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Biomedical subjects

V L Willman

Publications and source records attributed to V L Willman.

At least 37 records · Page 2Linked to original sources
PubMed1990

Aortic valve decalcification.

Ultrasonic decalcification of the aortic valve was performed in 22 elderly patients with critical aortic stenosis (aortic valve areas less than 0.8 cm2) as an alternative to prosthetic valve replacement. All of the patients had symptoms. The mean New York Heart Association class was 3.3 +/- 0.9. Adequate decalcification with restoration of leaflet mobility was achieved in all patients, including seven with bicuspid aortic valves. Leaflet perforation occurred and was successfully repaired in five patients. Ten patients underwent concomitant myocardial revascularization. There were two operative deaths (9%) and three late deaths. Echocardiograms were obtained preoperatively, postoperatively, and at 6 months. The mean aortic valve area increased significantly from 0.72 +/- 0.17 to 1.42 +/- 0.31 cm2 (p less than 0.001) and the peak gradient decreased from 74 +/- 34 to 25 +/- 13 mm Hg (p less than 0.001). At 6 months the aortic valve area (1.29 +/- 0.48 cm2) and peak gradient (31 +/- 12 mm Hg) continued to be significantly better than the preoperative measurements (p less than 0.001), but the 6-month aortic valve area was slightly decreased and the gradient increased when compared with the immediate postoperative values (p less than 0.02). The prevalence of mild to moderate aortic insufficiency increased from 50% of the patients preoperatively to 87% at 6 months (p less than 0.05). Two patients subsequently required aortic valve replacement for restenosis and aortic insufficiency. Ultrasonic decalcification is effective in relieving aortic stenosis, but subsequent restenosis and insufficiency may limit its application.

Aged↗
PubMed1989

Exercise capacity during the first year after cardiac transplantation.

Few data are available examining the influence of perioperative clinical parameters on exercise capacity after cardiac transplantation. Accordingly, 40 patients were studied by metabolic exercise testing early (1 to 3 months) and late (6 to 12 months) after cardiac transplantation. Various clinical parameters, including congestive heart failure class, length of hospital stay, age, cold ischemic time and histologic evidence of rejection were correlated with exercise capacity after transplantation. As expected, peak exercise capacity correlated inversely with both age and length of hospital stay. There was no correlation with preoperative congestive heart failure class or heart rate at rest. Interestingly, there was a statistically significant correlation between cold ischemic time and exercise capacity after transplantation. In addition, increased episodes of rejection during the first 6 months after transplantation resulted in statistically lower exercise capacity at 6 to 12 months after the operation. Thus, ischemic damage during transport of the donor organs and subclinical damage during early rejection may affect clinical status after heart transplantation and may only be apparent during increased physical demand such as exercise.

Adult↗
PubMed1989

Emergency coronary artery bypass grafting for failed angioplasty: risk factors and outcome.

It has been suggested that coronary artery bypass grafting (CABG) performed in the setting of emergent failure of percutaneous transluminal coronary angioplasty causes minimal increased risk compared with routine CABG. We reviewed the records of 103 patients undergoing emergency CABG for failed percutaneous transluminal coronary angioplasty (group 1) and compared them with an identical number of consecutive CABG patients from 1987 (group 2). Group 1 had a lower risk profile evidenced by lower mean age (p less than 0.01), fewer diseased vessels (p less than 0.0001), better ventricular function (p less than 0.001), fewer left main lesions (p less than 0.0001), and fewer patients with acute ischemia requiring intravenous administration of nitroglycerin (p less than 0.01). Despite these differences, the group 1 patients had a higher mortality rate (11% versus 1%; p less than 0.01) and a higher rate of perioperative infarctions (new Q wave) (22% versus 6%; p less than 0.01). An analysis of risk factors was performed in the group 1 patients using 36 preoperative and operative variables. Multivariate analysis revealed that left ventricular score (p less than 0.0001), preoperative (after percutaneous transluminal coronary angioplasty) need for inotropic support (p less than 0.005), and age (p less than 0.025) were independent predictors of operative mortality. In conclusion, emergency CABG after failed percutaneous transluminal coronary angioplasty carries a significantly greater risk of operative death and perioperative infarction than elective CABG.

Angioplasty, Balloon↗
PubMed1989

Coronary sinus versus aortic root perfusion with blood cardioplegia in elective myocardial revascularization.

The role of retrograde coronary sinus cardioplegia in patients undergoing elective coronary artery bypass grafting has not been fully defined. Forty patients undergoing coronary artery bypass grafting received either aortic root (20 patients) or coronary sinus (20 patients) cold potassium blood cardioplegia. The patients were similar with respect to age, ventricular function, severity of coronary artery disease, cross-clamp time, completeness of revascularization, frequency of internal mammary artery grafting, and mean infusate volume and temperature. The time required to deliver the initial dose of cardioplegic solution and the time to achieve arrest were prolonged in the coronary sinus group (p less than 0.001 and p less than 0.02, respectively). There were no differences between the two groups postoperatively with regard to enzymatic indices, hemodynamic measurement, or clinical outcome. Right ventricular function was preserved equally in both groups. We conclude that coronary sinus cardioplegia is a safe alternative to aortic root perfusion, but offers no advantage in elective myocardial revascularization.

Aged↗
PubMed1989

Valve replacement in the octogenarian.

Twenty-five patients (11 men and 14 women) aged 80 to 88 years (mean age, 82 years) underwent valve replacement at St. Louis University from August 1980 to June 1988. Isolated valve replacement was performed in 11 patients. Combined procedures included valve replacement with myocardial revascularization (7 patients), multiple valve procedures (5 patients), and ascending aortic plication (2 patients). Fifteen patients (60%) were in New York Heart Association functional class III and 10 (40%) were in class IV preoperatively. The operative mortality was 20% and late mortality was 20% (mean follow-up, 36 months). Isolated valve replacement carried a 9% early and 0% late mortality, whereas combined procedures of any type had a 16% early and 20% late mortality. Only 7 patients (28%) had a completely uncomplicated postoperative hospitalization. Twenty patients were discharged after a mean hospital stay of 18 +/- 16 days. Their mean New York Heart Association functional class was 1.6 +/- 0.66. The 1-year and 2-year actuarial survival rate is 79% and 69%, respectively. A significant increase in operative mortality is seen when valve replacement is combined with myocardial revascularization or an additional valve procedure. Late clinical improvement, as judged by return to an independent life-style, justifies this approach for select patients.

Actuarial Analysis↗
PubMed1989

Use of the Pierce-Donachy ventricular assist device in patients with cardiogenic shock after cardiac operations.

In spite of recent improvements in cardiac surgery, a small percentage of patients have severe postcardiotomy ventricular failure refractory to drugs and the intraaortic balloon. In our experience, the Pierce-Donachy external pneumatic ventricular assist device has proved to be one of the most effective devices for these patients. Since 1981, 30 patients aged 15 to 71 years (mean age, 52 years) with profound cardiogenic shock refractory to conventional therapy after cardiotomy were supported with the Pierce-Donachy ventricular assist device. Fourteen required left ventricular support, 7 needed right ventricular support with an intraaortic balloon, and 9 had biventricular assistance. Duration of support ranged from three hours to 22 days (mean length, 3.6 days). Seven of the first 11 patients seen died in the operating room of bleeding, biventricular failure, or both. However, 16 patients (53%) had improved cardiac function, 15 (50%) were weaned, and 11 (37%) were discharged. Of the last 19 patients in the series, 47% survived. Factors affecting survival were myocardial infarction (75%) and renal failure (90%). Common complications were bleeding (73%) and biventricular failure (83%).

Adolescent↗
PubMed1989

Left coronary ostial stenosis: comparison with left main coronary artery stenosis.

We compared 147 consecutive patients who had left coronary ostial stenosis with 254 consecutive patients who had left main coronary artery stenosis treated with coronary artery bypass grafting. Mean age for the left main group was 61.6 years versus 59.7 years for the left ostial group (p = not significant [NS]). In the left ostial group, 43.5% were female and in the left main group, 12% (p less than 0.005). Prior myocardial infarction had occurred in 53% of patients with left main stenosis and 36% of patients with left ostial stenosis (p less than 0.005). There were 2.45 +/- 1.00 diseased vessels in the left main group and 1.96 +/- 1.09 in the left ostial group (p less than 0.0005). Seven (3%) of the patients with left main stenosis had no associated coronary disease (greater than 50%) versus 24 (16%) of the left ostial group (p less than 0.005). The degree of left main stenosis was 90% or more in 28.3% of patients versus 42.8% with equivalent ostial narrowing (p less than 0.01). Left ventricular function was better in the left ostial group than in the left main group (1.61 +/- 0.93 versus 2.02 +/- 1.11, respectively; p less than 0.0005). One-month mortality was 10 patients (3.9%) in the left main group and 8 (5.4%) in the left ostial group (p = NS). Perioperative infarction occurred in 8.6% of patients with left main stenosis and 4.7% of patients with left ostial stenosis (p = NS). Mean follow-up was 6.1 years for the left main group and 5.4 years for the left ostial group.(ABSTRACT TRUNCATED AT 250 WORDS)

Aorta↗
PubMed1989

Coronary artery bypass grafting for unstable angina pectoris: risk analysis.

Unstable angina pectoris is a broad, nonspecific diagnosis encompassing a wide variety of clinical syndromes. The intravenous administration of nitroglycerin preoperatively is indicative of a more acute clinical situation, and allows for selection and analysis of a more homogeneous patient population. We reviewed the results of coronary artery bypass grafting for unstable angina defined as angina necessitating intravenous administration of nitroglycerin preoperatively. There were 129 patients (83 men and 46 women) with a mean age of 63.2 years (range, 36 to 86 years). Complications included operative death in 6.2%, postoperative low cardiac output in 11%, and perioperative myocardial infarction in 9%. Twenty perioperative variables were analyzed to identify risk factors for these end points. For operative death, age (p less than 0.05), cross-clamp time (p less than 0.05), and cardiopulmonary bypass time (p less than 0.001) were significant in the univariate analysis, but only age (p less than 0.05, F = 4.6) was an independent predictor using multivariate analysis (stepwise linear regression). For low cardiac output, univariate analysis demonstrated that cross-clamp time (p less than 0.01), preoperative use of an intraaortic balloon for angina (p less than 0.05), left ventricular score (p less than 0.05), number of diseased coronary vessels (p less than 0.05), and cardiopulmonary bypass time (p less than 0.001) were significant variables. However, only use of an intraaortic balloon for angina (p less than 0.0001, F = 14.3) and left ventricular score (p less than 0.005, F = 11.1) were significant independent predictors in the multivariate model. For perioperative myocardial infarction, only diabetes requiring insulin (p less than 0.005) was a significant predictor.

Adult↗
PubMed1989

Left subclavian-left coronary artery anastomosis for anomalous origin of the left coronary artery. Long-term follow-up.

From 1972 to 1987, seven patients, from two to 28 months of age, underwent left subclavian artery-left coronary artery anastomosis for anomalous origin of the left coronary artery from the pulmonary trunk. All of these infants, median age 4 months, had severe congestive heart failure caused by anterolateral myocardial infarctions. There were two hospital deaths (29% mortality rate) with no late deaths after an average 10-year follow-up. All survivors have good exercise tolerance New York Heart Association class I), reduction in heart size, and significant improvement or normalization of ventricular function by echocardiography. Patency of the subclavian-left coronary artery anastomosis has been documented in two of four patients who have undergone catheterization. In contrast to other revascularizing procedures for treatment of an anomalous origin of the left coronary artery, anastomosis of the left subclavian to the left coronary artery may be performed without cardiopulmonary bypass or aortic occlusion. Moreover, this procedure appears to have an acceptable mortality rate with excellent long-term functional results in critically ill infants.

Anastomosis, Surgical↗
PubMed1988

The changing profile of the patient undergoing coronary artery bypass surgery.

The first 100 consecutive patients undergoing isolated coronary artery bypass surgery in 1975 were evaluated with respect to the incidence of operative risk factors and outcome. When compared with an identically selected group from 1985, there was significant worsening of the preoperative condition over the decade with regard to mean age (p less than 0.0005), presence of congestive heart failure (p less than 0.05), left ventricular dysfunction (p less than 0.05), severity of coronary artery disease (p less than 0.001) and incidence of emergency operation (p less than 0.05). More patients in 1985 had associated medical diseases such as diabetes (p less than 0.01) and chronic lung disease (p less than 0.005). There was an increase in the occurrence of vascular diseases (hypertension, renal dysfunction, peripheral vascular and cerebrovascular disease) (p less than 0.05). Overall operative mortality increased from 1 to 8% (p less than 0.05) over the decade. Despite the deterioration in the clinical profile of the patient undergoing coronary bypass surgery, elective procedures were still performed with low mortality. The significant increase in overall mortality was chiefly in patients undergoing emergency operation (p less than 0.05). There were also increases in operative morbidity including low output syndrome (p less than 0.01) and respiratory (p less than 0.005) and neurologic (p = 0.06) complications.

Age Factors↗
PubMed1988

Bridging to cardiac transplantation with pulsatile ventricular assist devices.

As cardiac transplantation becomes more commonplace in the treatment of end-stage heart failure and as suitable donors become less available, an increasing number of patients will require mechanical circulatory assistance to bridge to transplantation. Since 1982, refractory hemodynamic instability requiring placement of pulsatile ventricular assist devices (VADs) has developed in 11 candidates for transplantation aged 24 to 54 years (mean, 39.6 years). A pneumatic Pierce-Donachy pump was used in 9 patients and an electrical Novacor pump in 2. The cause of the cardiomyopathy was ischemic in 6, postpartum in 2, idiopathic in 2, and doxorubicin hydrochloride toxicity in 1. Seven patients required left ventricular support (LVAD); 4 required biventricular mechanical support (BVAD). Duration of support ranged from 8 hours to 91 days with flows ranging from 4.1 to 8.5 L/min (mean, 5.5 L/min). Although hemodynamic stability was achieved in all 11 patients, contraindications to transplantation developed in 5 patients during VAD support (renal failure in 4, sepsis in 3, disseminated intravascular coagulopathy in 1). The remaining 6 patients (4 with an LVAD, 2 with a BVAD) remained good candidates for transplantation despite major complications in 5 (mediastinal bleeding in 3, driveline infection in 3, development of preformed antibodies in 2, small embolic stroke caused by device malfunction in 1). The 3 patients who were supported the longest (24, 75, and 91 days) were ambulatory while awaiting a donor heart. All 6 patients underwent successful transplantation after 8 hours to 91 days (mean, 24 days) of support. Other than one sternal wound infection, there were no major complications after transplantation.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Kidney Injury↗
PubMed1988

Coronary ostial stenosis.

From January 1970 to December 1986, 2.7% (228/8509) of all patients having coronary artery bypass grafting had atherosclerotic coronary ostial stenosis of 50% or more. There were 126 males (55%) and 102 females (45%) with mean ages of 60.2 +/- 9.0 and 59.2 +/- 10.2 years (P = NS), respectively. The left ostium was involved in 176 (77.2%) patients, the right in 41 (18.0%) and both in 11 (4.8%). Isolated ostial stenosis (no associated coronary disease of 50% or more) was present in 38/228 (17%) with females predominating (29/38, 76%). Isolated ostial stenosis occurred more frequently on the right (10/41, 25%) than on the left (18/176, 16%). Associated coronary disease occurred in a single vessel in 42 patients, in two vessels in 72 and in three vessels in 76 resulting in a mean of 2.0 diseased vessels per patient. If patients with isolated ostial stenosis are excluded there were 2.3 diseased arteries per patient. There were 687 grafts performed in these patients, an average of 2.3 grafts per patient. One month surgical mortality was 4.8% (11/228), but has been 2% (2/104) in the last 4 years. Nine of 27 late deaths were noncardiac with a mean follow-up of 49 +/- 44 months. Ostial stenosis is hemodynamically equivalent to left main disease when the left ostium is involved. Symptomatic ostial lesions, whether right or left, require operative therapy.

Adult↗
PubMed1988

Coronary artery bypass for recent infarction. Predictors of mortality.

The role of coronary artery bypass (CAB) surgery in patients with recent myocardial infarction remains controversial. To more clearly define the operative risks, we reviewed 336 patients who underwent isolated CAB within 30 days of infarction. There were 129 patients with stable or no angina (Group 1), 163 with angina at rest (Group 2), 21 with angina requiring intra-aortic balloon counterpulsation for pain control (Group 3), and 23 with severe postinfarction ischemia or extension complicated by cardiogenic shock (Group 4). There were 26 (7.7%) deaths overall. The mortality was 2.3% in Group 1, 6.1% in Group 2, 9.5% in Group 3, and 47.8% in Group 4. Univariate analysis (Student's t and chi 2 tests) and multivariate analysis (stepwise logistic regression model) were performed on 17 variables: age, gender, clinical Group (1-4), number of diseased vessels, presence of left main artery disease, left ventricular wall-motion score, left ventricular end-diastolic pressure, presence of mitral insufficiency, extent of infarction (subendocardial vs. transmural), interval from infarction to CAB, number of distal anastomoses performed, preoperative hemodynamic status, aortic cross-clamp time, and total cardiopulmonary bypass time. Only advanced age (p = 0.002), left ventricular wall-motion score (p = 0.004), and clinical group (p = 0.048) proved to be independent predictors of mortality by multivariate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1988

Follow-up of survivors of mechanical circulatory support.

Improvements in mechanical support for profound circulatory collapse have resulted in increasing survival of these critically ill patients. Since 1980, 27 patients aged 3 days to 69 years (mean 34.9 years) who required mechanical circulatory assistance have been followed up after discharge from the hospital. The refractory cardiogenic shock necessitating mechanical support occurred postoperatively in 22 patients (coronary artery bypass in nine, valve replacement in four, correction of congenital heart defects in nine) and with end-stage cardiomyopathy in five. Fourteen patients were supported with a Pierce-Donachy ventricular assist device (left ventricular assist in seven, right ventricular assist in three, both in four); nine were supported with extracorporeal membrane oxygenation, two with a Medtronic centrifugal left ventricular assist pump, one with biventricular Biomedicus pumps, and one with a Novacor left ventricular assist system. The duration of support ranged from 8 hours to 91 days with a mean of 3.5 days in patients supported for postoperative shock. Major complications occurred in 18 patients (67%), including bleeding that necessitated operative exploration in 14, serious infection in five, renal failure in two, and stroke in two. The five patients with cardiomyopathy underwent cardiac transplantation. The remaining 22 patients who had postoperative cardiogenic shock were weaned from support. There have been four late deaths: two cardiac related at 6 months and two of cancer at 46 and 53 months (one patient was in New York Heart Association class I and the other in class II before death). The remaining 23 survivors have been followed up for 3 to 79 months (mean 29 months) and at last examination 17 (74%) were in class I, two (9%) were in class II, three (13%) were in class III, and one (4%) was in class IV. Eight patients are employed full time, three are retired, four attend school, three are in preschool, one is a housewife, and one is unemployed but free of symptoms. Only four patients have significant cardiac disability, and one of these still works. In conclusion, mechanical circulatory assistance allows adequate support to permit satisfactory long-term survival in patients with refractory cardiogenic shock.

Adult↗
PubMed1987

Coronary artery bypass surgery in patients aged 80 years or older.

Between August 1980 and January 1986, 23 patients aged 80 years or older underwent coronary artery bypass grafting (CABG) operations. These patients had a higher incidence of severe left main coronary artery narrowing (p less than 0.0001), 3-vessel coronary artery disease (p less than 0.05) and moderate to severe left ventricular dysfunction (p less than 0.05) than patients in the Coronary Artery Surgery Study registry older than 65 years. Of 14 patients undergoing elective simple CABG procedures, none died; of 19 elective cases overall, 2 patients died (11%). Three of 4 patients undergoing emergency procedures (75%) and 4 of 6 patients (67%) requiring intraaortic balloon counterpulsation died. Significant complications occurred in 9 of 18 survivors (50%). All operative survivors improved at least 1 New York Heart Association class, with a mean classification improvement of 3.7 to 1.6 (p less than 0.0001); 13 of 16 long-term survivors were in class I or II. Actuarial survival at 1 and 2 years is 94% and 82%, respectively. CABG can be performed electively in octogenarian patients with increased but acceptable mortality and morbidity risks. Functional improvement and long-term survival are excellent.

Aged↗
PubMed1987

Primary repair of traumatic aortic disruption.

From 1979 to 1985, 22 patients (18 male) underwent repair of acute traumatic rupture of the aorta. Ages ranged from 15 to 75 years (mean, 35 years). All patients sustained deceleration injuries in automobile accidents. The majority had injuries to multiple systems and evidence of mediastinal widening on routine chest roentgenograms. Aortography confirmed transection in the descending thoracic aorta near the ligamentum arteriosum in 20. Primary repair was achieved in 15 patients; it was performed in the last 10 consecutive patients. Seven patients had repair with a prosthetic graft. Survival was 82%. Postoperative morbidity usually was related to associated injuries. Primary repair of aortic transection can be accomplished in most patients without the use of prosthetic material.

Accidents, Traffic↗