Biomedical subjects

R J Rizzo

Publications and source records attributed to R J Rizzo.

At least 19 recordsLinked to original sources

PubMed1996

Predictors of atrial fibrillation after coronary artery surgery. Current trends and impact on hospital resources.

BACKGROUND: Atrial fibrillation (AF) after coronary artery bypass surgery (CABG) is the most common sustained arrhythmia. Its pathophysiology is unclear, and its prevention and management remain suboptimal. The aim of this prospective study was to determine the current incidence of AF, identify its clinical predictors, and examine its impact on resource utilization. METHODS AND RESULTS: Over a 12-month period ending July 31, 1994, a CABG procedure was performed on 570 consecutive patients (age range, 32 to 87 years; median age, 67 years; 232 [41%] were > or = 70 years; 175 [31%] were women; 173 [30%] were diabetics; 364 [65%] required nonelective surgery; 86 [15%] had had a prior CABG; and 86 [15%] had had prior percutaneous transluminal coronary angioplasty). AF occurred in 189 patients (33%). The median age for patients with AF was 71 years compared with 66 for patients without (P = .0001). Multivariate logistic regression analysis (odds ratio, +/- 95% CI, P value) was used to identify the following independent predictors of postoperative AF: increasing age (age 70 to 80 years [OR = 2; CI, 1.3 to 3; P = .002], age > 80 years [OR = 3; CI, 1.6 to 5.8; P = .0007]), male gender (OR = 1.7; CI, 1.1 to 2.7; P = .01), hypertension (OR = 1.6; CI, 1.0 to 2.3; P = .03), need for an intraoperative intraaortic balloon pump (OR = 3.5; CI, 1.2 to 10.9; P = .03), postoperative pneumonia (OR = 3.9; CI, 1.3 to 11.5; P = .01), ventilation for > 24 hours (OR = 2; CI, 1.3 to 3.2; P = .003), and return to the intensive care unit (OR = 3.2; CI, 1.1 to 8.8; P = .03). The mean length of hospital stay after surgery was 15.3 +/- 28.6 days for patients with AF compared with 9.3 +/- 19.6 days for patients without AF (P = .001). The adjusted length of hospital stay attributable to AF was 4.9 days, corresponding to > or = $10 055 in hospital charges. CONCLUSIONS: AF remains the most common complication after CABG and consequently is a drain on hospital resources. Concerted efforts to reduce the incidence of AF and the associated increased length of stay would result in substantial cost saving and decrease patient morbidity.

Adult↗

PubMed1996

Thigh ischemia complicating femoral vessel cannulation for cardiopulmonary bypass.

Compartment syndrome of the lower leg is an occasional complication of prolonged ischemia and reperfusion. Compartment syndrome of the thigh is a less well-recognized complication. We present 2 patients with compartment syndrome of the ipsilateral thigh after femoral arterial and venous cannulation for cardiopulmonary bypass. Early diagnosis and urgent decompressive fasciotomy may limit the extent of local tissue damage and subsequent myonephropathic syndrome.

Aged↗

PubMed1996

Current incidence and determinants of perioperative myocardial infarction in coronary artery surgery.

Increasingly, patients undergoing coronary artery bypass grafting (CABG) are elders, have had previous CABG, and have poor left ventricular function. To evaluate determinants of perioperative myocardial infarction (PMI) after isolated CABG, 499 consecutive patients were reviewed. Definite PMI (total peak creatine kinase [CK] > 700 U/L, creatine kinase MB [CK-MB] > 30 ng/ml, and new pathologic electrocardiographic Q waves) occurred in 25 patients (5.0%) and probable PMI (total peak CK > 700 U/L, CK-MB > 30 ng/ml, and a new wall-motion abnormality) occurred in 10 (2.0%) patients. According to multivariate logistic regression analysis, independent risk factors for definite or probable PMI (adds ratios; 95% confidence intervals) were emergency surgery (3.1; 1.1 to 8.4; p = 0.003), aortic cross-clamp time > 100 minutes (4.2; 1.6 to 11.2; p = 0.004), myocardial infarction in the preceding week (2.6; 1.0 to 6.4; p = 0.04), and previous revascularization (2.4; 1.1 to 5.2; p = 0.02). In conclusion, both preoperative and intraoperative factors influence the risk of PMI after CABG. Despite changes in the profile of patients undergoing CABG, the incidence of PMI in this tertiary center is comparable with that found in earlier series, probably because of improvements in surgical techniques and postoperative care.

Aged↗

PubMed1996

Determinants of red cell, platelet, plasma, and cryoprecipitate transfusions during coronary artery bypass graft surgery: the Collaborative Hospital Transfusion Study.

BACKGROUND: Very little is known about the determinants of blood transfusions in patients undergoing coronary artery bypass graft surgery. STUDY DESIGN AND METHODS: To identify factors that influenced the transfusion of red cells, platelets, plasma, and cryoprecipitate, statistical methods were used to study 2476 consecutive diagnosis-related group 106 and 107 patients in five teaching hospitals who underwent coronary artery bypass surgery between January 1, 1992, and June 30, 1993. RESULTS: The likelihood of red cell transfusion was significantly associated with 10 preoperative factors: 1) admission hematocrit, 2) the patient's age, 3) the patient's gender, 4) previous coronary artery bypass surgery, 5) active tobacco use, 6) catheterization during the same admission, 7) coagulation defects, 8) insulin-dependent diabetes with renal or circulatory manifestations, 9) first treatment of new episode of transmural myocardial infarction, and 10) severe clinical complications. Platelet and/or plasma transfusions were strongly associated with the dose of red cells transfused. Transfusion requirements and other in-hospital outcomes were associated with patient characteristics, surgical procedure (reoperation vs. primary procedure), and the conduits used for revascularization (venous graft only, venous and internal mammary artery graft, or internal mammary artery graft only). Blood resource use and donor exposures were evaluated with respect to the risk to patients of contracting hepatitis C virus and human immunodeficiency virus infections. CONCLUSION: The classification of coronary artery bypass graft patients on the basis of attributes known preoperatively and by conduits used yields subsets of patients with distinctly different transfusion requirements and in-hospital outcomes.

Age Factors↗

PubMed1996

Reduced mortality and morbidity for ascending aortic aneurysm resection regardless of cause.

BACKGROUND: This study was done to answer the question, "What is the current risk of resection of ascending aortic aneurysms regardless of acuity or cause?" METHODS: One hundred fifteen consecutive patients who underwent ascending aortic aneurysm repair from January 1, 1990, to July 1, 1995, were retrospectively reviewed, excluding those with acute ascending aortic dissection. The mean age was 59 years; 55% were male. Concomitant procedures included coronary artery bypass in 23 (20%) and arch repair in 12 (10%). In group 1, 54 patients had replacement of the aortic valve, root, and ascending aorta with a valve-graft conduit using the "Bentall" technique, and of these 19 (35%) had Marfan's syndrome. In group II, 44 patients had separate aortic valve repair or replacement and supracoronary ascending aortic replacement. In group III, 17 patients had supracoronary ascending aortic replacement, without aortic valve operation. Operative techniques included frequent use of (1) intraoperative transesophageal echocardiography or epiaortic ultrasound scanning of the ascending and descending thoracic aorta to help guide arterial cannulation, avoid atherosclerotic embolization, and assess the repair; (2) antegrade and retrograde multidose cold blood cardioplegia for myocardial protection; (3) exclusion and button anastomotic techniques to ensure secure suture lines; (4) antifibrinolytic agents and collagen-impregnated aortic grafts to reduce bleeding; and (5) deep hypothermic circulatory arrest and the open distal anastomotic technique in patients with distal ascending and arch aortic disease. RESULTS: Operative mortality overall was 2/115 (1.7%). Mortality was 1/54 (1.8) in group I and 1/44 (2%) in group II, and there was no mortality in group III. The overall postoperative morbidity was 3% due to bleeding, 2% due to stroke, and 1% due to myocardial infarction. The length of stay in the past year has decreased to less than 7 days. CONCLUSIONS: The current risk for ascending aortic aneurysm repair is low (< 2%) whether or not the aortic root or valve also needs repair, regardless of the cause of the aneurysm.

Adult↗

PubMed1995

Determinants of early mortality and late survival in mitral valve endocarditis.

BACKGROUND: Infective mitral valve endocarditis continues to be a significant surgical challenge. The objective of this study was to examine our experience with mitral valve endocarditis surgery and identify determinants of early mortality and late survival. METHODS AND RESULTS: Over a 24-year period, mitral valve surgery was performed in 96 patients for infective mitral valve endocarditis. Patient age ranged from 20 to 78 years (median age, 52 years). There were 44 women (46%), and 48 of the 96 patients (50%) were in New York Heart Association functional class IV before surgery. Native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE) were present in 72 patients (75%) and 24 patients (25%), respectively. Surgery during the active phase of endocarditis (AE) was required in 60 patients (62%) and during the healed phase (HE) in 36 (38%). The main indications for surgery in the AE group were congestive heart failure (60%), active sepsis (67%), peripheral emboli (47%), and acute renal failure (20%), and for the HE group the main indication was progressive congestive heart failure (69%). The overall operative mortality was 5.2%. Multivariate logistic regression analysis identified PVE (odds ratio [OR] 22.5; +/- 95% confidence interval, CI, 1.9 to 268; P = .014) and an associated procedure (OR 13.3; +/- 95% CI, 1.5 to 120; P = .021) to be independent predictors for early mortality. Follow-up was 97% complete, with a median of 3.5 years. Overall 5- and 10-year survivals were 83 +/- 4% and 63 +/- 8%, respectively. Multivariate analysis for late mortality identified PVE to be a significant predictor of late mortality (hazards ratio = 3.1, +/- 95% CI, 1.4 to 6.8, P = .006). There were no significant differences in long-term morbidity results among the various subsets of mitral valve endocarditis. CONCLUSIONS: Mitral valve surgery for infective endocarditis is a significant high-risk procedure for PVE and when combined with associated procedures. The activity of endocarditis does not appear to have any influence on early mortality or long-term survival.

Adult↗

PubMed1995

Shed whole blood autotransfusion during aortic aneurysm operation with a modified collection infusion system.

We describe a modified shed whole blood collection and autotransfusion system that allows several options for the processing and autotransfusion of shed blood: use of the Cell Saver (Haemonetics, Braintree, MA) or the ultrafiltration of collected blood, and the autotransfusion of unprocessed shed whole blood. The system has proved useful for transfusion in the setting of thoracic aortic operations, and we describe here our experience in 5 patients undergoing resection of a descending thoracic aortic aneurysm in whom this system was used.

Aged↗

PubMed1995

The effect of pathophysiology on the surgical treatment of ischemic mitral regurgitation: operative and late risks of repair versus replacement.

Operative correction of ischemic mitral regurgitation (IMR) is associated with high risk approach. The objective of this retrospective study was to examine the interaction between the various underlying pathophysiologic mechanisms, the operative procedure, and their influence on short- and long-term outcomes. Over a 10-year period starting January 1984, mitral valve repair or replacement was performed on 150 patients with IMR. The age range was 42-86, mean 67, years; 71 (47%) were females; 139 (93%) were in NYHA functional class III or IV; 23 (15%) were reoperations; and 30 (20%) were in atrial fibrillation. Functional IMR due to annular dilatation or restrictive leaflet motion was present in 106 (71%), and structural IMR due to ruptured chordae or papillary muscle in 44 (29%). Mitral valve repair was performed in 94 (63%) with an annuloplasty ring employed in 80 (85%) patients. Mitral valve replacement was performed in 56 (37%), with 40 (71%) receiving a bioprosthesis (32 Hancock and 8 Carpentier-Edwards valves) and 16 (29%) a St. Jude valve. Coronary artery bypass graft surgery was performed in 139 (93%) patients. The overall operative mortality (OM) was 14/150 (9.3%). The OM for repair was 9.5% compared to 8.9% for replacement (P = NS). There was higher OM in the elderly, particularly in the repair group (P = 0.053), and a trend towards reduced OM in the recent years of the study (P = NS). No predictors of OM were identified by multivariate logistic regression analysis. Long-term follow-up was 98% complete and ranged from 2-120, mean 31.2, months for a total of 935 patient-years. The overall 5-year survival rate was 71 +/- 6%, with 91 +/- 5% for the replacement group compared to 56% +/- 10% for the repair group (P = 0.01). The functional subset of IMR who had a repair had the worse long-term survival (43 +/- 13%) compared to the structural/repair (76 +/- 13%) and structural/replacement groups (89 +/- 8%), and 92 +/- 7% for the functional/replacement group ((P = 0.0049). Multivariate logistic regression analysis identified the functional/repair group (hazards ratio 4.4; +/- 95%, confidence interval 1.6, 11, (P = 0.0031); and earlier years of surgery (hazards ratio 4.7; +/- 95% confidence interval 1.021; (P = 0.046) to be predictors of worse long-term survival. These results suggest that, in IMR, the underlying responsible pathophysiologic mechanisms appear to be the major determinants of survival, rather than the choice of the operative procedure.

Adult↗

PubMed1995

Repair of mitral regurgitation from myxomatous degeneration in the patient with a severely calcified posterior annulus.

Severe posterior annular calcification poses a particular challenge to mitral valve repair. In a series of 252 mitral valve repairs for myxomatous degeneration performed between 1980 and 1993, 14 patients had a severely calcified posterior mitral valve annulus. Ages ranged from 61 to 81 years. Twelve patients were preoperative NYHA Class III or IV, and five patients required concurrent coronary artery bypass procedures. Operative techniques included complete resection of the calcified posterior annulus, resections of portions of the posterior leaflet with leaflet advancement, and placement of an annuloplasty ring. There were no operative deaths and all patients had a postoperative echocardiographic confirmation of relief from mitral regurgitation. During a mean follow-up time of 36 months (6 months to 8 years), there has been one late valve reoperation and only one late death, from thromboembolism in a patient with atrial fibrillation. These data indicate that even in the presence of severe calcification of the posterior mitral annulus, mitral valve repair for myxomatous degeneration can be performed with a low-operative risk and satisfactory long-term results.

Aged↗

PubMed1995

Congenital abnormalities of the pancreas and biliary tree in adults.

Congenital abnormalities of the pancreaticobiliary tree may go undetected until adulthood. In adult patients with persistent and unexplained signs and symptoms, such as cholangitis, pancreatitis, jaundice, recurrent abdominal pain, and nausea and vomiting, a congenital anomaly of the pancreatic or bile duct must be considered and a low threshold for performing cholangiopancreatography is recommended. The most common congenital pancreaticobiliary abnormalities seen in adults are choledochal cyst, anomalous junction of the pancreatic and common bile ducts, aberrant biliary ducts, and pancreas divisum, with the following entities being more rarely seen: choledochoceles, multiple communicating intra- and extrahepatic duct cysts, Caroli disease, pancreaticobiliary abnormalities associated with situs anomalies, annular pancreas, and aberrant pancreatic ducts associated with enteric duplication cysts. Cholangiopancreatography allows confirmation of diagnosis and may demonstrate associated abnormalities such as choledocholithiasis or tumor. Recognition of congenital anomalies may aid in surgical planning and prevent inadvertent ductal injury. Although congenital pancreaticobiliary abnormalities are relatively uncommon, the increased prevalence of cholangitis, gallstones, and cholangiocarcinoma seen with the various types of biliary cystic disease and junctional anomalies and the increased association of pancreatitis seen with pancreatic anomalies make recognition of variant anatomy clinically important.

Adult↗

PubMed1994

Single-clamp technique: an important adjunct to myocardial and cerebral protection in coronary operations.

To determine the myocardial and cerebral protective properties of the single cross-clamp (group I; n = 160) versus the partial occluding clamp (group II; n = 150) technique for construction of the proximal anastomoses, a retrospective analysis of 310 patients operated on by the same surgeon was performed. Group I patients were older (median age, 70 versus 64 years; p < or = 0.0001), with 83 (52%), versus 41 (27%) in group II, 70 years and older (p < or = 0.0001). More group I patients were in New York Heart Association functional class IV (42 [26%] versus 22 [15%]; p = 0.008); more required preoperative balloon counterpulsation (35 [22%] versus 16 [11%]; p = 0.006); and more required emergent operation (20 [13%] versus 3 [2%]; p < or = 0.0001). Antegrade crystalloid cardioplegia was used in both groups. The median cross-clamp time was 58 minutes for group I versus 44 minutes for group II (p < or = 0.0001). However, there was no significant difference between the two groups in terms of the number of bypass grafts, the use of the mammary artery, or the bypass time. The operative mortality was 2.5% (n = 4) for group I versus 5.3% (n = 8) for group II (p = 0.16), and the perioperative myocardial infarction/low cardiac output state was seen in 6 patients (3.8%) in group I versus 18 patients (12%) in group II (p = 0.006). The median creatine kinase MB release was 13 U/L for group I versus 19 U/L for group II (p = 0.0029).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1994

Aortic valve endocarditis. Determinants of early survival and late morbidity.

BACKGROUND: Aortic valve surgery for endocarditis remains a high-risk procedure. The objective of this study was to analyze the interaction between the various subsets of endocarditis (native, prosthetic, healed, and active), timing of surgery, and their influence on early and late outcomes. METHODS AND RESULTS: During a 20-year period starting January 1972, 200 patients underwent aortic valve replacement for infective endocarditis (age range, 13 to 88 years; median, 53 years). There were 51 (26%) females, and 109 (55%) were in New York Heart Association functional class IV before surgery. Native valve endocarditis (NVE) and prosthetic valve endocarditis (PVE) were present in 132 (66%) and 68 (34%) patients, respectively. Surgery was required in 120 (60%) during the active phase (AE) and 80 (40%) during the healed phase (HE) of endocarditis. The main indication for surgery in the healed group was progressive congestive heart failure. The indications for the active group were congestive heart failure (68%), continuing active sepsis (70%), echocardiographic vegetation (28%), peripheral emboli (30%), and arrhythmias (13%). Streptococcal infections predominated in NVE, staphylococcal in PVE and AE; culture-negative endocarditis predominated in the healed group. Isolated aortic valve surgery was performed in 68% of the patients, and concomitant procedures (32%) included mitral valve and coronary bypass procedures. The overall operative mortality (OM) was 12.5%. The OM was 7.5% and 22% for NVE and PVE, respectively (P = .004), and 7% for HE versus 15% for AE (P = .06). The OM for early PVE was 33% versus 18% for late PVE (P < .05). Multivariate logistic regression analysis identified PVE and New York Heart Association functional class IV to be independent predictors for early death. Recurrent endocarditis occurred 26 times in 24 patients (11 early, 13 late), with three operative deaths in the early group, all due to residual staphylococcal infections. Freedom from recurrent endocarditis was significantly different between HE (96 +/- 3% and 86 +/- 6% at 5 and 10 years, respectively) and AE (89 +/- 3% and 83 +/- 4%, respectively (P = .02). Long-term survival for discharged patients was 81 +/- 3% and 63 +/- 5% at 5 and 10 years, respectively, with no significant difference between NVE, PVE, AE, and HE. CONCLUSIONS: These data suggest that for active endocarditis, surgery should be delayed to achieve a healed status provided there is no pressing need for immediate surgery. Patients with staphylococcal endocarditis, particularly on a prosthesis, should be operated on sooner and should be covered with antibiotics for an extended period to prevent recurrent PVE. This study stresses the need for aggressive antibiotic prophylaxis, particularly in the presence of a prosthesis.

Aortic Valve↗

PubMed1994

Rapid noninvasive diagnosis and surgical repair of acute ascending aortic dissection. Improved survival with less angiography.

Angiography has been considered the gold standard for the diagnosis of acute dissection of the ascending aorta, but it may increase mortality by imposing an unnecessary delay before surgical repair. In addition, coronary angiography has often been considered essential as well. From 1988 to 1993, 37 patients (median age 61 years, 30 men and 7 women) had acute dissection of the ascending aorta. All of the initial 15 patients (group I) had angiography, even through the diagnosis of aortic dissection had already been made noninvasively in 14; six (40%) of 15 died, three of aortic rupture and none of complications of coronary artery disease. Among the next 22 patients (group II), 21 had a noninvasive diagnosis of acute dissection of the ascending aorta (eight by echocardiography; 13 by computed tomography), and 19 (86%) were operated on without angiography; two died (9%, p = 0.03 versus group I) and neither death was due to aortic rupture or coronary artery disease. Overall, either root or selective coronary angiography was attempted in 18 of 37 patients, but it documented coronary artery disease in only two patients (11%). Coronary artery disease was found in four other patents at autopsy; three of them, including two that died of aortic rupture, had angiography that failed to reveal the coronary artery disease. Noninvasive diagnosis of acute dissection of the ascending aorta is reliable and avoids the risks and delays inherent in invasive angiography. Rapid noninvasive diagnosis of aortic dissection and avoidance of routine angiography appear to improve survival by expediting surgical intervention and thus decreasing the risk of aortic rupture.

Acute Disease↗

PubMed1994

Prevention of complement-induced pulmonary hypertension and improvement of right ventricular function by selective thromboxane receptor antagonism.

The effect of complement activation on the pulmonary vascular system and on right ventricular function was studied in sheep (n = 12) by injection of cobra venom factor. Animals were instrumented for measurement of pulmonary flow, mean pulmonary artery pressure, right ventricular stroke work, arterial blood gases, and systemic vascular resistance. Blood was sampled from the left atrium and pulmonary artery to measure thromboxane B2, the metabolite of thromboxane A2, by radioimmunoassay. After baseline measurements, animals were randomly assigned to receive a selective thromboxane receptor antagonist SQ30741 as a 10 mg/kg bolus with an infusion of 10 mg/kg per hour or else to receive vehicle. Cobra venom factor was then injected (30 U/kg) in all animals, and data were recorded at 15, 30, 60, 90, and 120 minutes. In control animals there was a 2.4-fold increase in mean pulmonary artery pressure and a 76% increase in right ventricular stroke work at 15 minutes from baseline (p < 0.05); these values remained elevated for 30 minutes and returned to baseline by 1 hour with no change in systemic vascular resistance. Arterial oxygenation decreased by 124% at 15 minutes and remained depressed through the experiment, but in treated animals oxygen tension remained unchanged from baseline. Thromboxane B2 increased 95% from baseline in the control group and 1.5 fold in treated animals and followed a similar time course as the functional measurements (p < 0.05). A pulmonary vascular thromboxane B2 gradient of approximately 1000 pg/ml was measured at 15 and 30 minutes in both control and treated groups. (p < 0.05) We conclude that after complement activation in this model pulmonary hypertension and decreased oxygen tension are mediated by thromboxane release from the pulmonary vascular bed. This increased afterload causes a stress on the right ventricle as demonstrated by the increased right ventricular stroke work. Selective thromboxane receptor antagonism may be a beneficial therapy for pulmonary hypertension in patients after cardiopulmonary bypass.

Animals↗

PubMed1994

The long-term results of mitral valve reconstruction for the "floppy" valve.

The myxomatous degenerated, prolapsed, or floppy mitral valve is the most common etiology of mitral regurgitation in North American populations. We performed mitral valve reconstruction for this diagnosis in 252 patients from 1984 to 1993. There were 165 males and 87 females ranging in age from 23 to 84 years (mean 64 years); 93 (37%) were > or = 70 years. One hundred eighty-six were New York Heart Association Functional Class III or IV and 29% (72) underwent concomitant coronary bypass operation. Operations included posterior leaflet resection, anterior leaflet resection treatment of chordal pathology by shortening or Gore-Tex replacement, and ring annuloplasty. There were five operative deaths for an operative mortality of 2%. The operative risk in patients under 70 years was 1 of 159 (0.6%) and 4 of 93 (4%) in patients older than 70 years. Ninety percent of patients are asymptomatic in a follow-up period extending 10 years, while structural valve degeneration requiring reoperation at 5 years was 85%. From 1990 to 1993 there has been a less than 5% absolute incidence of structural valve degeneration. Mitral valve reconstruction for complicated floppy mitral valve is feasible and offers excellent early and medium-term results.

Adult↗

PubMed1994

Long-term results of mitral valve reconstruction for regurgitation of the myxomatous mitral valve.

The myxomatous, degenerated, prolapsed or "floppy" mitral valve is the most common cause of mitral regurgitation in North America. Mitral valve reconstruction for mitral regurgitation was carried out in 219 consecutive patients with a myxomatous mitral valve from 1984 to 1993. Of the 139 men and 80 women, 23 to 84 years of age (mean 63 years), 36% of patients were 70 years of age or older, 77% were in New York Heart Association functional class III or IV, and 29% had coronary artery disease necessitating coronary bypass. The most common operation was posterior leaflet resection (161 patients [73%]). The anterior leaflet was resected in 14 patients, and both the anterior and posterior leaflets were resected in 15 patients. A variety of other techniques were used, including commissuroplasty and use of annuloplasty rings. A flexible Duran ring was used in 111 patients (51%), a Carpentier-Edwards ring in 44 patients (20%), and no ring was used in 64 patients (29%). Five operative deaths occurred (2.3%); four of the five deaths occurred in patients 70 years of age or older (5.1%); and one in 141 patients (0.7%) was younger than 70 years of age. In the late postoperative period (mean follow-up 2 years), 90% of patients had no symptoms, two had endocarditis, and seven patients had thromboemboli (transient in four, permanent in three). Structural valve degeneration requiring reoperation occurred late in 12 patients; eight were in posterior leaflet resection and two in anterior or anterior and posterior; six of 12 had no annuloplasty ring. The incidence of structural valve degeneration was less than 5% from 1990 to 1993. No systolic anterior motion of the mitral valve was seen with postoperative echocardiography before discharge. Actuarial analysis at 5 years for overall survival was 86% +/- 5%, freedom from infectious valve degeneration 97% +/- 2%, and freedom from thromboembolism 94% +/- 3%. Freedom from structural valve degeneration overall was 83% +/- 4%, with a flexible ring it was 89% +/- 6%, with a rigid ring it was 88% +/- 6%, and with no ring it was 67% +/- 12% (p = 0.03). Mitral valve reconstruction for complicated myxomatous disease of the mitral valve, regardless of leaflet involvement, is feasible and offers excellent early and late results.

Actuarial Analysis↗

PubMed1993

Decrease in operative risk of reoperative valve surgery.

We analyzed the risk of valve re-replacement in 640 patients reoperated on between 1980 and 1992. This represented 17% of total valve operations (640/3,764) during that period. A univariate and logistic multivariate analysis was carried out for four sequential periods for the 640 re-replacement patients to determine if changing methods of perfusion and myocardial protection affected recent results. There were 323 female and 317 male patients with a mean age of 58 years (range, 17 to 84 years). Ninety-seven (15%) had coronary artery bypass grafting, 135 (21%) were 70 years old or older, 377 (59%) were in New York Heart Association functional class III or less, and 263 (41%) were in functional class IV. The aortic valve was re-replaced in 245, the mitral valve in 289, and both aortic and mitral synchronously in 106. Four periods were analyzed: 1980 through 1982, 1983 through 1985, 1986 through 1988, and 1989 through 1992. The overall operative mortality was 65 of 640 patients (10%), falling from 12/73 (16%) in 1980 through 1982 to 23/268 (8%) in 1989 through 1992 (p = 0.05). Univariate and multivariate logistic analysis documented that New York Heart Association functional class was highly significant for operative mortality; operative mortality was 4% for functional classes I through III, and 19% for functional class IV (p < or = 0.001). The requirement for coronary bypass was of borderline significance (p = 0.05), and year of operation was also significant. Mortality for re-replacement of aortic valve fell from 15% to 10%, double valve from 20% to 9%, and mitral valve from 16% to 6%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗

PubMed1993

Femoral veno-arterial extracorporeal life support with minimal or no heparin.

Recent technological advances in cardiopulmonary bypass circuits achieving surface bonding with heparin have permitted prolonged extracorporeal life support (ECLS) in experimental studies without the use of systemic anticoagulation. Excessive bleeding and the need for massive transfusions after extended ECLS with systemic heparinization have often led to the development of sepsis and multisystem organ failure. The Carmeda bioactive surface circuit, along with a Bio-Medicus centrifugal pump (Bio-Pump) and the femoral veno-arterial route, were used successfully in 3 patients requiring ECLS between April 1992 and December 1992. In 2 patients the need for ECLS was acute allograft dysfunction after orthotopic cardiac transplantation with no evidence of cellular rejection. Both patients were receiving multiple inotropes and intraaortic balloon counter-pulsation; their condition continued to deteriorate rapidly before the initiation of ECLS. The third patient failed to be weaned from cardiopulmonary bypass after myocardial revascularization for ischemic cardiomyopathy. Time on ECLS ranged from 57 to 128 hours. No systemic anticoagulation was used. One patient received no heparin, and the other 2 patients received intermittent heparin infusion to maintain an average activated clotting time of 195 and 214 seconds. Multisystem organ dysfunction present before initiation of ECLS was rapidly reversed, and all patients were weaned successfully without any immediate major complications. The ability to conduct prolonged ECLS without systemic anticoagulation and without repeat sternotomy opens new avenues for the use of this procedure in profound heart failure.

Blood Coagulation↗