanced computed tomography. Neither of these methods led to the correct finding in our case of an inflammatory aneurysm of the ascending aorta. Both assessments resulted in the diagnosis of an acute dissection of the ascending aorta.

Aortic Dissection↗
PubMed1998

Long-term follow-up in hypertrophic obstructive cardiomyopathy after septal myectomy.

BACKGROUND: Controversy exists about the choice of treatment for patients with hypertrophic obstructive cardiomyopathy. The purpose of this study was to evaluate clinical and echocardiographic long-term results in patients with hypertrophic obstructive cardiomyopathy after septal myectomy and to determine predictors of event-free survival in these patients. METHODS: Between 1965 and 1995, 110 consecutive patients 2 to 66 years old (mean age, 37 +/- 15 years) with an invasively measured left ventricular outflow tract gradient of 86 +/- 39 mm Hg (81 +/- 42 mm Hg by Doppler echocardiography) underwent either septal myectomy only (n = 87) or myectomy combined with additional procedures (n = 23). Mean follow-up was 11.7 +/- 7.5 years. Predictors of late events were calculated using multivariate Cox regression analysis. RESULTS: The perioperative mortality rate was 3.6% (n = 4). The cumulative survival rate at 5, 10, and 15 years was 93%, 80%, and 72%, respectively, and symptom-free survival, 77%, 50%, and 33%, respectively. Predictors of late death were New York Heart Association class III or IV (p < 0.05), congestive heart failure (p < 0.05) and additional procedures (p < 0.05). The left ventricular outflow tract gradient was nearly eliminated in all patients, the left atrial dimension decreased significantly during the early years, and left ventricular dilatation occurred late in 17 patients. CONCLUSIONS: Septal myectomy is associated with a low perioperative mortality and a high late survival rate (72% at 15 years' follow-up). Septal myectomy is still an excellent modality in the treatment strategy for symptomatic patients with hypertrophic obstructive cardiomyopathy.

Adolescent↗
PubMed1998

Aprotinin in pediatric cardiac operations: a benefit in complex malformations and with high-dose regimen only.

BACKGROUND: The benefits and the current indications of aprotinin in congenital operations are not well defined. At present there are only a few studies available that have investigated a small number of patients in several heterogeneous groups of malformations. METHODS: We investigated efficacy and safety of aprotinin in three groups of children < 15 kg, presenting with isolated ventricular septum defect (n = 60), tetralogy of Fallot (n = 52), and transposition of the great arteries (n = 56). Low-dose aprotinin regimen A1 (500,000 KIU in pump prime only) and high-dose aprotinin A2 (50,000 KIU/kg during induction of anesthesia, 50,000 KIU/kg in pump prime, and 20,000 KIU/h continuous infusion) were compared to a control group A0 (without aprotinin) regarding perioperative blood loss, transfusion requirements, and effects on the coagulation system. RESULTS: The most common coagulation tests of aprotinin-treated patients and the platelet numbers were comparable with those of control patients preoperatively and 15 minutes after protamine administration. A significant dose-dependent reduction in fibrin-fibrinogen split products was observed at the end of cardiopulmonary bypass in the majority of aprotinin-treated patients with transposition. In patients with ventricular septum defect and Fallot, no significant difference in blood loss and transfusion requirements could be observed between patients with or without aprotinin and no difference was observed between low- and high-dose regimen. In transposition of the great arteries, high-dose aprotinin led to significant reduction of blood loss (p = 0.02) and postoperative blood transfusion (p = 0.003). Severe side effects as a result of administration of aprotinin were not observed. CONCLUSIONS: High-dose aprotinin reduces blood loss and transfusion requirement only in complex congenital cardiac operations; therefore aprotinin cannot be recommended as a blood conservation agent in routine pediatric operations.

Anesthesia, General↗
PubMed1998

Preoperative predictors of recurrent atrial fibrillation late after successful mitral valve reconstruction.

OBJECTIVE: Late outcome after mitral valve repair was examined to define preoperative predictors of recurrent atrial fibrillation late after successful mitral valve reconstruction. METHODS: One hundred and eighty-nine patients, 112 with preoperative sinus rhythm and 72 with preoperative chronic or intermittent atrial fibrillation, were followed for 12.2 +/- 10 years after valve repair. Clinic, hemodynamic end echocardiographic data were entered into Cox-regression and Kaplan-Meyer analysis to assess predictors for recurrent atrial fibrillation late after successful mitral valve repair. RESULTS: Univariate and multivariate predictors for recurrent atrial fibrillation late after successful mitral valve reconstruction were preoperative atrial fibrillation (P = 0.0001), preoperative antiarrhythmic drug treatment (P = 0.005), heart rate (P = 0.01), left ventricular ejection fraction (P = 0.01) and increased left ventricular posterior wall thickness (P = 0.05). Patients > 57.5 years with a mean pulmonary artery pressure > or =23 mm Hg and a history of preoperative antiarrhythmic drug treatment had an odds ratio of 53.33 (95% confidence limits 6.12-464.54) for atrial fibrillation late after successful mitral valve repair. CONCLUSION: Older patients with a history of atrial fibrillation, antiarrhythmic treatment or an elevated pulmonary artery pressure may present atrial fibrillation late after successful mitral valve repair. They could be considered for combined mitral valve reconstruction and surgery for atrial fibrillation even though sinus rhythm is present preoperatively.

Adult↗
PubMed1997

[Is hemofiltration following acute kidney failure in elderly cardiovascular surgery patients justified?].

In a retrospective study, 47 patients with acute renal failure following cardiovascular surgery were evaluated in the Cardiovascular Surgery ICU of the University Hospital, Zurich, from 1991 to 1994. The object of the study was to investigate the contribution of hemofiltration for acute renal failure following cardiovascular surgery. The aim was further to identify risk factors which impair survival. We found that overall mortality was 70.2%, but was influenced by the patients' age. In patients under 60 (n = 9) the mortality rate was 55.6%; in patients from 60 to 69 (n = 19) the mortality rate was 57.9%. However, in patients aged 70 and over (n = 19), there was an increase in mortality to 89.5%. Specifically, the outcome was tested in a stepwise logistic regression and we found that recovery of renal function following hemofiltration was the most important factor favoring survival (p < 0.001). Further statistical analysis revealed that age 70 years or over was one of the main risk factors leading to death (p < 0.03), whereas preoperative renal insufficiency had no influence on postoperative outcome (p < 0.29). We conclude that postoperative renal function represents the crucial factor in survival. Although hemofiltration achieved adequate results in all groups, the patients of 70 years and more experienced a significantly higher mortality rate. This suggests that the increased mortality of the elderly was not due to renal failure in itself but rather was related to polymorbidity. Hence we propose that in the latter group of elderly patients candidates for hemofiltration are to be very carefully selected, particularly if they have additional complications.

Acute Kidney Injury↗
PubMed1997

Perioperative risk and long-term results of heart transplantation after previous cardiac operations.

BACKGROUND: In recent years, there has been an increasing proportion of candidates for heart transplantation who have sustained one or several previous cardiac operations. This study analyzes the perioperative management and the long-term survival of patients undergoing orthotopic heart transplantation as a redo operation and compares the results with those obtained in patients undergoing transplantation as the first cardiac operation. METHODS: From October 1985 to October 1994, 204 heart transplantations were performed in 202 patients. Thirty-eight transplantations were performed in patients who had undergone prior cardiac operations because of coronary artery disease (n = 21) and valvular disease (n = 8) as well as one or several palliative or corrective procedures because of complex congenital heart disease (n = 9). These 38 patients were compared in a case-control fashion with 76 patients who underwent orthotopic cardiac transplantation as a primary cardiac procedure during the same period and using similar techniques. The majority of preoperative variables (hemodynamics, inotropic support, liver and renal function, coagulation, and priority to transplantation) were comparable in the two groups of patients. Mean age was significantly younger in the group of patients with a previous operation (42.2 +/- 9.5 versus 50.1 +/- 7.3 years; p < 0.001). RESULTS: Except the problem of more fastidious hemostasis, which is nowadays under better control since aprotinin has been routinely administered, the results show no significant difference in term of perioperative risk (hospital mortality: 5.2% in study group versus 7.8% in the control group) and long-term outcome. The 1-year survival rate was 92.7% +/- 3.6% in the study group versus 90.8% +/- 3.6% in the control group, and the 5-year survival rate was 79.4% +/- 4.5% versus 74.8% +/- 7.5%, respectively. CONCLUSIONS: These results are very acceptable and confirm the fact that carefully selected candidates for transplantation are not exposed to a particularly high perioperative risk when a prior cardiac operation has been performed. The incidences of early and late rejection episodes as well as the numbers of postoperative infections are similar in the two groups. Although multiple prior procedures do constitute significant risk factors for perioperative morbidity and mortality in isolated lung and heart-lung transplantation, this is not the case in heart transplantation.

Adult↗
PubMed1997

Minimally invasive coronary artery bypass techniques as adjunct to extracardiac procedures.

BACKGROUND: Surgical management of coronary artery disease has improved dramatically over the last decades in terms of short- and long-term results. Nevertheless, elderly patients (more than 75 years); patients with reduced ejection fraction (less than 0.25), heavily calcified aorta, or coexisting noncardiac diseases; and patients requiring cardiac reoperation have an increased perioperative risk when operated on with cardiopulmonary bypass. Successful minimally invasive coronary artery bypass grafting without cardiopulmonary bypass has been reported in selected cases. METHODS: In 8 of 40 high-risk patients undergoing operation on a beating heart, minimally invasive coronary bypass grafting was combined with vascular (carotid endarterectomy, n = 3; aortic replacement, n = 2) and abdominal procedures (a second look after combined pancreas and kidney transplantation) or defibrillator implantations (n = 2). RESULTS: Postoperatively, there was no mortality, no morbidity, and no blood transfusion. Patients are free of symptoms at an average follow-up time of 5.5 +/- 5 months. CONCLUSIONS: Our results indicate that minimally invasive coronary artery bypass grafting technique can be particularly useful if noncardiac procedures have to be performed in high-risk patients with significant coronary artery disease.

Abdomen↗
PubMed1997

Cardiac surgery in a high-risk group of patients: is prolonged postoperative antibiotic prophylaxis effective?

OBJECTIVE: In a prospective, randomized study, postoperatively prolonged antibiotic prophylaxis is evaluated in a high-risk group of patients undergoing cardiac operations. These patients had postoperative low cardiac output necessitating inotropic support and intraaortic balloon pumping. METHODS: Between January 1991 and 1994, 53 patients were enrolled in the study (42 men, mean age 65 years). All patients received the usual perioperative (24 hours) cefazolin prophylaxis. In the study group (n = 28) a prolonged regimen of prophylaxis with ticarcillin/clavulanate was performed for 2 days and vancomycin was added in a low dose until removal of the intraaortic balloon pump. The control group (n = 25) did not receive a prolonged regimen of prophylaxis. Follow-up ended at hospital discharge. RESULTS: Early mortality was 7 of 28 patients (25%) in the prophylaxis group and 8 of 25 patients (32%) in the control group (p = 0.397). Defined infections (pneumonia, n = 22; sepsis, n = 8; deep sternal wound infection, n = 2) occurred in 50% of the study group and 68% of the control group (p = 0.265). In all patients with septicemia, only coagulase-negative staphylococci could be isolated from the bloodstream (5 patients in the prophylaxis group vs 3 in the control group). Infectious parameters were controlled daily and did not differ significantly between groups. A total of 1158 bacteriologic tests were performed (blood cultures, n = 389; intravascular catheters, n = 208; bronchial aspirates, n = 411; intraaortic balloon pumps, n = 42; wound secretions, n = 108) showing bacterial growth in 322 (28%) without a significant difference between the groups. In the prophylaxis group, 13 intravascular catheters and intraaortic balloon pumps showed bacterial growth versus 11 in the control group. No side effects were seen. CONCLUSIONS: In a high-risk group of patients undergoing cardiac operations, infectious outcome could not be effectively influenced by an additional and prolonged postoperative prophylaxis regimen with low-dose vancomycin and ticarcillin/clavulanate. Low-dose vancomycin did not reduce the rate of infections or colonizations of intravascular catheters with gram-positive organisms.

Aged↗
PubMed1997

Emergency surgery for acute infective aortic valve endocarditis: performance of cryopreserved homografts and mode of failure.

OBJECTIVE: To describe our experience in the surgical treatment of infective, native and prosthetic aortic valve endocarditis, using cryopreserved homograft valves. METHODS: Between January 1988 and September 1995, cryopreserved homografts were implanted in 49 patients (mean age 47 +/- 15 years; range 19-79) with acute infective endocarditis of the native (21/49; 43%) or the prosthetic (28/49; 57%) aortic valve. Aortic root abscesses were found in 39/49 (80%) patients, ventriculo-aortic disconnection in 27/49 (55%). An intracardiac fistula, originating from the left ventricular outflow tract was found in 25/49 (51%) patients. Indications for emergency surgery were congestive heart failure due to severe aortic valve regurgitation in 44/49 (90%) and systemic emboli in 5/49 (10%) patients. Preoperatively, 23/49 (47%) patients were in New York Heart Association (NYHA) class IV, and 5/49 (10%) were in acute circulatory failure. Mean left ventricular ejection fraction was 53 +/- 10% (25-65). Streptococci (27%) and staphylococci (27%) were the most important microorganisms found. The homograft was implanted as a scalloped freehand valve (34/49; 70%), as an intra-aortic inclusion cylinder (4/49; 6%) or as a free-standing root replacement (12/49; 24%). Combined procedures were necessary in 11/49 (22.5%) patients. RESULTS: Hospital mortality was 8.2% (4/49): 2/49 (4.1%) patients died from endocarditis-related sepsis, one (2%) from low cardiac output and one (2%) from a cerebrovascular accident. After a mean interval of 21 +/- 15 months (2-48), 9/45 (20%) patients had to be reoperated, all reoperations except one being homograft related. After a mean follow-up of 35 +/- 22 months (2-90), 4/44 (9%) patients had their homograft replaced by a mechanical prosthesis. After 5 years, actuarial freedom from late death was 97 +/- 3%; from late reoperation 69 +/- 9%; from late endocarditis 85 +/- 8%; and from late homograft degeneration 87 +/- 6%. Explanted homografts were acellular and non-vital, containing bacteria and/or leucocytes. B-lymphocytes were found in all and in one, T-cell lymphocytes were present. CONCLUSION: Emergency aortic valve replacement with cryopreserved homografts for acute native or prosthetic aortic valve endocarditis has a low operative mortality. The late incidence of recurrent endocarditis or homograft failure up to 7 years is acceptable. Cryopreserved homografts are non-viable. The presence of T-cell lymphocytes in explanted homografts indicates that rejection may be possible.

Actuarial Analysis↗
PubMed1997

Temporary loss of cardiac autonomic innervation after the maze procedure.

OBJECTIVE: Blunted sinus node response to exercise has been reported after the maze operation. We suggested the autonomic vegetative function of the heart to be disturbed after the maze procedure. METHODS: 17 patients, mean age 63 +/- 15 years, with chronic atrial fibrillation for 49 +/- 46 months (range 5-65) underwent the maze procedure during mitral valve surgery. Bicycle stress test, 24-h electrocardiography and heart rate variability were analysed in 11 patients after three and in six after 14 +/- 3 months. Spectral analysis within two frequency bands, vector analysis of the main circular resultant and influence of orthostasis and Valsalva manoeuvre on different R-R intervals were calculated. RESULTS: One patient died from a perioperative ischaemic stroke. At follow-up, all patients were in sinus rhythm. Heart rate reached 84 +/- 14%, the mean circular resultant was 60 +/- 48%, the ratio of the longest to the shortest R-R interval during the Valsalva manoeuvre was 92 +/- 8% and the ratio of maximal to minimal R-R interval after orthostasis was 98 +/- 4% of the age-adjusted normal value. Maximal workload was 116 +/- 31 watts. All patients had abnormal heart rate variability. Heart rate variability was significantly more blunted after three months, than after 14 months (P < 0.05). The minimal heart rate and the difference between the maximal and the minimal heart rate during the 24-h electrocardiography were significantly correlated to the number of normal physiological tests (r = -0.52; P < 0.05; r = 0.71; P < 0.005); for the maximal heart rate, there was a positive trend only (r = 0.44; P = 0.07). CONCLUSIONS: Early after the maze procedure, a nearly total denervation of the sinus node is present, similar as seen after heart transplantation, with partial restoration of the autonomic function after one year. The exercise capacity of the patients was satisfactory.

Adult↗
PubMed1997

Aortobronchial and aortoesophageal fistulae as risk factors in surgery of descending thoracic aortic aneurysms.

OBJECTIVE: Assess outcome of patients with descending thoracic aortic aneurysms complicated by aortobronchial and aortoesophageal fistulae in comparison to patients undergoing repair of aortic aneurysms without fistulae. METHODS: In a consecutive series of 145 patients (age 60 +/- 12 years) with repair of descending thoracic and thoracoabdominal aortic aneurysms, 11 patients (8%; age 63 +/- 9; NS) primarily presented for hematemesis and/or hemoptysis. In 8/11 patients (73%) an aortobronchial fistula was identified, and 3/11 patients (27%) suffered from an aortoesophageal fistula. Five of 11 patients (45%) had undergone previous aortic surgery in the same region. RESULTS: Extent of aortic segments (range 1-8) replaced was 3.1 +/- 1.4 for all versus 2.6 +/- 0.9 for fistulae (NS). Aortic cross clamp time was 38 +/- 22 min for all versus 45 +/- 15 min for fistulae (NS). Mortality at 30 days was 18/145 (12%) for all versus 16/134 (12%) without fistulae versus 2/11 (18%) with fistulae (NS). Paraparesis and or paraplegia was observed in 11/145 (8%) for all versus 10/134 (7%) without fistulae versus 1/11 (9%) for cases with fistulae (NS). Nine additional patients died after hospital discharge, seven without fistulae and two with fistulae (days 80, and 120) bringing the 1-year mortality up to 23/134 (17%) without fistulae versus 4/11 (36%) with fistulae (NS). Further analysis shows that the 1-year mortality accounts for 1/8 patients (13%) with aorto-bronchial fistulae versus to 3/3 patients (100%) with aorto-esophageal fistulae (esophageal versus bronchial fistula: P = 0.018; esophageal versus no fistula: P = 0.006). CONCLUSIONS: Outcome of patients suffering from descending thoracic aortic aneurysms complicated by aorto-bronchial fistulae can be similar to that without fistulae, whereas for cases complicated by aorto-esophageal fistulae the prognosis seems to remain poor even after successful hospital discharge.

Aged↗
PubMed1997

Cardiac papillary fibroelastoma excision combined with reconstructive surgery.

Three cases of cardiac papillary fibroelastomas are described. Two-dimensional echocardiography detected the tumors in the mitral valve, the cordae tendinae and in the apex of the left ventricle--a unique location. The tumor excisions were combined with bypass operation, mitral valve reconstruction, repair of cordae tendinae and Maze-procedure. The three patients are doing well after surgery.

Adult↗