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Biomedical subjects

R J Cleveland

Publications and source records attributed to R J Cleveland.

At least 37 records · Page 2Linked to original sources
PubMed1988

Successful repair of postoperative ascending aortic mycotic false aneurysms using circulatory arrest.

Mediastinal wound infections following open-heart operations are successfully managed in most patients by aggressive debridement and placement of substernal drainage catheters or application of omental or muscle flaps. Nonetheless, the involvement of foreign bodies, such as felt pledgets adjacent to cardiac structures, can result in infections that persist despite flap coverage and can present as mycotic false aneurysms of the ascending aorta. We present the cases of 3 patients who underwent successful repair of such aneurysms late after surgical treatment of mediastinal wound infections. We describe our technique of repair using groin cannulation for bypass, moderate hypothermia, and circulatory arrest to improve exposure and minimize bleeding.

Aged↗
PubMed1988

Tracheoesophageal fistula associated with Barrett's ulcer: the importance of reflux control.

A benign tracheoesophageal fistula occurring as a complication of Barrett's ulcerative esophagitis is described. Surgical control of gastroesophageal reflux resulted in healing of the fistula, obviating the need for a resective procedure or esophageal exclusion. Although Barrett's ulcer has been reported as a cause of acquired esophagorespiratory fistula, to our knowledge, the important role of reflux control in the management of this difficult problem has not been discussed.

Aged↗
PubMed1987

In vitro analysis of mechanisms of balloon valvuloplasty of stenotic mitral valves.

Preliminary reports indicate that percutaneous balloon valvuloplasty is efficacious for treatment of mitral stenosis. The present study was designed to evaluate whether anatomic features of stenotic mitral valves in older adults affect the efficacy of balloon valvuloplasty and to determine the mechanism by which increased orifice area is accomplished. Fifteen mitral valves excised intact at the time of mitral valve replacement from patients with no more than 2+/4+ mitral a regurgitation were selected for study. Balloon valvuloplasty was performed using a sequence of dilation catheters with balloons 18 to 25 mm in inflated diameter. Mitral valve area, measured with a conical valve sizer, increased from 0.71 +/- 0.06 cm2 (mean +/- standard error of the mean) to 1.77 +/- 0.19 cm2 (p less than 0.0001) after valvuloplasty, resulting in an increase in calculated orifice area of 185 +/- 27% (range 34 to 407%). The increase in calculated orifice area correlated inversely with orifice area before valvuloplasty (r = -0.57; p = 0.026), but was unrelated to extent of calcific deposits on the prevalvuloplasty x-ray of the excised mitral valve. Gross examination together with x-ray analysis after valvuloplasty revealed that the mechanism of balloon valvuloplasty in each case involved commissural splitting, including splits through heavily calcified commissures, without grossly apparent detachment of tissue fragments. These findings suggest that balloon valvuloplasty augments the functional mitral valve orifice area in a manner analogous to standard surgical commissurotomy, and balloon valvuloplasty is likely to be efficacious for a wide spectrum of adult mitral valvular stenosis, including severe stenosis with extensive calcific deposits.

Adult↗
PubMed1987

Laser-assisted endocardiectomy for refractory ventricular tachyarrhythmias: preliminary intraoperative experience.

Previous in vitro investigations utilizing necropsy specimens have suggested a potential role for laser irradiation in the treatment of refractory ventricular tachyarrhythmias associated with pathologically thickened endocardium. In the patient described in the present report, findings of these previous in vitro studies were applied intraoperatively to a patient undergoing surgery for ischemic heart disease associated with ventricular tachyarrhythmias. Aneurysm resection and manual subendocardial resection were performed using standard techniques. Laser irradiation was used to ablate pathologically thickened endocardium involving the papillary muscle and thereby avoid mitral valve replacement. Postoperatively, there was no auscultatory evidence of mitral regurgitation, and ventricular tachycardia could not be induced by electrophysiologic provocative testing. This preliminary experience confirms that laser irradiation is both a feasible and potentially advantageous means of accomplishing endocardial debridement in patients undergoing arrhythmia-ablation procedures.

Cardiomegaly↗
PubMed1987

Intraoperative, two-dimensional echocardiography-guided removal of retained intracardiac air.

The removal of intracardiac air after cardiotomy may be simplified with the use of two-dimensional echocardiography. This technique can be used to readily identify retained pockets of air and can function as a guide to needle aspiration of the ventricular chambers. With a valve prosthesis in place, de-airing can be accomplished with minimal displacement of the heart. The technique is easy to use and the images are simple to interpret.

Air↗
PubMed1987

Methemoglobinemia from intravenous nitroglycerin: a word of caution.

The dose of intravenously administered nitroglycerin (IV NTG) used to control ischemic chest pain usually is limited by hypotension from decreased preload. Herein we describe 2 patients who tolerated IV NTG without hemodynamic compromise but in whom severe impairment of blood oxygen content developed from methemoglobinemia noted during coronary bypass surgery. Methemoglobinemia must be suspected if chocolate-brown blood is encountered despite a normal arterial oxygen tension and calculated oxygen saturation. Before a methemoglobin level is available, the extent of hypoxemia can be determined by an oximetric oxygen saturation and therapy begun with intravenous administration of methylene blue. These case reports focus attention on the potential deleterious effects of undetected hypoxemia from methemoglobinemia in patients being stabilized with high-dose IV NTG for urgent cardiac surgery.

Aged↗
PubMed1987

Arterial bypass of the descending thoracic aorta with the BioMedicus centrifugal pump.

Bypass of the descending thoracic aorta is frequently advocated as an adjunct for repair of traumatic tears and degenerative aneurysms. Many methods of bypass have been proposed to provide distal perfusion and reduce left ventricular afterload during cross-clamp of the thoracic aorta. We describe a simple method of direct arterial (aortoaortic or aortofemoral) bypass using the BioMedicus centrifugal pump with limited systemic heparinization.

Aorta, Thoracic↗
PubMed1987

Cystic medial necrosis in coarctation of the aorta: a potential factor contributing to adverse consequences observed after percutaneous balloon angioplasty of coarctation sites.

Percutaneous transluminal angioplasty has been shown to be both feasible and efficacious for the treatment of aortic coarctation. Recent reports, however, have indicated that the development of aortic aneurysms at or near the coarctation segment may complicate attempts to treat this lesion by catheter-based intervention. Accordingly, we examined the light microscopic features of coarctation segments excised at surgery (n = 31) or obtained at autopsy (n = 2) in 33 patients with coarctation of the aorta. Cystic medial necrosis, defined as depletion and disarray of elastic tissue, was observed in each of the 33 specimens. In the majority of coarctation specimens (22 of 33 or 67%) the extent of cystic medial necrosis, graded semiquantitatively on a scale of 0 (normal aorta) to 3+, was severe (3+). The finding that cystic medial necrosis represents a consistent histologic feature of coarctation of the aorta provides a pathologic basis for the formation of aneurysms observed after balloon angioplasty of coarctation sites.

Angioplasty, Balloon↗
PubMed1987

Vascular surgery in the United States. Report of the Joint Society for Vascular Surgery--International Society for Cardiovascular Surgery Committee on Vascular Surgical Manpower.

The Joint Committee on Vascular Surgical Manpower was established in 1985 by the Society for Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. It was charged to provide recommendations regarding vascular surgical manpower requirements for the next 15 years. Analysis of National Center for Health Statistics vascular operative rate data and 1690 questionnaire responses from vascular surgeons documented that vascular surgeons performed 235,400 (41%) of the total of 571,000 vascular operations undertaken in 1985. Vascular surgeons performed 87% of 30,000 aortoiliofemoral reconstructions, 77% of 72,000 peripheral vessel bypasses, 75% of 33,000 abdominal aortic aneurysm repairs, 59% of 55,000 angioaccess procedures, and 50% of 107,000 carotid endarterectomies. However, lack of accurate data on caseloads of surgeons who were not vascular specialists precludes precise prediction of manpower requirements for vascular surgery. It is important that surgical leaders and policy makers define the types of vascular surgical procedures that may be undertaken by vascular and other surgeons. Ongoing analyses must include such determinations to establish accurate data for the prediction of future manpower needs for vascular surgery. Furthermore, future manpower studies should be linked to outcome studies to assess not only numbers of surgeons and operations but quality of care as well.

Forecasting↗
PubMed1986

Digoxin prophylaxis following coronary artery bypass surgery.

The effect of the postoperative administration of digoxin to patients undergoing coronary artery bypass surgery on the incidence of supraventricular arrhythmias was studied. Patients were randomly assigned to a control group (n = 51) or digoxin group (n = 47) on a prospective basis. Patient characteristics were similar in both groups, and no patients were receiving digoxin therapy preoperatively or other antiarrhythmic medications. All patients had normal systolic ejection fractions, renal function, and hepatic function. Eight patients (16%) in the control group developed postoperative arrhythmias while seven patients (15%) in the digoxin group developed supraventricular arrhythmias. This difference was not significant. Two patients in the digoxin group developed digoxin-induced arrhythmias, and two other patients experienced digoxin-related nausea and vomiting, which were resolved with discontinuation of the drug. The postoperative administration of digoxin to patients undergoing coronary artery bypass surgery had no effect on the incidence of supraventricular arrhythmias. The prophylactic use of digoxin therapy in this patient population is not recommended unless there is a history of arrhythmias responsive to digoxin therapy.

Adult↗
PubMed1985

Laser photoablation of pathological endocardium: in vitro findings suggesting a new approach to the surgical treatment of refractory arrhythmias and restrictive cardiomyopathy.

In selected patients, malignant ventricular tachyarrhythmias have been successfully abolished by excision of subendocardial arrhythmogenic foci. Likewise, in certain patients in whom restrictive cardiomyopathy is due to endocardial thickening, endocardial resection has resulted in hemodynamic improvement. The present study was designed to explore the utility, in vitro, of laser photoablation of pathologically thickened endocardium. Endocardial photoablation was easily accomplished regardless of etiological or anatomical variations using either the focused beam of a carbon dioxide laser or argon laser light delivered through a 200-microns optical fiber. Photoablation of areas as large as 3.9 X 1.3 cm was performed within 40 seconds. The extent or depth of endocardial photoablation could be limited to 2 mm2 in area or 1 mm in depth using either form of laser therapy. These in vitro results suggest that either carbon dioxide or argon laser phototherapy can be successfully applied to the surgical treatment of refractory arrhythmias and restrictive cardiomyopathy. Advantages of laser photoablation include speed and precision. Furthermore, laser photoablation obviates the difficulty associated with conventional techniques in establishing tissue planes.

Argon↗
PubMed1985

Digital subtraction angiography in patients with transposition of the great arteries after surgical repair.

Digital subtraction angiography was used for postoperative evaluation of seven patients who underwent the Senning procedure for repair of d-transposition of the great arteries. Their ages ranged from 2.5 to 3 years. The patients were premedicated with methohexital (25 mg/kg rectally), and 0.3 to 0.4 ml/kg of diatrizoate was injected into a peripheral vein through a plastic needle. Images were obtained on a Technicare DR-960 or Diasonics DA 100 digital angiographic unit at four frames per second using 256 X 256 matrix and a 6 inch (15.24 cm) field size. In all patients, the venous systems, cardiac chambers and great arteries were well visualized. Two patients had obstruction of the superior vena cava with a dilated azygos vein draining into the inferior vena cava. One patient had severe obstruction of the left pulmonary artery. Digital subtraction angiography is safe and easy to perform and appears to be a valuable alternative method for evaluating patients after surgical repair of transposition of the great arteries. The small amount of contrast material required and the low radiation dose make it attractive for use in children.

Arterial Occlusive Diseases↗
PubMed1984

Laser myoplasty for hypertrophic cardiomyopathy. In vitro experience in human postmortem hearts and in vivo experience in a canine model (transarterial) and human patient (intraoperative).

The feasibility of performing a myotomy/myectomy for hypertrophic cardiomyopathy (HC) by means of laser phototherapy was evaluated experimentally in vitro and in vivo, and the procedure then applied to a patient intraoperatively. In vitro experience revealed that the beam of an argon laser, delivered directly or via an optical fiber, could both cut and vaporize myocardium, producing a myotomy/myectomy morphologically similar to that produced by the conventional blade technique. In vivo experiments, in which the beam of an argon laser was delivered via an optical fiber to the ventricular septum of a canine heart, confirmed that a laser myoplasty could be achieved in 4 of 5 dogs by a transarterial approach. Finally, laser myoplasty was performed intraoperatively in a patient with HC, using a 200-mu fiber interfaced with an argon laser. Measured laser power was 1.5 W; cumulative exposure was less than 4 minutes; the myoplasty was 4 X 1 X 0.5 cm. These investigations establish the feasibility of using laser therapy to create a myoplasty trough that is similar in appearance to that typically achieved by the conventional blade technique. Illumination of the intraventricular operative field and precise modeling of the myoplasty trough constitute the principal advantages of laser myoplasty for HC.

Adult↗
PubMed1984

Combined discrete subaortic stenosis and ventricular septal defect in infants and children.

Eight patients, aged 1 to 8 years, with discrete subaortic stenosis (DSS) and ventricular septal defect (VSD) were studied by 2-dimensional (2-D) and M-mode echocardiography. Initial cardiac catheterization and angiocardiography showed VSD and other associated cardiac lesions, including coarctation of the aorta and patent ductus arteriosus. None had evidence of DSS. Six patients underwent surgical repair of the associated lesions, but none required closure of the VSD. Ultimately, 6 patients had spontaneous closure of VSD, and 2 had a residual small VSD. Subsequent serial echocardiography showed evidence of subaortic membrane, prompting repeat cardiac catheterization, which confirmed moderate to severe peak systolic pressure gradients between the left ventricle and ascending aorta. Surgical resection of the membrane was performed in 5 patients. Thus, in patients with small or spontaneously closed VSDs, DSS may develop. Evaluation of the left ventricular outflow tract area is recommended in patients with small or closed VSD in whom a significant heart murmur or electrocardiographic abnormality remains.

Abnormalities, Multiple↗
PubMed1983

The impact of coronary artery disease on carotid endarterectomy.

In a series of 531 CENDX, preoperative cardiac risk was categorized by clinical criteria. Patients with CAD (history of previous MI, angina, congestive heart failure, and/or electrocardiographic evidence of CAD were selected for more invasive studies based on clinical criteria. The overall incidence of postoperative myocardial infarction was 2.5% and increased slightly to 4% in patients with symptomatic cardiac disease. More importantly, the overall mortality was 0.9% and only 3 of 13 (23%) postoperative myocardial infarctions were fatal. Neurologic complications averaged 1.4% and approximately 70% were related to preceding cardiac events. Twenty-two patients or 4% of the entire series underwent carotid endarterectomy combined with coronary artery bypass graft and this approach was associated with one death and one stroke. Therefore, we conclude that a selective approach to coronary arteriography and subsequent CABG based on clinical criteria is associated with an acceptably low mortality and cardiac morbidity.

Arteriosclerosis↗