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Biomedical subjects

R J Gray

Publications and source records attributed to R J Gray.

At least 91 records · Page 5Linked to original sources
PubMed1987

The St. Jude valve: analysis of thromboembolism, warfarin-related hemorrhage, and survival.

From March 1978-86, 590 St. Jude prostheses (232 aortic, 232 mitral, and 63 double aortic-mitral) were implanted in 527 patients (mean age 63 years) and followed for up to 8 years (mean 33 months; three lost; 99% complete). The early (30-day) mortality rate was 8.9% and was strongly associated with preoperatively depressed left ventricular function (ejection fraction less than 0.55), ischemic mitral regurgitation, and advanced functional class (IV) (p less than 0.05). Actuarial survival rates at 5 years were 72% +/- 4%, 72% +/- 8%, and 63 +/- 4% after aortic, double, and mitral valve replacement (p less than 0.01). There have been no structural failures. Embolism (28 events, 2.1%/patient-year) was less common with warfarin treatment (1.5%/patient-year; n = 492) than with antiplatelet (3.2%/patient-year; n = 19) or no drug therapy (18.9%/patient-year; n = 16) (p less than 0.01). One embolic event was fatal (3.6%). Warfarin-treated patients remained 91% +/- 1% free of emboli after 8 years. Valve thrombosis (six events; 0.4%/patient-year) occurred exclusively in patients not treated with effective warfarin therapy; one (17%) died. The most common complication was hemorrhage (39 events; 2.9%/patient-year); nine (23%) were fatal, and these constituted 82% of 11 valve-related late deaths. In warfarin-treated patients (target prothrombin time ratio 1.5 to 2.5), hemorrhage was twice as frequent (2.9%/patient-year) as embolism (1.5%/patient-year).(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMed1987

Treatment of severe platelet dysfunction and hemorrhage after cardiopulmonary bypass: reduction in blood product usage with desmopressin.

Impairment of platelet function commonly occurs after cardiopulmonary bypass, and may result in substantial bleeding. Because desmopressin acetate (a synthetic analogue of vasopressin) shortens bleeding time in a variety of platelet disorders, a controlled clinical trial of intravenous desmopressin was performed in 39 patients with excessive mediastinal bleeding (greater than 100 ml/h) and a prolonged template bleeding time (greater than 10 minutes) more than 2 hours after termination of cardiopulmonary bypass. Twenty-three desmopressin recipients and 16 control patients (no desmopressin) were similar in surgical procedure, pump time, platelet count, template bleeding time and amount of bleeding before therapy (p = NS). Compared with the control group, the patients receiving desmopressin (20 micrograms; mean 0.3 micrograms/kg) utilized fewer blood products (29 +/- 19 versus 15 +/- 13 units/patient; p less than 0.05), especially platelets (12 +/- 9 versus 4 +/- 7 units/patient; p = 0.004), while achieving a similarly effective reduction in mediastinal bleeding (4.8- and 4.3-fold, p = 0.001 for both). Severe platelet dysfunction was partially corrected within 1 hour after desmopressin infusion, during which interval no blood products were administered: the template bleeding time shortened (from 17 to 12.5 minutes, p less than 0.05), whereas the platelet count remained unchanged (at 96 +/- 35 and 105 +/- 31 X 10(3)/mm3, p = NS). The plasma levels of two factor VIII components increased: procoagulant activity (VIII:C) from 0.97 +/- 0.43 to 1.52 +/- 0.74 units/ml (p less than 0.05) and von Willebrand factor (VIII:vWF) from 1.28 to 1.78 units/ml (p less than 0.05); these increases correlated with the shortening of the bleeding time (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Platelet Disorders↗
PubMed1987

Mitral valve replacement early after myocardial infarction: attendant high risk of left ventricular rupture.

Between 1969 and 1983, 608 patients underwent mitral valve replacement surgery at Cedars-Sinai Medical Center. Perioperative rupture of the left ventricular myocardium complicated seven operations (1.2%), five of them in the 247 patients with concomitant ischemic heart disease. Six ruptures were fatal. Relative incidences of seven previously hypothesized predisposing factors were determined for patients with and without myocardial rupture. In addition, because of the apparent frequency of association with ischemic heart disease and because all ruptures were posterior or posterolateral, patients were also categorized by prior history of posterior myocardial infarction: 177 patients had none, whereas 49 patients had a remote and 21 patients a recent (less than or equal to 1 month) posterior wall infarct. Four ruptures (accounting for 57% of all ruptures) occurred in the 21 patients (19% incidence) with a recent posterior infarct, compared with only three ruptures in the 587 patients (0.5%) without a recent posterior wall infarct (p = 0.000). None of the factors of age, sex, valve pathology, etiology of valve lesion, concomitant coronary disease, valve substitute or intraoperative myocardial preservation were associated with perioperative rupture. These data establish a low overall incidence of ventricular rupture after mitral valve replacement, high fatality and possible etiologic association with recent posterior wall infarction.

Adolescent↗
PubMed1987

Prospective evaluation of ultrafast cardiac computed tomography for determination of coronary bypass graft patency.

Twenty-five consecutive patients with 68 independent (single distal anastomosis) saphenous vein aortocoronary and 12 internal mammary bypass grafts (27 to left anterior descending, 10 to diagonal, 23 to left circumflex, 20 to right coronary artery) entered a reader-blinded, prospective, standardized study to establish the accuracy of ultrafast (cine) cardiac computed tomography (CT) for determining graft patency compared with invasive angiography. All patients underwent imaging after injection of 35 to 45 ml of meglumine diatrizoate (Renografin-76; 7 to 9 ml/sec for 5 sec) into an arm vein. Electrocardiographically triggered images were acquired over eight to 16 tomographic levels at 1 cm intervals from aortic arch to mid left ventricle. Criteria for graft patency were contrast opacification on at least two noncontinguous levels and contrast density-time curves morphologically similar to that of the aorta. Ultrafast CT correctly determined that 46 of 48 bypass grafts were patent and 31 of 32 were occluded (sensitivity, specificity, and accuracy 96%, 97%, and 96%); there were no interpretation errors in 23 (92%) of the 25 patients. Accuracy was independent of vessel bypassed and not different for saphenous veins (96%) compared with internal mammary bypasses (100%). This study establishes a 20 min outpatient intravenous injection technique that is highly accurate for determining patency of coronary artery bypass grafts.

Coronary Angiography↗
PubMed1987

Comparative clinical experience with porcine bioprosthetic and St. Jude valve replacement.

From 1976 to 1984, 656 patients underwent aortic, mitral, or double valve replacement with a Hancock or Carpentier-Edwards porcine bioprosthesis (POR; n = 293) or with a St. Jude bileaflet valve (SJ; n = 363). Recipients of the St. Jude valve were of more advanced NYHA class preoperatively, required smaller prosthetic sizes, and more often had associated coronary artery disease necessitating bypass grafting (p less than .05). Despite these differences, POR and SJ recipients demonstrated similar 30-day mortality (7.5 vs 10.2 percent), five-year freedom from embolism (92 +/- 2 percent vs 92 +/- 2 percent), freedom from all valve-related complications (79 +/- 3 percent vs 79 +/- 4 percent), and survival (72 +/- 3 percent vs 71 +/- 3 percent) (p = NS). Structural failures occurred exclusively in POR recipients (3.0-4.5 percent/pt-yr after four years), and endocarditis was more common (1.0 vs 0.5 percent/pt-yr); as a result, the reoperation rate was three times higher in POR than SJ recipients (1.4 vs 0.46 percent/pt-yr, p less than .05). Warfarin-related bleeding (2.5 percent/pt-yr) was the most common complication in SJ recipients, but occurred equally frequently in POR recipients requiring anticoagulation; seven (44 percent) of 16 valve-related late deaths were warfarin-related. In properly anticoagulated patients, the thromboembolic rate was low (2.0 percent and 1.1 percent/pt-yr, POR and SJ); this rate increased significantly in SJ recipients receiving antiplatelet drugs alone (4.2 percent/pt-yr; n = 16) or no anticoagulant or antiplatelet therapy (26.4 percent/pt-yr; n = 18) (p less than .05), but increased only slightly in POR recipients (to 1.5 percent/pt-yr, n = 108, and 2.0 percent/pt-yr, n = 63, respectively). Postoperatively, NYHA class 1 was more often achieved in SJ than POR recipients (60 vs 39 percent, p less than .05), perhaps because of the better hemodynamic performance of the SJ valve. Thus, despite differences in patient selection and the nature of complications observed with each prosthetic type, porcine and St. Jude valves provide similar early and late survival, frequency of embolism, total complication rate, and freedom from valve-related morbidity and mortality after five years of follow-up. Limited durability, susceptibility to infection, and inferior hemodynamics remain drawbacks to use of the porcine bioprosthesis. The necessity for warfarin anticoagulation and the frequency of resultant bleeding complications are the major shortcomings of the St. Jude valve.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1987

Harken caged-disc mitral valve replacement, 1969-1975: analysis of late mortality, thromboembolism, and valve failure.

We evaluated the long-term outcome of mitral valve replacement with a Harken caged-disc prosthesis for up to 11 years (range, 50 to 130 months; mean, 81 months) in 170 patients whose mean age was 55 years. The early (30-day) mortality was 11.2% (19 out of 170 patients). Late follow-up information was obtained for 144 (95%) of the 151 survivors. The actuarial survival was 57% at 5 years and 40% at 10 years. Overall mortality was associated with advanced age, male sex, an ischemic origin for the mitral valve disease, and nonuse of warfarin anticoagulation. Late deaths (n=59) were valve-related in 46%, cardiac but non-valve-related in 44%, and noncardiac in 10% of the cases. One thromboembolic event or more occurred in 41 patients (incidence, 5.7% per patient year), 14 of whom died (24% of the late deaths). All four patients who were not on warfarin, aspirin, or other antithrombotic therapy experienced thromboemboli. This complication was correlated with the nonuse of warfarin-type anticoagulation, with mitral regurgitation, and with late cardiac death. Mechanical prosthetic failure resulted in reoperation or death in 7.6% of the late survivors (1.5% per patient year). In 75 patients with normally functioning prostheses, the disc-to-sewing ring ratio was established by means of cinefluoroscopy (0.93 +/- 0.04, mean +/- 25D). Because of the high proportion of cardiac valve-related deaths (46%), the high incidence of late mortality due to thromboembolic events (24%), and the 7.6% incidence of reoperation or death resulting from mechanical valve failure, close follow-up with cinefluoroscopy and continued warfarin anticoagulation (alone or in combination with dipyridamole) are essential after mitral valve replacement with the Harken caged-disc prosthesis.

Journal Article↗
PubMed1987

Intraoperative evaluation of mitral regurgitation by Doppler color flow mapping.

Excessive residual mitral regurgitation after mitral valve reconstruction or coronary artery bypass graft surgery may necessitate reoperation. We evaluated a new intraoperative technique for assessment of mitral regurgitation, real-time two-dimensional Doppler color flow mapping, in 96 patients undergoing cardiac surgery. In comparison with technically adequate preoperative left ventriculography (n = 68) obtained at a similar level of afterload (systolic arterial pressure), Doppler color flow mapping demonstrated a sensitivity of 94% (50/53) and specificity of 93% (14/15) for detection of the presence and absence of mitral regurgitation, respectively. Semiquantitative comparison of color Doppler with angiography demonstrated excellent agreement (kappa = .80, p less than .001), differing by more than one grade in two patients (3%). The pulmonary capillary wedge "V" wave pressure (absolute magnitude, and height above mean) correlated poorly with the simultaneously obtained mitral regurgitation grade by color Doppler, both before (r = .37 and .45) and after (r = .04 and -.15, p = NS) cardiopulmonary bypass. No value of the V wave clearly distinguished 3 + or 4 + regurgitation from lesser degrees of regurgitation. In 15 patients who underwent mitral valve repair, fluid filling of the ventricle was falsely positive (leak, with no regurgitation) in 40% (2/5), and falsely negative (no leak, with 2 + to 3 + regurgitation) in 30% (3/10). Regurgitation grade by color Doppler demonstrated a highly significant (p less than .01) dependence on systolic pressure, suggesting that intraoperative changes in afterload conditions importantly influence mitral regurgitation severity. Thus, Doppler color flow mapping provides accurate intraoperative evaluation of mitral regurgitation and may aid surgical decision making.(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Vessel Prosthesis↗
PubMed1986

Combined valve and coronary artery bypass procedures in septuagenarians and octogenarians: results in 120 patients.

A consecutive series of 96 septuagenarians (mean age, 74) and 24 octogenarians (mean age, 83) underwent coronary artery bypass (CAB) and valve operations using hypothermia and hyperkalemic cardioplegia in a 45-month period; there was a mean of 2.6 grafts per patient. Most patients were in New York Heart Association (NYHA) class IV (57% of the septuagenarians and 88% of the octogenarians) preoperatively. The early deaths were 19% for septuagenarians and 37% for octogenarians; late deaths were 9% and 6%, respectively, after a mean of 25 months. Of 92 survivors, 78% of the septuagenarians and 87% of the octogenarians improved by one or more NYHA class postoperatively. Of 58 patients with combined CAB and aortic valve replacement, 12 (21%) died; of 38 with combined CAB and mitral valve replacement 19 (50%) died; 2 of 9 (22%) with combined CAB and double valve replacement died; and 2 of 11 (18%) with CAB and MV repair died. In comparison, of patients with isolated valve replacement in the same period, 2 of 30 (7%) in the AVR group died, 5 of 17 (29%) died in the MVR group, 2 of 7 (33%) in the DVR group died. The risk of combined valve procedures and bypass surgery was significantly increased in the elderly and may warrant a less aggressive procedure, especially in the mitral position.

Aged↗
PubMed1986

Cine computed tomographic evaluation of aortocoronary bypass graft patency.

Evaluation of the patency of coronary bypass grafts has previously required hospitalization for invasive angiography. This report of three cases documents the unique capability of cardiac cine computed tomography to easily and accurately define coronary bypass graft patency. In each case, the findings altered therapeutic decisions. This early experience justifies wider application of this technique and suggests that it may eliminate the need for diagnostically motivated graft angiography. Large scale studies to establish the sensitivity and specificity of cardiac cine computed tomography for determining graft patency are indicated.

Coronary Angiography↗
PubMed1986

Hemodynamic differentiation of pathologic and physiologic stenosis in mitral porcine bioprostheses.

Porcine bioprostheses are physiologically stenotic valves. Degenerative calcification leading to pathologic stenosis is an increasingly recognized serious late complication of mitral valve replacement with a porcine bioprosthesis. Hemodynamic differentiation of pathologic from physiologic stenosis is important for identification of porcine bioprosthetic valve dysfunction. In 42 patients with a normal Hancock porcine bioprosthesis (standard model, sizes 27 to 33 mm), mean diastolic flow (65 to 461 ml/s), mean gradient (2.0 to 13.4 mm Hg) and effective orifice area (1.1 to 4.4 cm2) were determined at rest, during epicardial pacing (90, 110 and 130/min) and with isoproterenol infusion. A statistically significant increase in mean gradient occurred with increases in flow and decreases in valve size (p less than 0.05). Effective orifice area increased significantly as flow rate increased and as valve size increased (p less than 0.05). These measurements were compared with those in 16 patients with pathologically confirmed porcine bioprosthetic valve stenosis: 8 patients with reoperation (1.1% per patient-year) 3 to 8.5 years after mitral valve replacement and 8 previously reported abnormal cases. Stenotic failure rate was inversely related to valve size (2.1, 1.4, 0.5 and 0% per patient-year for sizes 27 to 33 mm). Stenotic and normal bioprostheses were not accurately differentiated on the basis of a single value for gradient or effective orifice area. A mathematical model that related flow to the square root of the mean gradient allowed complete separation of stenotic from normal prosthetic valve function, after valve size was accounted for and normal confidence limits were established (r = 0.74 to 0.94, sizes 27 to 33, p less than 0.0001). The effective orifice area-flow relation did not provide accurate differentiation of abnormal from normal function. Thus, normal mitral bioprostheses have significant transvalvular gradients whose magnitude depends on flow. Risk of stenotic failure is increased in the smaller valves, which have a larger gradient at implantation. Differentiation of pathologic from physiologic stenosis cannot be made on the basis of a single value for gradient or effective orifice area. Accurate hemodynamic differentiation is achieved by relating mean gradient to mean diastolic flow rate and valve size.

Bioprosthesis↗
PubMed1986

Cardiac surgery in the octogenarian.

Seventy-six consecutive patients, aged 80 to 89 (mean 82), underwent cardiac operations with cardiopulmonary bypass. Hypothermia (22 degrees C) and hyperkalemic cardioplegia were used in each. There were 35 men and 41 women. Thirteen patients (17%) were in New York Heart Association Functional Class III and 62 patients (81%) were in Class IV preoperatively. Coronary bypass procedures (Group I) were performed in 38 patients, of whom five had combined carotid endarterectomy. The average number of grafts was 3.7 per patient. There were two early deaths (5.2%). Single or double valve replacement, without coronary bypass (Group II), was done in 15 patients, with one early death (6.6%). Coronary bypass and valve procedures (Group III) were performed in 23 patients with seven early deaths (30%). Total early mortality was 10 deaths in 76 patients (13%). Of the 66 (87%) 30 day survivors, 19 (29.1%) had major postoperative complications, including bleeding, pericardial tamponade, sternal dehiscence, myocardial infarction, arrhythmia, and pump failure. Mean hospital stay was 23 days (9 to 117 days). Late cardiac-related deaths occurred in eight patients (9%) during the 58 (mean 28) months of follow-up. Thus combined early and late mortality was 18 deaths (24%). Mortality at any time was related to Functional Class IV status (17/18 deaths, 94% in Class IV); combined procedures (12/28 patients died, 43%); use of intra-aortic balloon pumping (8/13 patients died, 62%); and postoperative bleeding necessitating reoperation (4/6 patients died, 67%). At follow-up 84% of survivors had improved by one or more functional classes, and there was a low incidence of cardiac-related late deaths. This experience supports the concept that in octogenarians the indications for operation should be as for other patients of less advanced age, especially in those with isolated coronary artery disease and pure valve disease. Operation should not be delayed, so that these patients will not advance to higher-risk Class IV status preoperatively.

Age Factors↗
PubMed1985

Use of esmolol in hypertension after cardiac surgery.

Systolic hypertension, which is common soon after cardiac surgery, increases cardiac work and may threaten fresh vascular anastomoses. Because postoperative hypertension is often associated with elevated catecholamines and preoperative use of beta-blocking agents, esmolol, an ultrashort-acting beta-blocking agent, was compared with nitroprusside in a crossover study in this setting. Twelve patients, 18 to 28 hours after cardiac surgery (coronary artery bypass graft in 9, aortic valve replacement in 2 and valved aortic conduit with reimplantation of coronary arteries in 1 patient) received controlled infusions of esmolol (mean dosage 142 +/- 100 micrograms/kg/min, range 50 to 300 micrograms/kg/min) and nitroprusside (mean dose 1.6 +/- 1.3 micrograms/kg/min, range 0.5 to 2.75 micrograms/kg/min). In this open-label study, choice of the first drug was randomized, after which patients were then crossed over to the other study drug. Therapeutic response (greater than or equal to 15% systolic blood pressure reduction) was achieved in 11 of 12 esmolol patients and 12 of 12 nitroprusside patients. Both drugs significantly lowered systolic and diastolic blood pressure, as well as left ventricular stroke work index. While the cardiac index was decreased by esmolol and increased by nitroprusside, neither drug significantly changed stroke volume index. Systemic vascular resistance, unchanged by esmolol, was decreased significantly by nitroprusside. Oxygen saturation and Pao2, unchanged with esmolol, were both significantly reduced with nitroprusside. Thus, for hypertension early after cardiac surgery, esmolol is safe, effective and rapid and, compared with nitroprusside, results in less unwanted decrease in diastolic blood pressure and oxygen saturation, but there is more decrease in heart rate and cardiac index.

Adrenergic beta-Antagonists↗
PubMed1985

Effects of intubation on coronary blood flow and myocardial oxygenation.

Effects on haemodynamics and myocardial oxygenation of endotracheal intubation were examined in 17 patients after halothane induction and 12 after 1 mg X kg-1 of IV morphine. Six patients having each anaesthetic were pretreated with IV propranolol (0.1 mg X kg-1) 45 minutes earlier. Arterial and intracardiac pressures, cardiac output and total coronary sinus blood flow (CSBF), both by thermodilution, were determined plus arterial-coronary differences of oxygen, haemoglobin and lactate. Blood pressure (BP), heart rate and CSBF were recorded continuously during intubation. The subjects were candidates for coronary bypass grafts, but had good ventricular function (mean ejection fraction 0.68 +/- 0.13 SD). From their reduced levels after induction, BP, cardiac index and systemic vascular resistance increased to awake levels following intubation. Mean CSBF in nonbetablocked patients increased to awake level along with BP. More myocardial oxygen was extracted and consumed after intubation, but lactate extraction continued: these data are evidence of adequate oxygen supply. Induction with either halothane or morphine effectively prevented the hypertensive response to intubation. Acute beta blockade led to less increase in heart rate from intubation.

Aged↗
PubMed1985

Adrenal function following coronary bypass surgery.

Little is known about adrenocortical function after coronary bypass surgery in which moderate to deep hypothermia and cardiopulmonary bypass are used particularly with intraoperative steroid administration. Therefore, we performed a pilot study in which immediately preoperative and 18-hour postoperative serum cortisol levels were determined in eight patients who received 1.0 to 1.5 gm of methylprednisolone intravenously during surgery; postoperative serum cortisol (3 +/- 1 microgram%) levels were lower than preoperative levels (15 +/- 3 microgram%, p less than 0.05). To determine the possible cause of these striking findings, the effects of moderate to profound hypothermia and cardiopulmonary bypass upon adrenocortical functioning were investigated without the influence of intraoperative steroid administration. Serum cortisol and aldosterone levels and their response to adrenocorticotropic hormone (ACTH) (Cortrosyn) were determined before coronary bypass surgery and at various postoperative intervals in seven patients. Postoperative cortisol and aldosterone levels increased markedly over their preoperative values, reaching a maximum at 6 to 12 hours (cortisol 16 +/- 8 vs 63 +/- 23 micrograms%, p less than 0.05, aldosterone 15 +/- 5 vs 51 +/- 22 ng%, p less than 0.05). Adrenal response to ACTH was normal preoperatively, during rewarming from hypothermia, and 18 hours, and 7 days postoperatively. In summary, normal adrenal responsiveness occurs after coronary bypass surgery, in spite of hypothermic cardiopulmonary bypass and the effects of anesthesia, and a single dose of methylprednisolone during surgery is associated with markedly lower serum cortisol levels and prevents the usual adrenal stress response to bypass surgery for at least 18 hours postoperatively.

Adrenal Cortex Function Tests↗
PubMed1985

Fibrinolytic therapy of St. Jude valve thrombosis under guidance of digital cinefluoroscopy.

Fibrinolytic therapy is an alternative to urgent reoperation for patients with St. Jude prosthetic valve thrombosis, but requires an accurate method for repeated assessment of prosthetic function. Since the St. Jude valve is not well visualized by conventional cinefluoroscopy, digital subtraction techniques were developed that improved visualization of the value and allowed assessment of leaflet separation and velocity. A 74 year old woman with prosthetic valve thrombosis 5 years after St. Jude aortic valve placement had an opening angle of 58 degrees (normal range 10 to 13; n = 8) with a maximal opening velocity of 1.37 degrees/ms (normal range 2.46 to 2.93). The closing angle was 125 degrees (normal range 120 to 127) with a maximal closing velocity of 1.38 degrees/ms (normal range 2.24 to 3.60). The patient received 250,000 U of streptokinase intravenously, then 100,000 U/h for 72 hours. Improvement in auscultatory findings occurred at 12 hours; repeat digital cinefluoroscopy showed an opening angle of 20 degrees with a maximal velocity of 2.77 degrees/ms, and a closing angle of 126 degrees with a maximal velocity of 1.91 degrees/ms. Digital cinefluoroscopy 4 weeks after discharge on warfarin and dipyridamole therapy was unchanged. There have been no thromboembolic complications after 6 months of follow-up. Thus, digital cinefluoroscopy is a new noninvasive technique that permits accurate measurement of normal and abnormal St. Jude leaflet function. Intravenous streptokinase dissolution of prosthetic valve thrombosis under digital cinefluoroscopic guidance may be an acceptable alternative to emergency reoperation. The frequency and significance of residual subclinical leaflet dysfunction after fibrinolytic therapy and the indications for elective reoperation require further evaluation.

Aged↗