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Biomedical subjects

R W Emery

Publications and source records attributed to R W Emery.

At least 19 recordsLinked to original sources
PubMed1995

Modification of the elephant trunk procedure for treatment of acute aortic dissection.

The distal anastomosis constructed during repair of an aortic dissection is prone to bleeding, reentry, and neodissection. To protect the hemostasis, a modification of Borst's elephant trunk procedure has been devised. This "mini-trunk" protects the anastomosis with an internal buttress using the crease of an infolded graft and with a short flap of graft everted into the distal lumen preventing access of the blood stream to this newly constructed suture line.

Acute Disease↗
PubMed1995

Warm heart surgery: a prospective comparison between normothermic and tepid temperature.

Due to concerns about complications from normothermic core temperature during cardiopulmonary bypass, we initiated a prospective randomized study of 200 consecutive patients. In one group (group A), both the heart and the body temperature were kept at 37 degree C. In the second group (group B), both the body and myocardial temperature were allowed to drift down to 34 degree C. There were no differences between these two groups in age, sex, preoperative numbers of elective, urgent, emergent, redo patients, or coronary artery bypass (CAB), valve, CAB/valve procedures. Their preoperative neurological, pulmonary, renal, and vascular disease status were similar. Preoperative EF was 53% in group A (100 patients) and 52.5% in group B (100 patients). Group A required more volume (p = 0.001) and had less urine output (p = 0.03) during and post bypass. Group A required more phenylephrine hydrochloride (p = 0.05) and had more difficulty managing blood pressure. Strokes and renal failure necessitating dialysis occurred more often in group A but without statistical significance. More difficulties occurred in the normothermic (37 degrees C) group and cardioprotective effects of warm heart surgery may remain intact at 34 degrees C. Mild "drifted/tepid" hypothermic heart surgery could be a better and safer procedure.

Body Temperature↗
PubMed1995

Cost-effectiveness and predictors of early extubation.

BACKGROUND: This study examined predictors and cost-effectiveness of early extubation after coronary artery bypass grafting. METHODS: Six hundred forty-five patients admitted to intensive care units after coronary artery bypass grafting at our institutions in 1993 were reviewed. There were 455 male and 190 female patients, which included all patients in DRG 106 and DRG 107. The patients were categorized into three groups: group A (269 patients) were extubated in less than 12 hours (7.55 +/- 2.5 hours), group B (291 patients) were extubated between 12 and 24 hours (16.85 +/- 3.3 hours), and group C (376 patients) were extubated any time after 12 hours. RESULTS: The reintubation rate for the entire group was less than 1%. Univariate preoperative analyses revealed small differences between groups A and B: only 6 of 25 variables were found to reach statistical significance. Stepwise logistic regression analyses were carried out in 269 patients of group A and 376 patients of group C. Older patients (log of age, p = 0.0001), female sex (p = 0.0129; odds ratio = 1.634), use of preoperative diuretics (p = 0.0010; odds ratio = 1.965) and unstable angina (p = 0.0301; odds ratio = 1.544) were noted to be clinical factors associated with late extubation (> or = 12 hours). Early extubation was accomplished in 42%; however, further analysis revealed that many patients who were intubated overnight should have been extubated sooner. CONCLUSIONS: Early extubation shortened the postoperative length of stay, resulting in reduction of cost and resource utilization. The average hospital charge per patient was approximately $6,000 less in the early extubation group.

Aged↗
PubMed1992

Coronary sinus cardioplegia: clinical trial with only retrograde approach.

The cases of 100 consecutive patients who underwent coronary artery bypass grafting with coronary sinus (retrograde) cardioplegia (group R) without the antegrade-retrograde approach were reviewed. To evaluate the safety and the efficacy of this technique, another 100 consecutive patients who underwent a similar procedure but with conventional aortic root (antegrade) cardioplegia (group A) were used as a comparison. The two groups were similar with respect to age, male to female ratio, associated medical problems, extent of coronary artery disease, mean preoperative ejection fraction (0.56 +/- 0.13 versus 0.53 +/- 0.18), pump time (113.1 +/- 43 versus 111.7 +/- 38 minutes), aortic cross-clamp time (57.4 +/- 20 versus 60.8 +/- 23 minutes), number of grafts per patient, level of hypothermia, complication rate, rate of postoperative myocardial infarction (4% versus 3%), and mortality rate (2% versus 2%). Hemodynamic measurements were made 6 hours after operation in 59 patients in group R and 47 patients in group A. The cardiac index, left ventricular stroke work index, and right ventricular stroke work index were better in group R but not significantly so (p greater than 0.05). However, only 27% of patients in group R required a temporary pacemaker, and only 9% needed inotropic agents after 6 hours of operation in contrast to 51% and 42%, respectively, in group A (p less than 0.05). There were no complications from catheter intubation. In group R, right ventricular wall temperature (11 degrees +/- 3.6 degrees C) was higher than the septal (10.8 degrees +/- 3.2 degrees C) and left ventricular wall temperatures (9.1 degrees +/- 2.8 degrees C) (p greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1992

Experience with the symbion total artificial heart as a bridge to transplantation.

From December 1985 through January 1991, 9 patients underwent bridging to transplantation using a Symbion J-7-70 total artificial heart. There were 4 female and 5 male patients aged 31 +/- 14 years (range, 15 to 52 years). Five patients were supported on an intraaortic balloon pump before total artificial heart support, and 2 had biventricular assist devices as well. Total artificial heart support was maintained for 17 +/- 12 days (range, 4 to 44 days); all patients underwent transplantation. Three patients died after transplantation on day 0 (primary donor organ failure), 25 (acute rejection), and 256 (multiorgan failure). The remainder were discharged at 41 +/- 32 days (range, 13 to 101 days). One patient died 28 months after transplantation of late acute rejection. Actuarial 1-year and 3-year survival is 67% and 55%. There were no surgical wound infections. Problems encountered in the J-7-70 period and the period after transplantation were for the most part related to patient condition in the period before implantation. The Symbion J-7-70 total artificial heart is an effective device for total circulatory support in patients with end-stage cardiogenic shock when an organ donor is not available. Organ system failure and infection before implantation may persist into the transplantation period resulting in long-term complications, increased mortality, and prolonged hospital stay; therefore, early implantation of the device when indicated should be applied.

Adolescent↗
PubMed1991

Transesophageal echocardiography in patients with mechanical circulatory assistance.

Transesophageal echocardiography was used to assess myocardial function and to detect complications after mechanical circulatory support for 8 patients with cardiogenic shock. In 3 of 8 patients, serial transesophageal echocardiography documented improvement of systolic ventricular function, and it was possible to wean these 3 patients from the ventricular assist device. In all patients, transesophageal echocardiography added clinically important information including the extent of left and right ventricular dysfunction (6 patients), presence of atrial or ventricular thrombus (5 patients), presence of pericardial effusion or clot (2 patients), and verification of the position of the intravascular device (1 patient). Thus, transesophageal echocardiography may provide clinically useful information regarding both the underlying cardiac disease and potential complications from the mechanical circulatory assistance.

Adult↗
PubMed1991

Mechanical circulatory assistance after heart transplantation.

From October 1985 through December 1989, 92 heart transplant procedures were performed in 89 patients. Nine patients (aged 19 to 66 years; 7 male, 2 female) required mechanical circulatory support after transplantation because of primary idiopathic organ failure (n = 2), implant difficulty (2), poor organ quality (2), or acute right heart failure (3). Devices used included the intraaortic balloon pump (6), centrifugal right ventricular assist device (2), left ventricular assist (1), biventricular assists (2), and total artificial heart (1). Two patients required multiple devices. One patient underwent retransplantation. Implant time ranged from 1 to 18 days. One early death occurred owing to right heart failure 6 days after transplantation, 7 hours after removal of a right ventricular assist device, for an overall mortality of 11%. The remaining 8 patients are alive 4 months to 28 months after transplantation. The actuarial 1-year survival of 89% +/- 10% compares well with the survival of 87% +/- 4% for the entire transplant group. All surviving patients are in functional class I. Echocardiographic examination in all patients revealed left ventricular ejection fraction to be normal in 7 and depressed in 1. Extending the criteria for organ donors or difficulty with the implant procedure can lead to early organ failure, which may be reversible with circulatory assistance allowing excellent survival.

Adult↗
PubMed1991

Directions in cardiac assistance.

The use of mechanical circulatory support devices came to prominence with the use of the Jarvik 7 total artificial heart, both as a permanent implant and as a bridge to transplantation. Over the past decade, however, interest in the use of left ventricular assist devices has overshadowed that of the total artificial heart and great strides have been made, both in the use of such devices as temporary support, and towards the ultimate goal of permanent implantation. A variety of devices are available to support either or both ventricles with a great range of complexity and expense. This test discusses the use of ventricular assist devices and briefly describes the options available. The era is rapidly approaching when the use of implantable circulatory support devices will become commonplace and may outpace, and possibly outperform, the results currently obtained with cardiac transplantation.

Cardiac Output, Low↗
PubMed1991

Treatment of end-stage chronic obstructive pulmonary disease with double lung transplantation.

Six patients with end-stage emphysema (age 44 +/- 2 years) underwent double lung transplantation (Tx) from June 1988 through May 1990. All suffered from severe inanition and required oxygen therapy. The ischemic time was 193 +/- 28 minutes. Post-Tx immune suppression was OKT3 (14 days), cyclosporine (trough levels of 150 +/- 25 ng/ml), azathioprine to keep WBC at 3,000 to 5,000/cu mm (1 to 3.0 mg/kg/day) and following OKT3, a tapering prednisone regimen. Two rejection episodes that occurred in two patients on post-Tx day 5 and 10 were treated with bolus doses of methylprednisolone. The mean hospital stay was 32 +/- 7 days (range, 20 to 69 days). Four patients required treatment of cytomegalovirus (CMV) infection: gastritis (+donor, +recipient) in one and CMV pneumonia in two (+donor, -recipient). A fourth (+donor, -recipient) had right-sided Candida empyema six weeks post-Tx, developed CMV and staphylococcal sepsis, and died 64 days post-Tx. One patient required pyloroplasty eight weeks post-Tx and one patient underwent tracheal suture line repair at eight weeks. During a follow-up of 81 patients months (range, 8 to 24 months), one patient had developed Epstein-Barr viral (EBV) induced lymphoproliferative disease in the lung and one patient had developed EBV lymphoma. Three patients are at work, one is continuing rehabilitation, and one is at home. Double lung Tx offers a definitive benefit to patients with emphysema; however, a prolonged postoperative course can be expected. Viral infections remain serious but treatable problems.

Adult↗
PubMed1991

Emergency cardiopulmonary bypass support in patients with cardiac arrest.

Emergency percutaneous cardiopulmonary bypass support was instituted in 11 patients in cardiac arrest refractory to conventional resuscitation measures. Emergency percutaneous cardiopulmonary bypass support was used in five patients in whom cardiac arrest occurred as a result of a complication in the cardiac catheterization laboratory (group 1) and in six other patients in cardiac arrest (group II). A 21F cannula and a 17F cannula were percutaneously inserted into the femoral vein and artery. Flow rates of 3 to 5 L/min were achieved with restoration of mean arterial pressure to 70 mm Hg (range 50 to 75). The status of all 11 patients was improved initially both clinically and hemodynamically with percutaneous cardiopulmonary bypass. Of the group II patients, three had anatomy unsuitable for percutaneous transluminal coronary angioplasty or coronary bypass grafting, could not be weaned from cardiopulmonary support, and died; three of these patients had coronary artery bypass grafting and two survived. All five group I patients underwent successful coronary bypass grafting and survived. Of the seven patients with anatomically correctable disease, all seven were discharged from the hospital. With conventional management nearly all seven of these patients would have died. Nine of 11 patients underwent a cardiac operation and seven of the nine survived. The operative mortality rate was 22% and the overall survival rate was 64%. At follow-up (mean 7 months), all seven patients are alive and six have resumed a normal and active life-style. In conclusion, emergency percutaneous cardiopulmonary bypass support is a powerful resuscitative tool that may stabilize the condition of patients in cardiogenic shock and cardiac arrest to allow for definitive intervention.

Cardiac Catheterization↗
PubMed1990

Use of the pericardial fat pad in pulmonary transplantation.

Historically, the healing of tracheal or bronchial anastomoses has been the Achilles heel in pulmonary transplantation. In the past, steps taken to enhance healing of these structures and have allowed single-lung, double-lung, and heart-lung transplantation to be accomplished safely. This report presents a simplified technique for protection of the tracheal anastomosis in heart-lung and double-lung transplantation. This technique, wherein the pericardial fat pad from the right side is utilized to wrap the tracheal anastomosis, not only allows for excellent healing of the anastomosis but separates the aorta from the trachea. In 19 patients having heart-lung (N = 13) or double-lung (N = 6) transplantation there were no tracheal healing problems, dehiscence or stenosis found.

Adipose Tissue↗
PubMed1989

Gastrointestinal complications after human transplantation and mechanical heart replacement.

One hundred fifty-three patients underwent 159 heart transplants; 7 of these patients received 8 artificial hearts used as a bridge before implantation. The 1-year survival rate was 81 percent. One hundred forty gastrointestinal complications developed in 70 patients. Thirty-eight operations were required. Twenty-nine were intraabdominal operations. Of these, 22 were elective and 7 were emergency procedures. Five of the seven patients who underwent emergency procedures died, for an overall total mortality rate of 17 percent for major intraabdominal interventions. There were no complications or deaths in patients who underwent elective procedures. Major elective intraabdominal surgical interventions can be safely carried out in heart transplant patients. Repeated physical examination, aggressive use of endoscopy and imaging techniques, sound surgical judgement and a mutual relationship of trust and respect between cardiac and general surgeons are keys to a successful outcome.

Emergencies↗
PubMed1989

Ten years' experience with the St. Jude Medical valve prosthesis.

Records of 1,298 consecutive patients who had received the St. Jude Medical prosthesis were reviewed (713 male and 585 female patients; mean age, 61.79 +/- 13.4 years). Early mortality was 5.7% (74 patients). Ninety-three percent complete follow-up was accomplished for the 1,224 patients who left the hospital (4,306.50 patient-years). One hundred ninety-two of these patients died, a late mortality of 16.9%. Sixty-four patients experienced thromboembolic episodes (17 major and 35 permanent). Twenty-four patients had anticoagulant-related bleeding, 4 had valve thrombosis, 7 had prosthetic valve endocarditis, 9 had paravalvular leak, and 10 underwent reoperation. There was no structural valve failure in this series. Twenty-two of the 118 patients who had valve-related complications died; another 15 patients died of sudden and unknown causes. Therefore, the total number of valve-related deaths was 37. Of those patients who survived, New York Heart Association functional class improved significantly (98% in classes II and III preoperatively and 96% in classes I and II postoperatively). Linearized rates for thromboembolism, valve thrombosis, and anticoagulant-related bleeding were 1.49% +/- 0.19%, 0.09% +/- 0.05%, and 0.56% +/- 0.11%/100 patient-years, respectively. The actuarial estimate of incidence free from all complications, operative death, and valve-related death was 66.9% +/- 8.2% at the end of 9 years. In spite of old age and advanced heart disease, the patients who received the St. Jude Medical prosthesis had very good results over a 10-year period.

Actuarial Analysis↗
PubMed1989

Cranial arteritis mimicking odontogenic pain: report of case.

A 65-year-old patient treated for pain of apparent odontogenic origin did not respond to appropriate dental treatment. While the signs and symptoms mimicked a dental problem, further diagnostic evaluation determined the "culprit"--cranial arteritis. Proper treatment immediately after diagnosis is advised as the complications of cranial arteritis can include the rapid onset of blindness.

Aged↗
PubMed1989

Ten-year follow-up study of patients who had double valve replacement with the St. Jude Medical prosthesis.

Records of 100 consecutive patients who had received double valve replacement were reviewed (41 men, 59 women, mean age, 60.86 +/- 13.0 years). The early death rate was 6% (six patients). A completed follow-up rate of 93% was accomplished in these 94 patients who left the hospital (mean, 309.8 patient-years). Twenty-three of these patients died. The late death rate was 26.4%. Four patients experienced thromboembolic episodes (one transient and three permanent; all were minor). One patient had a paravalvular leak (mitral), and another had thrombosis of the tricuspid valve. There was no clinical evidence of hemolysis, infective endocarditis, or structural failure or anticoagulant-related bleeding. One of those 23 patients who died was the patient who had thrombosis of the tricuspid valve. Another three patients died of sudden and unknown causes, 15 of cardiac-related problems and four of noncardiac problems. Of those patients who survived, New York Heart Association functional class improved significantly (from 66% class III before to 85% class I after). Linearized rates for thromboembolism and thrombosis were 1.29 +/- 0.65 and 0.32 +/- 0.32 per 100 patient-years, respectively. The actuarial estimates of incidence free of all complications and valve-related deaths were 77.9% +/- 10.6%. Despite the advanced heart disease involving two native valves, the patients who had double valve replacement with the St. Jude Medical prosthesis had very good results over a 10-year period.

Actuarial Analysis↗
PubMed1989

Mechanical circulatory support as a bridge to transplantation.

From December 1985 through April 1988, 11 patients (three female and eight males), 33.1 +/- 3.9 (+/- SEM) years of age (range, 15 to 50 years), underwent heart transplantation preceded by the use of mechanical circulatory support. The causes of cardiac failure were ischemic (four), viral cardiomyopathy (three), idiopathic cardiomyopathy (two), congenital heart disease (one), and valvular heart disease (one). All patients were preterminal. Mechanical circulatory support consisted of intra-aortic balloon pump (eight), the total artificial heart (seven), biventricular assist (three), and left ventricular assist (two). Seven patients had more than one form of support. The duration of mechanical circulatory support was 12.2 +/- 4.1 days (range, 1 to 44 days). Once listed for transplantation, patients waited for 8.1 +/- 2.4 days for a donor. Seven patients received OKT3 monoclonal antibody as prophylaxis, in addition to triple-drug immunosuppression. There were four rejection episodes and 12 serious infections. In addition, eight patients suffered a major posttransplant complication of a distant organ system: central nervous system (three), renal (two), and respiratory (three). Post transplant hospitalization was 48 +/- 22 days (range, 15 to 248 days). Two patients (18%) died after transplant, one of severe acute rejection (29 days) and one of multisystem failure (248 days). All patients surviving transplant hospitalization are alive 6 to 34 months after the transplant procedure. Eight patients are in functional class I and 1 patient class II. This patient attends school full-time but has a premechanical support system neurologic defect. In follow-up of 163 patient-months except for yearly catheterization, these nine patients required only 5 hospital days. Although the use of the mechanical circulatory support as a bridge to transplantation can result in a prolonged, complicated hospitalization after transplant, the long-term results are gratifying.

Adolescent↗
PubMed1988

Value of urinary polyamines as noninvasive markers of cardiac allograft rejection in the dog.

A noninvasive marker of cardiac allograft rejection would be useful clinically. Lymphocyte proliferation and organ rejection may cause changes in urinary polyamine excretion. To test this hypothesis, cervical heterotopic heart transplantations were performed in a group of 6 nonimmunosuppressed dogs and in a group of 9 dogs treated with cyclosporine (N = 3) or cyclosporine and steroids (N = 6). A group (N = 3) having a sham operation was also studied. Serial biopsies of the transplanted hearts were performed. Urinary polyamine levels were measured daily by high-pressure liquid chromatography of urine specimens. Between 2 and 4 days after transplantation, the transplanted hearts of all animals without immunosuppression demonstrated histological rejection. An early increase in putrescine levels and in total urinary polyamine levels was observed in this group. In the treated groups, histological rejection appeared from the second to the eighth day after transplantation. Each episode of rejection occurred from 1 day to 4 days after a significant increase in urinary polyamine levels compared with the preoperative baseline level (p less than 0.01). In contrast, polyamine excretion in 3 dogs after sham operations remained unchanged. Thus, urinary excretion of polyamines increases before the appearance of histological rejection; this suggests that changes in urinary polyamine levels may be a useful marker of cardiac allograft rejection.

Animals↗