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Biomedical subjects

R C Elkins

Publications and source records attributed to R C Elkins.

At least 55 records · Page 3Linked to original sources
PubMed1993

Neonatal coarctation repair. Influence of technique on late results.

BACKGROUND: Coarctation repair in the neonate (< or = 28 days) is associated with higher mortality and increased incidence of restenosis compared with older infants. It has been suggested that resection of pericoarctation ductal tissue may reduce this risk of restenosis. METHODS AND RESULTS: To further clarify these issues, we reviewed our experience with 111 consecutive neonates undergoing primary repair between 1973 and 1991. Hospital mortality was 14.4% (16 of 111) and was not significantly different for the type of repair:resection and end-to-end anastomosis (RETE) 10.7% (6 of 56), subclavian flap angioplasty (SFA) 16.7% (6 of 36), and patch angioplasty (PA) 16.7% (3 of 18). Associated complex cardiac pathology was associated with higher operative risk: 25% (10 of 40) versus 8.4% (6 of 71) (P = .02). Median follow-up of 4.2 years (range, 0.1 to 18.5 years) was 99% complete. Late mortality was 13.6% (13 of 95), of which 92% occurred within 1 year of repair. Twenty percent (19 of 95) needed reintervention for restenosis, RETE 16% (8 of 50), SFA 13% (4 of 30), and PA 47% (7 of 15) (P = .02). Of these, 84.2% (16 of 19) required reintervention within 1 year of repair. Freedom from reintervention 1 and 8 years after operation was 80 +/- 4% and 77 +/- 5%, respectively. Actuarial survival 8 years after operation was 73 +/- 4%; for simple coarctation, this was 90 +/- 4%. By multivariate analysis, survival was negatively influenced only by presence of associated cardiac pathology (P = .002) and reintervention only by patch angioplasty technique of repair (P = .007). CONCLUSIONS: In the neonate, resection of coarctation (RETE) does not diminish the risk for reintervention compared with SFA. The risk for both late death and recurrent coarctation are highest within the first year after repair, and follow-up should be particularly vigilant during this period.

Actuarial Analysis↗
PubMed1993

Successful thrombectomy for thrombosis of the right side of the heart after the Fontan operation. Report of two cases and review of the literature.

We performed operative thrombectomy for the treatment of cardiac thrombosis on the right side of the heart in two patients; thrombosis occurred after a total cavopulmonary connection (modified Fontan operation). In the first case, thrombosis occurred approximately 6 months postoperatively, and the thrombus was evacuated without cardiopulmonary bypass. In the second case, an emergency open atrial thrombectomy and revision of the stenotic inferior cavopulmonary anastomosis was performed on the tenth postoperative day. Review of the literature identified 12 previously reported cases that were similar. In these 12 cases 6 patients died, 5 of them early after diagnosis and institution of treatment. We believe that appropriate management should include thrombectomy and revision if a surgically remediable cause of the thrombosis is identified; otherwise, thrombolytic therapy should be initiated. The use of heparin and then sodium warfarin (Coumadin) has also been successful. Risk of thrombosis of the right side of the heart after the Fontan repair may be minimized by the use of prophylactic anticoagulation in high-risk patients soon after the Fontan operation.

Emergencies↗
PubMed1992

Pulmonary autograft. An aortic valve replacement alternative.

In selected patients, the pulmonary autograft procedure utilizing cryopreserved homografts for reconstruction of the right ventricular outflow tract is becoming an increasingly popular aortic valve replacement alternative. Longitudinal statistical reports show that patients need reoperation less often with this procedure. Because the valve is autogenous tissue, all indications to date show that the valve continues to function for extended periods of time in all patients and can accommodate growth in children. At the same time, transfer of the pulmonary valve to the aortic position provides a natural valvular flow pattern and freedom from the degenerative changes associated with bioprosthetic valves or the need for anticoagulation associated with mechanical valves.

Aortic Valve↗
PubMed1992

Pulmonary autograft replacement in children. The ideal solution?

Fifty-one children, aged 1.8 to 21 years (mean, 11.4) with aortic valve replacement using a pulmonary autograft are reviewed. Twenty-nine were intra-aortic implants and 22 were root replacements. There was one operative death, no late deaths, and two have required reoperation. Actuarial freedom from reoperation was 93% +/- 5.5 at 5.6 years. Freedom from progression of aortic insufficiency (AI) was 81% +/- 9 at 5.6 years in the intra-aortic implants and 86% +/- 10 in the root replacement. Enlargement of the pulmonary autograft was seen echocardiographically in both groups. This enlargement was consistent with somatic growth and not associated with progression of AI. Ten of 19 patients with aortic stenosis had an LV mass index suggestive of LV hypertrophy before operation. At 1 year, 18 of 25 had a normal LV mass index. Thirteen of 16 patients with AI had preoperative abnormal LV mass index. All but four returned to normal by 1 year. Low operative risk, excellent function, resolution of abnormal LV hemodynamics, and enlargement consistent with somatic growth suggest that the pulmonary autograft is the ideal replacement for the malfunctioning aortic valve.

Adolescent↗
PubMed1992

Pulmonary autograft replacement of the aortic valve: an evolution of technique.

The use of the patient's pulmonary valve for replacement of the patient's diseased aortic valve was introduced and developed by Mr. Donald Ross. Its demonstrated durability, freedom from thromboembolism, and potential for growth has led to increased utilization of this technique. Modifications of the earlier techniques have led to a reproducible operation with low operative risk and excellent mid-term results.

Aortic Valve↗
PubMed1991

Normal left ventricular function following pulmonary autograft replacement of the aortic valve in children.

To assess growth potential and hemodynamic sequelae of pulmonary autograft valves implanted into aortic outflow tracts of children, we reviewed our experience with 37 patients (2-21 years) from August 1986 to December 1990. Twenty patients had predominantly aortic stenosis (AS), and 17 had aortic insufficiency (AI). Operative mortality was 3%. Two technical failures required reoperation. Of survivors, six (18%) have moderate AI. Pre- and postoperative echocardiograms were reviewed. The AS group showed increased left ventricular (LV) cavity size by greater than 1-year follow-up, and decreased LV wall and interventricular septal thickness. In the AI group, wall and septal thickness increased by 10 days and LV cavity decreased by 10 days, 60 days, and greater than 1 year. Root replacements (n = 14) showed mean increases of 4.3 mm and 5.3 mm, respectively, in diameters of the aortic annulus and aortic sinuses at greater than 1 year. Intraaortic implants increased 3.1 mm (annulus) and 3.9 mm (sinuses) at greater than 1 year. The pulmonary autograft procedure is safe, and successful implantation normalizes LV dimensions and function rapidly. The autograft valve shows evidence of growth at greater than 1 year postoperative. The pulmonary autograft may be the ideal valve replacement in children.

Adolescent↗
PubMed1990

Correction of truncus arteriosus with truncal valvar stenosis or insufficiency using two homografts.

Surgical correction of truncus arteriosus requires the creation of right ventricular to pulmonary artery continuity and closure of the ventricular septal defect. A variety of conduits have been used including valved and nonvalved. Despite a significant incidence of truncal valvar stenosis and insufficiency, this valve has seldom been replaced. We present 4 cases of truncus arteriosus with truncal valvar stenosis or insufficiency that were repaired using two valved homografts: one to create the pulmonary outflow tract and the other to replace the abnormal truncal valve. Two of these patients are doing well after 4 months. Another child survived the operation and did well for 2 months when she died suddenly. The last child died 14 hours postoperatively from low cardiac output syndrome secondary to diabetic hypertrophic cardiomyopathy. When truncal valvar abnormalities are present, the primary repair of truncus arteriosus in an infant should include replacement of the truncal valve. Total correction can be successfully achieved using two valved homografts, resulting in long-term palliation and freedom from thromboembolic events and the use of anticoagulants.

Abnormalities, Multiple↗
PubMed1990

Delayed detection of coarctation in infancy: implications for timing of newborn follow-up.

During a recent 5-year period, 74 patients younger than 6 months of age were diagnosed with coarctation of the aorta. Coarctation was correctly diagnosed in only 22% of patients prior to referral despite readily apparent femoral pulse abnormalities in 86%. Infants whose symptoms were detected between 5 and 14 days of age were significantly more ill than infants outside this age range and had a high mortality rate (25%). The number of associated cardiac defects was not related to the severity of clinical illness in this group, suggesting that closure of the ductus arteriosus is the primary determinate of disease severity. Observations in two patients suggested that a detectable pulse discrepancy occurs between 3 and 5 days postnatally. Upper extremity hypertension was found commonly in infants after 5 days of age despite the presence of congestive heart failure. Earlier detection of coarctation in the newborn requires a diligent cardiovascular and peripheral pulse examination between 3 and 7 days of life, upper extremity and lower extremity blood pressure measurement, and a high index of suspicion.

Age Factors↗
PubMed1989

Aortic valve and left ventricular outflow tract replacement using allograft and autograft valves: a preliminary report.

A comparison of allograft and autograft (pulmonary) replacement of the aortic valve has, to our knowledge, not been done in America. Fifty-seven patients (age range, 2 to 70 years; mean age, 30 years) underwent 59 operations for replacement of the aortic valve (20) or entire left ventricular outflow tract (39) using autograft (35) or allograft (24) valves. Many had undergone a previous operation (25) or had concomitant procedures (13). Postoperative mortality was 8.5% (5/59). Two deaths occurred in the allograft group and three in the more complex pulmonary autograft group. One late death occurred. One autograft was replaced with an allograft 7 months postoperatively for severe aortic regurgitation. There have been no episodes of either endocarditis or thromboembolism. Forty-nine of 51 survivors are in New York Heart Association class I. Preliminary results suggest that congenital or acquired disease of the left ventricular outflow tract and aortic valve can be safely and effectively treated with either allograft or autograft valve transplantation.

Adolescent↗
PubMed1989

Aortic root replacement with pulmonary autograft.

Transfer of the pulmonary valve to the aortic position has been used successfully by Ross for more than 20 years and in our own institution since August 1986. To expand the use of this concept to patients with root disease and/or narrow annulus, we employed the main pulmonary artery with its valve as a conduit to replace the proximal ascending aorta, reimplanting the coronary ostia into the pulmonary trunk. Seventeen patients, aged 2-62 years, underwent the procedure with three deaths. Hemorrhage precipitated each death, and there was one reexploration for control of bleeding. Postoperative echocardiography showed excellent valvular function. No anticoagulants were used except daily aspirin in three patients who underwent concomitant procedures. There were no thromboembolic episodes. Right ventricular outflow tract reconstruction was accomplished with cryopreserved aortic (three) and pulmonary (14) allograft conduits. This operation has potential for superior long-term results in complex aortic valve disease.

Adult↗
PubMed1987

Cardiovascular time course after digoxin administration in left ventricular dysfunction after coronary artery bypass grafting.

Intravenous digoxin, 1 mg, was administered over 8 hours to 10 cardiac patients with left ventricular (LV) dysfunction after coronary artery bypass grafting. The cardiovascular effects of digoxin were monitored over 20 hours by indwelling pulmonary artery and radial artery lines and were compared with those of a control group of 10 patients who had normal postoperative LV function. Digoxin administration produced an increased cardiac index and mean arterial blood pressure within 2 hours. Within 4 hours after digoxin administration pulmonary artery wedge pressure in patients receiving digoxin was significantly lower than in control patients. At 16 hours there was a significant increase in both the LV stroke work and LV stroke work index in patients receiving digoxin vs control patients. Two patients receiving digoxin and 3 control patients had changes in cardiac rhythm during the study. Thus, digoxin can be safely administered to postoperative patients with LV dysfunction and is an acceptable inotropic agent.

Arrhythmias, Cardiac↗
PubMed1987

Pulmonary autograft: an American experience.

Pulmonary valve autograft replacement of the aortic valve has been performed in nine patients in an effort to duplicate in the United States the experience of Sir Donald Ross in London. Four male and five female patients ranging in age from seven to thirty-four years have been operated on for indications of aortic stenosis in six and aortic regurgitation in three. Three patients had associated procedures performed concomitantly. All patients survived the surgery and were clinically improved, however, one patient did require reoperation for progressive aortic insufficiency. Specific indications, results, and technical considerations are discussed and illustrated.

Adolescent↗
PubMed1986

Cardiovascular effects of atropine in postoperative cardiac patients receiving digoxin for ventricular dysfunction.

Digoxin is clinically useful as a cardiac antiarrhythmic and inotropic agent. Its antiarrhythmic actions are mediated through the cholinergic nervous system. The cholinergic system, when activated, can depress ventricular function. We have sought to further increase the cardiovascular effects of digoxin by blocking its cholinergic effects with atropine. Atropine, 1 mg intravenously, was given to 10 postoperative cardiac patients. The cardiovascular time course was monitored by an ECG, radial arterial line, and pulmonary artery thermodilution catheter for 8 hours. A significant increase (p less than 0.05) in the cardiac output (CO), from 5.98 +/- 0.24 L/min to 6.60 +/- 0.34 L/min, was evident within 2 hours after atropine administration. The CO returned to control levels by 6 hours. There were no significant changes in heart rate, systemic vascular resistance, pulmonary artery wedge pressure, or systemic blood pressure. The results indicate that the cholinergic blockade of digoxin with atropine will acutely increase the cardiac output in postoperative cardiac patients.

Atropine↗
PubMed1986

Treatment of esophageal cancer: the continued need for surgical resection.

We conclude that preoperative radiotherapy and chemotherapy is very likely to improve the length of survival in patients with squamous cell carcinoma undergoing surgical resection and decreases the incidence of symptomatic local recurrence requiring additional palliative treatment. A favorable tumor response to adjuvant therapy, however, did not significantly improve the survival curves in our study, does not guarantee complete tumor regression, and should not be cited as a basis for elimination of esophagectomy in treatment protocols. Adenocarcinoma treated with surgical resection has a better prognosis than similarly treated squamous cell carcinoma, but has a poorer prognosis than squamous cell carcinoma treated with preoperative adjuvant therapy and surgical resection.

Actuarial Analysis↗