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Biomedical subjects

T L Spray

Publications and source records attributed to T L Spray.

156 records · Page 9Linked to original sources
PubMed1976

Tension on coronary bypass conduits. A neglected cause of real or potential obstruction of saphenous vein grafts.

Of 41 saphenous vein aorta-coronary bypass grafts from 21 patients, abnormal graft tension was judged to be present at necropsy in 6 grafts (15 per cent) from 5 patients (24 per cent). Five (33 per cent) of 15 grafts placed to the right coronary system and one (3 per cent) of 26 grafts to the left coronary system were under excess tension. The abnormal tension appeared to result from the insertion of grafts too short to accommodate normal or abnormal distention of the right atrium and ventricle (graft to distal right coronary or posterior descending coronary artery) or of the pulmonary trunk (graft to left coronary system) after discontinuation of cardiopulmonary bypass or development of acute congestive cardiac failure.

Cardiopulmonary Bypass↗
PubMed1976

Histologic changes in saphenous vein aorta-coronary bypass grafts. The effect of the angle of the aortic anastomosis.

Thirteen dogs were subjected to bypass grafting from the aorta to the left circumflex coronary artery with the saphenous vein to determine whether the angle of insertion of the saphenous vein into the aorta influences the functional and histologic fate of the grafts. The angle of the aortic anastomosis was obtuse in 6 dogs, acute in 5, and perpendicular in 2. Histologic examination of all 13 grafts 6 to 19 months (mean 9.4) postoperatively showed fibrous intimal proliferative lesions of variable severity along the entire length of the grafts, occasionally with extension into the native coronary arteries. Loss of medical smooth muscle and adventitial fibrosis also occurred in all 13 grafts. The extent and severity of these changes, however, were not related to the angle aortic anastomosis.

Animals↗
PubMedDate not supplied

The incidence of arrhythmias in a pediatric cardiac intensive care unit.

A pediatric cardiac intensive care unit (CICU) manages critically ill children and adults with congenital or acquired heart disease. These patients are at increased risk for arrhythmias. The purpose of this study was to prospectively evaluate the incidence of arrhythmias in a pediatric CICU patient population. All patients admitted to the CICU at the Cardiac Center at The Children's Hospital of Philadelphia between December 1, 1997, and November 30, 1998, were evaluated prospectively from CICU admission to hospital discharge via full disclosure telemetry reviewed every 24 hours. Arrhythmias reviewed included nonsustained and sustained ventricular tachycardia (VT), nonsustained and sustained supraventricular tachycardia (SVT), atrial flutter and fibrillation, junctional ectopic tachycardia, and complete heart block. We reviewed 789 admissions consisting of 629 patients (age range, 1 day-45.5 years; median, 8.1 months). Hospital stay ranged from 1 to 155 days (total of 8116 patient days). Surgical interventions (n = 602) included 482 utilizing cardiopulmonary bypass. During the study period, there were 44 deaths [44/629 patients (7.0%)], none of which were directly attributable to a primary arrhythmia. The operative mortality was 5.1%. Overall, 29.0% of admissions had one or more arrhythmias the most common arrhythmia was nonsustained VT (18.0% of admissions), followed by nonsustained SVT (12.9% of admissions). Patients admitted to a pediatric CICU have a high incidence of arrhythmias, most likely associated with their underlying pathophysiology and to the breadth of medical and surgical interventions conducted.

Adolescent↗
PubMedDate not supplied

Patterns of right aortic arch and mirror-image branching of the brachiocephalic vessels without associated anomalies.

It is unusual to have a right aortic arch with mirror-image branching of the brachiocephalic vessels and no associated congenital cardiac anomalies. Pathogenetic factors of this anomaly, and associated development of the derivatives of the pharyngeal arches, have not been explored extensively. Eleven patients with a mirror-image right aortic arch and no intracardiac anomalies have undergone evaluation at our institution since 1987. Of these, 4 had stenosis (n = 2) or atresia (n = 2) of the proximal left pulmonary artery. These included 2 with bilateral ductus arteriosus. Six patients had a vascular ring formed by a ductus arteriosus or ligamentum arteriosum from the descending aorta to the left pulmonary artery. Six patients were evaluated for deletion within the DiGeorge critical region of chromosome 22q11. All 6 of the patients with a vascular ring underwent division of the ductus arteriosus or ligamentum through a left lateral thoracotomy. None of the patients with stenosis or atresia of the LPA have undergone intervention. Two of the 6 patients who underwent evaluation for chromosome 22q11 deletion were found to have the deletion. At a median follow-up of 7 years (15 months to 12 years), the patients who underwent division of the ring are all alive and asymptomatic. Two of these patients have undergone repeat magnetic resonance imaging, 1 of whom had mild residual tracheal compression. A right aortic arch with mirror-image branching of the brachiocephalic vessels and no associated intracardiac anomalies is extremely uncommon. We have observed two basic patterns of this lesion: (1) with associated abnormalities of the proximal left pulmonary artery, (2) with a vascular ring formed by a ductus arteriosus or ligamentum from the descending aorta to the left pulmonary artery. Pathogenetic considerations are explored, with a focus on flow-related vascular development and the role of deletions within chromosome 22q11.

Abnormalities, Multiple↗
PubMedDate not supplied

Accessory mitral valve tissue: an increasingly recognized cause of left ventricular outflow tract obstruction.

Subvalvar left ventricular outflow tract obstruction (LVOTO) may be secondary to congenital abnormalities of the mitral valve, including abnormal attachments of the anterior leaflet of the mitral valve, parachute mitral valve, and accessory valve tissue. Successful correction of LVOTO due to accessory mitral valve tissue is reported in a 44-year-old man. Twenty-five patients with LVOTO due to accessory mitral valve tissue have been previously reported; however, only a few have been recognized preoperatively. A high index of suspicion is necessary for preoperative and intra-operative recognition and correction of the abnormality.

Adult↗
PubMedDate not supplied

Heart transplantation in patients requiring preoperative mechanical support.

Since January 1985, the members of the Heart Transplant Program at Washington University Medical Center, St. Louis, have performed 53 transplants in 50 patients. Thirteen patients have required preoperative mechanical support. These patients ranged in age from 32 to 58 years, with a mean of 47 years. Seven patients had undergone a total of 12 prior cardiac surgical procedures. Preoperative diagnosis was coronary artery disease in nine patients, cardiomyopathy in three, and valvular heart disease in one. Two patients had mechanical ventilatory support before operation. Five patients required preoperative intraaortic balloon counterpulsation (IABP). Five patients required left ventricular assistance with the Bio-Medicus centrifugal pump (Bio-Medicus Inc., Eden Prairie, Minnesota). Two of these patients had the left ventricular assist device (LVAD) inserted at the end of a failed cardiac procedure. One patient required the extracorporeal membrane oxygenator (ECMO) for right ventricular decompensation and cardiac arrest 4 hours after a seemingly successful orthotopic transplantation. Twelve of the 13 patients (92%) who required mechanical assistance of circulation and/or respiration before operation underwent a successful transplant. One patient who had IABP support perioperatively did not survive surgery. All patients who had a bridge to transplantation with the LVAD and the one patient with a bridge to transplant with ECMO are long-term survivors of transplantation. There has been one late death from cardiac causes in a patient who had IABP support before operation; the death was presumed to be from acute rejection, though this could not be documented at autopsy. Actuarial survival in this group is 82% at 12 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMedDate not supplied

Use of aprotinin in pediatric lung transplantation.

BACKGROUND: Aprotinin has been shown to decrease perioperative bleeding in adults undergoing cardiac surgery. We evaluated its efficacy in reducing blood loss in pediatric lung transplantation. METHODS: Aprotinin was given to a group of pediatric lung transplant recipients (n = 24) identified as being at high risk for bleeding by virtue of preoperative diagnosis of cystic fibrosis or previous cardiothoracic operation (group 1). Comparison was made to a group of pediatric recipients (n = 19) believed to be at low risk for bleeding who did not receive aprotinin (group 2). All transplantations were accomplished with the use of cardiopulmonary bypass. RESULTS: No difference in intraoperative blood requirement was identified between groups (18 +/- 3 cc/kg [group 1] versus 30 +/- 8 cc/kg [group 2], p = 0.16). Neither postoperative blood transfusion requirement (12 +/- 5 cc/kg [group 1] versus 16 +/- 6 cc/kg [group 2], p = 0.55) nor chest tube output in the first 24 postoperative hours (43 +/- 9 cc/kg [group 1] versus 53 +/- 13 cc/kg [group 2], p = 0.55) was significantly different between groups. Reexploration for bleeding was required in 8% (2 of 25) in group 1 and 16% (3 of 19) in group 2 (p = 0.64). CONCLUSIONS: Aprotinin reduced the amount of perioperative hemorrhage in a group of pediatric patients at high risk for bleeding after lung transplantation. The magnitude of the effect could not be quantified but was sufficient to normalize the transfusion requirement to that of a low risk group of patients.

Aprotinin↗
PubMedDate not supplied

Steroid withdrawal in the pediatric heart transplant recipient initially treated with triple immunosuppression.

We prospectively evaluated the feasibility of withdrawing steroids 6 to 12 months after heart transplantation in 26 consecutive infants and children (median age at transplantation 6 weeks; range 5 days to 10.1 years) initially treated with triple immunosuppression (cyclosporine, azathioprine, and corticosteroids). Ongoing surveillance for cellular rejection was performed by endomyocardial biopsy in all patients and was performed electively in all subjects within 2 weeks after administration of steroids was discontinued. Significant rejection was defined as grade 2. Twenty-three of 26 patients were 6-month survivors and steroids were withdrawn in 21, with the other two survivors followed up elsewhere with triple immunosuppression. Seventeen (81%) of 21 patients were ultimately treated without maintenance steroids for a mean duration of 17 months (range 1 to 34 months), including 6 of 17 patients who had at least one episode of rejection within the first 6 months of transplantation. Five (24%) of 21 patients had rejection 2 weeks (n = 3) and 6 months (n = 2) after steroids were withdrawn, with one patient successfully withdrawn from steroids after a second attempt. In this latter group one patient underwent retransplantation because of severe coronary arteriopathy by angiography 10 months after transplantation and another died suddenly 18 months after transplantation despite resumption of steroids.(ABSTRACT TRUNCATED AT 250 WORDS)

Azathioprine↗
PubMedDate not supplied

Projections for pediatric heart-lung and lung transplantation.

There is limited international experience in heart-lung or lung transplantation in children less than 16 years of age. Although the indications for lung transplantation are quite different in children compared with adults, the indications for heart-lung versus lung transplantation in children are quite similar. These indications consist of end-stage pulmonary disease, such as cystic fibrosis, or end-stage pulmonary vascular disease that is either primary or associated with correctable or corrected congenital heart disease. The results reported in the international registries show little difference in early and intermediate survival between children who underwent transplantation by the heart-lung or the lung techniques. Actuarial survival at 1 year is approximately 70%, with a survival at 2 years of 40% to 50%. These results are probably slightly inferior to the results in adults, even if differences in indications for transplantation are taken into account. Children may be more susceptible to rejection, infection, and viral challenges, the consequences of which may be more significant in pediatric lung transplantation than in pediatric heart transplantation. In addition, lymphoproliferative diseases are more common in children and may be harder to control by decreasing immunosuppressive therapy than in adults. In spite of these caveats, surviving children often have good functional results and a markedly improved quality of life after heart-lung and lung transplantation unless or until severe chronic rejection and obliterative bronchiolitis occur.(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMedDate not supplied

Utility of surveillance biopsies in infant heart transplant recipients.

BACKGROUND: Endomyocardial biopsy remains the primary means of rejection surveillance after orthotopic heart transplantation in adults. Perpetual surveillance endomyocardial biopsy has been questioned, however, because of low yield beyond the early posttransplantation period. This issue has not been adequately studied in the pediatric population. The objectives of this study were to define the rate of rejection in infants undergoing orthotopic heart transplantation, correlate rejection with signs and symptoms, and evaluate the utility of surveillance endomyocardial biopsy. METHODS: Records of all patients 24 months of age or younger undergoing orthotopic heart transplantation were reviewed; 38 patients underwent 42 transplantation; 256 endomyocardial biopsies were performed for surveillance, cardiac symptoms, noncardiac symptoms, or lowered immunosuppression. RESULTS: There were 22 rejection episodes International Society for Heart and Lung transplantation grade 1B or higher, half of which occurred in neonates 30 days of age or younger. Linearized rejection rates and actuarial freedom from rejection were not different between neonates and older infants. Linearized rejection rates reached a plateau 3 months after orthotopic heart transplantation of 0.07 episodes/100 patient days. No positive surveillance endomyocardial biopsies were obtained beyond 6 months after orthotopic heart transplantation. The probability of a positive biopsy (International Society for Heart and Lung Transplantation grade 1B or higher) was 20% or more for any other indication (odds ratios for rejection were 12.9 for cardiac symptoms, 3.3 for noncardiac symptoms, and 10.8 for lowered immunosuppression as determined by logistic regression more than 6 months after orthotopic heart transplantation). CONCLUSIONS: Rejection rates are not different between neonatal and older infants, and endomyocardial biopsies done solely for surveillance beyond 6 months after orthotopic heart transplantation rarely yield positive results.

Actuarial Analysis↗