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Biomedical subjects

R W Emery

Publications and source records attributed to R W Emery.

At least 55 records · Page 3Linked 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↗
PubMed1994

Practices of cardiothoracic transplant centers regarding hepatitis C-seropositive candidates and donors.

The purpose of this survey was to determine current practices of cardiothoracic transplant centers regarding transplantation of hearts and lungs into hepatitis C (HCV)-seropositive candidates and the use of organs from HCV-seropositive donors. A telephone survey of 48 cardiothoracic transplant centers was conducted in October 1992. Questions included the center's policy for listing HCV-seropositive candidates; if, and under what conditions, organs from HCV-seropositive donors would be used; and which HCV assays were used. Forty-five programs responded; 75% will list an HCV-seropositive candidate, either directly or by lack of routine screening to exclude such patients; only 16% will not accept HCV-seropositive candidates; 9% had no policy. Overall, 69% will accept organs from HCV-seropositive donors, at least for selected recipients (22% for any recipient, 45% for HCV-seropositive and/or status I recipients; 2% do not screen donors). A total of 27% will never accept organs from an HCV-seropositive donor, and 4% had no policy. Thirty centers provided information on HCV methodology. All but one use a second generation ELISA or EIA as a first-line test. A positive result will be followed by a confirmatory assay/liver biopsy in 42%. The variation in practices reflects the ambiguity in the literature. Adequate evaluation of morbidity and mortality due to HCV infection in this population has not yet been possible, although currently available reports do not show a substantial increase. Prospective controlled trials in cardiothoracic transplant patients are necessary.

Data Collection↗
PubMed1994

Decreased postoperative drainage with addition of epsilon-aminocaproic acid before cardiopulmonary bypass.

Desmopressin (DDAVP, 0.3 microgram/kg) has been used routinely after cardiopulmonary bypass, particularly in patients having antiplatelet therapy. Recently epsilon-aminocaproic acid (single dose of 5 g) given before cardiopulmonary bypass has been added to the protocol. One hundred consecutive patients taking desmopressin and epsilon-aminocaproic acid (group A) and another 100 taking desmopressin alone (group B) were analyzed. There was no difference among these two groups in patient age, sex, preoperative history of bleeding and drug consumption, or number of patients for elective, urgent, emergent, redo, and reoperation for bleeding. Results of routine preoperative coagulation studies were within normal limits in both groups. Preoperative hemoglobin level was 13.5 g/dL in group A and 13.8 g/dL in group B (p = 0.12). Estimated blood loss in the operating room was 513 mL for group A and 587 mL for group B (p = 0.07). The total chest drainage at the end of 24 hours was 492 mL in group A and 746 mL in group B (p = 0.0001). Amicar given before cardiopulmonary bypass does not lessen operating room blood loss, but significantly decreases postoperative chest drainage. Group B patients received more fresh frozen plasma (60 U versus 4 U), more platelets (130 U versus 16 U), and more cryoprecipitate (118 U versus 10 U) than group A patients. Adding epsilon-aminocaproic acid could save $206.18 in blood product use per patient, compared with the expense of $24.12 per patient for E-aminocaproic acid administration.

Aminocaproic Acid↗
PubMed1994

Operative considerations in implantation of the Perma-Flow graft.

The Perma-Flow coronary bypass graft (Possis Medical, Inc, Minneapolis, MN) currently is undergoing expanded clinical trial. From November 1992 through June 1994 we have used this artificial conduit in 8 patients without autologous alternatives. These cases allowed the establishment of a technical basis for successful implantation of this graft. All studied coronary anastomoses are patent.

Aorta↗
PubMed1994

Long-term clinical outcome with small size Standard St Jude Medical valves implanted in the aortic position.

Records of 144 patients who received size 19 or 21 mm (Group A) aortic Standard St. Jude Medical (SSJM) prostheses were retrospectively reviewed and compared to 219 patients who received size 25 mm SSJM valves (Group B). Group A patients were older (70 +/- 9 years vs. 62 +/- 13 years) and had smaller body surface area (BSA) (1.65 m2 vs. 1.9 m2 p < 0.05). Operative mortality (5% vs. 2%) and postoperative unadjusted Doppler mean gradient (31 mmHg vs. 22 mmHg) were higher in Group A (p < 0.05). Total follow up was 1255 patient-years (450.6 Group A/804.4 Group B). There were no perivalvular leaks, valve thrombosis, or endocarditis in either group. Freedom from thromboembolism and anticoagulant-related hemorrhage was 89% and 95% in Group A and 93% and 98% in Group B, respectively. The major causes of late death were older age and progressive cardiac disease. The five-year actuarial analysis revealed a survival rate of 74% in Group A and 83% in Group B (p < 0.05). Of those who were alive, more than 70% were in functional class I and II. These patients not only enjoy a complication-free living but are able to perform daily routine activity despite being older. 19 mm and 21 mm SSJM aortic valve prostheses had higher transprosthetic gradient, but provided satisfactory performance in adult patients with a BSA of less than 1.7 m2. This valve can be used in the small aortic annulus with a valve size index of at least 12 mm/m2 as an alternative to an annular enlargement procedure.

Aged↗
PubMed1993

First clinical use of the Possis synthetic coronary graft.

The Possis polytetrafluoroethylene Permaflow coronary graft incorporates a Venturi resistor within the graft. Insertion is constructed by creating an anastomosis to the superior vena cava with subsequent anastomoses in sequence to coronary arteries requiring grafting. Finally, the graft is sewn to the aorta. The Venturi resistor controls flow through the aortocaval fistula, maintaining systemic pressure proximal, permitting systolic and diastolic flow to the grafted coronary arteries while maintaining constant flow through the graft. Animal studies demonstrated long-term patency. This graft was implanted in a patient with unstable angina pectoris and inadequate native conduit. Catheterization 6 weeks postoperative revealed patency of all anastomoses.

Aged↗
PubMed1993

Results with retrograde delivery of cardioplegia for myocardial protection during cardiac surgery.

From November 19, 1990 through November 18, 1991 242 consecutive patients underwent cardioplegic arrest using retrograde delivery of crystalloid cardioplegia via blind transatrial cannulation of the coronary sinus. Of these procedures 196 (81%) were coronary artery bypass procedures. The overall operative mortality was 0.4%. Ten patients (3%) had enzyme and/or ECG criteria for myocardial damage in the peri-operative period and there was one deep sternal wound infection (0.4%). Two patients required VAD assistance post-operative, one following Protamine reaction (LVAD) and one following RV infarction and failed PTCA (RVAD). Both survived. Ninety-seven patients (40%) developed supraventricular arrhythmias and 20% required temporary pacing post-op for less than 6 hours. These results indicate the safety and effectiveness of retrograde delivery of intermittent crystalloid cardioplegia solution in general cardiac surgery.

Adult↗
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↗