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Biomedical subjects

V Rao

Publications and source records attributed to V Rao.

At least 37 records · Page 2Linked to original sources
PubMed2001

Surgical management of valvular disease in patients requiring left ventricular assist device support.

BACKGROUND: Success with long-term implantable left ventricular assist devices (LVAD) has led to increased use in patients previously thought to be unsuitable for mechanical circulatory assistance. Patients with preexisting or newly diagnosed valvular disease have been traditionally excluded from device placement. The purpose of this study was to review our experience with LVAD support in patients with valvular disease and to develop a management algorithm for these difficult patients. METHODS: We reviewed the clinical records of 199 consecutive patients who received the ThermoCardiosystems, Inc, HeartMate Pneumatic or Vented Electric LVAD. There were 18 patients (9%) who required surgical management of native or prosthetic valvular disease during LVAD implantation. RESULTS: Suture or patch closure of the aortic valve was performed in 6 patients, aortic valve plication and repair in 1 patient, mitral valve repair in 4 patients, and tricuspid valve annuloplasty in 5 patients. Two patients with mechanical mitral valve prostheses were treated with postoperative warfarin anticoagulation. Fifteen of the 18 patients with valvular pathology survived the immediate postoperative period (17% mortality). Eleven patients have either undergone transplantation or continue to be supported with an LVAD (61%). Operative mortality in LVAD patients without concomitant valve repair was 18% (n = 33) with a late mortality of 7% (n = 13). Seven of these late deaths occurred in patients who received a device as destination therapy. In the remaining 6 patients, the cause of death was sepsis (n = 2), multisystem organ failure (n = 2), driveline rupture (n = 1), and massive gastrointestinal bleed (n = 1). CONCLUSIONS: Preexisting native or prosthetic valve pathology does not increase the immediate perioperative risk of LVAD insertion; however, these patients continue to pose a challenge for postoperative management while awaiting transplantation.

Adult↗
PubMed2001

Lactate release during reperfusion predicts low cardiac output syndrome after coronary bypass surgery.

BACKGROUND: Cardioplegic arrest induces anaerobic myocardial metabolism with a net production of lactate from glycolysis. However, persistent lactate release during reperfusion suggests a delayed recovery of normal aerobic metabolism and may lead to depressed myocardial function necessitating inotropic or intraaortic balloon pump support (low output syndrome [LOS]). We examined the relation between perioperative myocardial metabolism and postoperative clinical outcomes in patients undergoing isolated coronary artery bypass surgery (CABG). METHODS: We reviewed 623 patients who were enrolled in clinical studies evaluating perioperative myocardial metabolism between 1983 and 1996. Arterial and coronary sinus blood samples were obtained intraoperatively to assess myocardial metabolism. Clinical data regarding patient demographics and postoperative outcomes were prospectively collected and entered into our institutional database. RESULTS: Low output syndrome developed in 36 patients (5.8%). Myocardial lactate release was higher in these patients compared with those who did not develop postoperative LOS. Advanced age and poor preoperative left ventricular function were independent predictors of lactate release during reperfusion. Persistent lactate release after 5 minutes of reperfusion was the only independent predictor of postoperative LOS in this low-risk population. CONCLUSIONS: Persistent lactate release during reperfusion occurs in a significant proportion of low-risk patients undergoing isolated CABG and is an independent predictor of postoperative low cardiac output syndrome. Persistent lactate release during reperfusion suggests a delayed recovery of aerobic myocardial metabolism and may be related to intraoperative misadventure or inadequate myocardial protection. Myocardial lactate release may be useful as an alternative end-point in clinical trials evaluating perioperative myocardial protection.

Aged↗
PubMed2001

Optimal time for cardiomyocyte transplantation to maximize myocardial function after left ventricular injury.

BACKGROUND: This study was designed to determine the optimal time for cell transplantation after myocardial injury. METHODS: The left ventricular free wall of adult rat hearts was cryoinjured and the animals were sacrificed at 0, 1, 2, 4, and 8 weeks for histologic studies. Fetal rat cardiomyocytes (transplant) or culture medium (control) were transplanted immediately (n = 8), 2 weeks (n = 8), and 4 weeks (n = 12) after cryoinjury. At 8 weeks, rat heart function, planimetry, and histologic studies were performed. RESULTS: Cryoinjury produced a transmural injury. The inflammatory reaction was greatest during the first week but subsided during the second week after cryoinjury. Scar size expanded (p < 0.01) at 4 and 8 weeks. Cardiomyocytes transplanted immediately after cryoinjury were not found 8 weeks after cryoinjury. Scar size and myocardial function were similar to the control hearts. Cardiomyocytes transplanted at 2 and 4 weeks formed cardiac tissue within the scar, limited (p < 0.01) scar expansion, and had better (p < 0.001) heart function than the control groups. Developed pressure was greater (p < 0.01) in the hearts with transplanted cells at 2 weeks than at 4 weeks. CONCLUSIONS: Cardiomyocyte transplantation was most successful after the inflammatory reaction resolved but before scar expansion.

Animals↗
PubMed2001

Stroke during coronary bypass surgery: principal role of cerebral macroemboli.

OBJECTIVE: The purpose of this study was to gain insight into the etiology of stroke during coronary bypass surgery. METHODS: Retrospective review of prospectively gathered data on 6682 consecutive coronary bypass patients. Patients undergoing simultaneous procedures, including carotid endarterectomy, were excluded. We performed a systematic chart review of all patients who suffered a perioperative stroke. Predictors of stroke were determined with stepwise logistic regression analysis. RESULTS: The prevalence of stroke was 1.5% (n=98). Stroke patients had significantly increased intensive care unit and hospital length of stays, as well as increased mortality when compared to patients without stroke (all P< 0.001). Independent predictors of stroke were (in decreasing order of magnitude): age >70 years, left ventricular ejection fraction <40%, previous stroke or transient ischemic attack, normothermic cardiopulmonary bypass, diabetes, and peripheral vascular disease. Chart review revealed that the probable cause of stroke was macroemboli, likely from ascending aorta atherosclerosis, in 37% of patients and unknown in 38% of patients. Computerized tomography (CT) scans were obtained in 79 patients (81%). Lesions detected by CT were consistent with a macroembolic etiology: nearly all lesions were ischemic in nature and located in the distribution of major cerebral arteries, particularly the middle cerebral artery. CONCLUSIONS: Stroke is a devastating complication of coronary bypass surgery. Our multivariable risk factors for stroke, chart review, and CT findings all suggest that macroemboli, presumably from the ascending aorta, are the predominant cause of stroke during coronary bypass surgery. Future studies should be directed at minimizing the risk of embolization during cardiac surgery.

Aged↗
PubMed2001

Cockroach allergy appears early in life in inner-city children with recurrent wheezing.

BACKGROUND: Cockroach allergy and exposure to high levels of this allergen are important in the increasing asthma-related health problems among young inner-city children. However, there are very little data regarding the prevalence of cockroach allergy in infants and young children with asthma. OBJECTIVE: This retrospective study was designed to test the hypothesis that cockroach allergy appears early in life in young children with recurrent wheezing. METHODS: We reviewed the medical records of all 196 children (ages 5 months to 16 years) evaluated between January 1995 and September 1997 at the Cook County Hospital Pediatric Allergy Clinic for recurrent wheezing. The patients were assigned into two age groups, less than 4 years old and 4 to 16 years old. The percentages of IgE skin tests positive for common aeroallergens were compared within and between the two age groups. All children in the younger age group were tested for cockroach and dust mites, cat, and dog when indicated by positive environmental history. All children in the older age group were tested for indoor and outdoor allergens. RESULTS: Sixty-three children were younger than 4 years of age, and of these, 15 (23.8%) had cockroach allergen sensitivity, compared with only eight patients (12.7%) who were skin test positive to dust mite allergen (P = .01). The youngest patient with a positive reaction to cockroach allergen was 6 months old. Patients with a single allergen skin reactivity were considered as monosensitized. Nine children younger than 4 years of age (14.3%) were monosensitized only to cockroach allergen in contrast to three children (4.8%) who were monosensitized to house-dust mites (P < .05). CONCLUSIONS: Our data suggest that cockroach allergen sensitivity starts early in life and may be the only sensitizing allergen in many young inner-city children.

Adolescent↗
PubMed2001

The relationship of acculturation and gender to attitudes toward counseling in Italian and Greek American college students.

This exploratory study examined attitudes toward professional psychological services and help provider characteristics among 232 self-identified Italian and Greek American college students in 3 Northeast colleges. Regarding general attitudes toward psychological services in the Italian American sample, women had a greater recognition of personal need for help and higher confidence in the ability of mental health professionals to meet these needs than did men. With regard to preferred counselor demographic characteristics, regardless of gender, lower acculturated Italian American students had a stronger preference for seeing an ethnically similar counselor. With the Greek American sample, there was an interaction effect between acculturation level and gender on attitudes toward services. Among the higher acculturated Greek students, women were more open regarding their personal concerns than men; however, within the lower acculturated cohort, no gender differences were found. With regard to counselor characteristic variables, and similar to Italian Americans, regardless of gender, lower acculturated Greek Americans had a stronger preference for seeing an ethnically similar counselor to discuss a personal problem. Limitations and implications for further research are noted.

Acculturation↗
PubMed2001

Reoperative coronary bypass surgery: effect of patent grafts and retrograde cardioplegia.

OBJECTIVE: To determine the effects of patent or diseased aorta-coronary bypass grafts and retrograde cardioplegia on mortality during reoperative coronary bypass surgery. METHODS: We conducted a retrospective review of prospectively gathered data, supplemented by systematic chart review, of all patients (n = 744) undergoing reoperative coronary bypass surgery at our institution between 1990 and 1997. Independent predictors of survival were determined by stepwise logistic regression analysis. RESULTS: At least one patent or stenosed graft to the left anterior descending artery was present in 50% of patients, to the circumflex territory in 27% of patients, and to the right coronary artery territory in 33% of patients. The previous left anterior descending graft was a saphenous vein in 82% and a left internal thoracic artery in 18% of patients. In-hospital mortality occurred in 42 (5.6%) patients. Patent or diseased grafts of any coronary artery territory did not significantly increase the risk of mortality. Retrograde cardioplegia use increased in more recent years, was more frequent in patients with stenosed grafts, and was associated with improved survival. Independent predictors of mortality were as follows (with odds ratios and 95% confidence intervals in parentheses): failure to use retrograde cardioplegia (odds ratio 2.81; 1.28-6.20), New York Heart Association class (odds ratio 2.69; 1.25-5.81), peripheral vascular disease (odds ratio 2.60; 1.25-5.41), and left ventricular grade (2.07; 1.31-3.27). CONCLUSIONS: In this series, patent or stenosed grafts were not associated with an increased risk of mortality during reoperative coronary bypass surgery, possibly because of increased use of retrograde cardioplegia in this patient group. We strongly recommend the routine use of retrograde cardioplegia during redo coronary bypass surgery.

Coronary Artery Bypass↗
PubMed2001

Is profound hypothermia required for storage of cardiac allografts?

BACKGROUND: Improved methods of cardiac allograft protection are required to expand the pool of potentially available organs and to enhance the recovery of grafts subjected to prolonged ischemia. We have previously demonstrated that limited coronary perfusion provided by donor blood harvested at the time of organ procurement can improve both metabolic and functional recovery after transplantation. In this study we evaluated the hypothesis that limited coronary perfusion may enable prolonged cardiac storage while avoiding the potentially detrimental effects of profound hypothermia. METHODS: Fourteen orthotopic cardiac transplants were performed in female Yorkshire pigs by using donor blood perfusion during 5 hours of either tepid (25 degrees C) or cold (4 degrees C) storage. Assessments of myocardial metabolism and function were performed at baseline and after 45 minutes of normothermic (37 degrees C) reperfusion. RESULTS: Hearts protected with tepid perfusion displayed improved recovery of myocardial function (89% +/- 18% vs 63% +/- 25%, P =.05). Diastolic compliance was adversely affected in both groups after transplantation. Aerobic myocardial metabolism was better preserved in the tepid group. CONCLUSIONS: Profound hypothermia results in depressed myocardial metabolic and functional recovery after transplantation. Limited coronary perfusion with shed donor blood can permit cardiac allograft storage at tepid temperatures, resulting in improved myocardial performance.

Animals↗
PubMed2001

The effect of insulin cardioplegia on atrial fibrillation after high-risk coronary bypass surgery: a double-blinded, randomized, controlled trial.

UNLABELLED: Atrial fibrillation after coronary bypass (CABG) surgery is an important cause of morbidity and increased resource utilization. Insulin-enhanced cardioplegia may reduce postoperative arrhythmias by improving aerobic myocardial metabolism and mitigating the deleterious effects of ischemia. We performed a double-blinded, randomized, controlled clinical trial to determine if insulin-enhanced cardioplegia decreases the risk of post-CABG atrial fibrillation in a high-risk patient population. We randomized 501 patients undergoing urgent CABG to receive insulin-enhanced (Humulin R 10 IU/L, Insulin group, n = 243) or standard (Control group, n = 258) blood cardioplegia during cardiopulmonary bypass. Patients were monitored by using continuous electrocardiography for a minimum of 3 days postoperatively. All standard cardiac medications, including beta-adrenergic blockers, were continued postoperatively. Insulin-enhanced cardioplegia did not result in a significant reduction in postoperative atrial fibrillation. Furthermore, we failed to detect a difference in the incidence of conduction defects, ventricular tachycardia, or pacemaker requirements between insulin and placebo patients. Atrial fibrillation was the most common arrhythmia, occurring in 31% of all patients. Independent predictors of atrial fibrillation were elderly age, preoperative atrial fibrillation, and renal insufficiency. Right bundle branch block was the most common conduction abnormality. Predictors of right bundle branch block were elderly age, female sex, and circumflex coronary artery disease. The incidence of postoperative ventricular tachycardia, left bundle branch block, and permanent pacemaker requirement was small. We conclude that insulin-enhanced cardioplegia does not reduce the incidence of postoperative atrial fibrillation in high-risk CABG patients. IMPLICATIONS: We conducted a double-blinded, randomized, placebo-controlled trial of insulin-enhanced cardioplegia in 501 patients undergoing urgent coronary bypass surgery. Insulin did not decrease the incidence of postoperative atrial fibrillation when compared with placebo. We also failed to demonstrate a difference in the incidence of other postoperative arrhythmias between the two groups of patients.

Aged↗
PubMed2001

Hyperhomocysteinemia enhances vascular inflammation and accelerates atherosclerosis in a murine model.

Although hyperhomocysteinemia (HHcy) is a well-known risk factor for the development of cardiovascular disease, the underlying molecular mechanisms are not fully elucidated. Here we show that induction of HHcy in apoE-null mice by a diet enriched in methionine but depleted in folate and vitamins B6 and B12 increased atherosclerotic lesion area and complexity, and enhanced expression of receptor for advanced glycation end products (RAGE), VCAM-1, tissue factor, and MMP-9 in the vasculature. These homocysteine-mediated (HC-mediated) effects were significantly suppressed, in parallel with decreased levels of plasma HC, upon dietary supplementation with folate and vitamins B6/B12. These findings implicate HHcy in atherosclerotic plaque progression and stability, and they suggest that dietary enrichment in vitamins essential for the metabolism of HC may impart protective effects in the vasculature.

Animals↗
PubMed2000

Aortic valve repair for adult congenital heart disease: A 22-year experience.

BACKGROUND: Aortic valve-preserving procedures have resulted in excellent outcomes in selected patients, particularly those with normal aortic valve leaflets and dilated aortic roots. However, several congenital heart lesions are associated with abnormal aortic valve leaflets. The long-term results of aortic valve repair for these lesions are not well defined. METHODS AND RESULTS: We reviewed the clinical records of 54 adult (age >18 years) patients who underwent repair of congenital abnormalities of the aortic valve between 1976 and September 1999. Follow-up data were available on 52 (96%) patients (mean 50+/-67 months, range 1 to 266). Patients underwent repair at a mean age of 34+/-14 years with associated diagnoses of subaortic stenosis (n=10), ventricular septal defect with prolapsing aortic valve (n=17), bicuspid aortic valve (n=23), sinus of Valsalva aneurysm (n=10), and bacterial endocarditis (n=2). There was 1 operative death (1.9%) and 3 late deaths. Survival at 5 and 10 years was 98+/-2% and 74+/-12%, respectively. Freedom from reoperation was 74+/-9% and 51+/-15% at 5 and 10 years, respectively. The presence of a ventricular septal defect predicted failure of valve repair (59% versus 22%, P:=0.01). A bicuspid aortic valve, subaortic stenosis, or the requirement for mitral valve surgery did not affect outcomes. CONCLUSIONS: Aortic valve repair in adult patients with congenital heart disease can be performed with minimal morbidity and mortality rates. The medium-term results of repair are acceptable, regardless of valvular or associated pathology. However, only 31 patients (57%) demonstrated long-term competence of the aortic valve, suggesting that most adult patients with congenital aortic valve disease will eventually require aortic valve replacement.

Adult↗
PubMed2000

Prosthesis-patient mismatch affects survival after aortic valve replacement.

BACKGROUND: Surgeons traditionally avoid the use of "small" aortic prostheses because of the potential for residual left ventricular outflow tract obstruction and persistent transvalvular gradients. This study examines the ratio between prosthetic valve size and the body surface area (BSA) of patients undergoing aortic valve replacement (AVR). We sought to determine the effect of potential "prosthesis-patient" mismatch on long-term survival. METHODS AND RESULTS: Follow-up was conducted on 2981 patients who underwent AVR with stented bioprostheses between 1976 and 1996. To account for differences between manufacturers' labeled valve sizes, we calculated the ratio between the prosthetic valve effective orifice area (EOA) and the patient's BSA (recorded for 2154 patients). The lowest decile in this cohort had a calculated EOA/BSA of <0.75 cm(2)/m(2) (Small group, n=227) compared with the control group (n=1927), in whom the EOA/BSA ratio was >0.75 cm(2)/m(2). Operative mortality was higher in the Small group (8% versus 5%, P:=0.03). Actuarial survival at 12 years was 50+/-5% in the Small group compared with 49+/-2% in the control group (P:=0.27). However, freedom from valve-related mortality was significantly lower in the Small group (75+/-5% versus 84+/-2%, P:=0.004). Cox regression analysis determined age and NYHA functional class to be the multivariate predictors of overall mortality, whereas advanced age and EOA/BSA <0.75 cm(2)/m(2) were found to be the predictors of valve-related mortality. CONCLUSIONS: Prosthesis-patient mismatch results in significantly higher early and late mortality after bioprosthetic AVR. We recommend careful selection of stented bioprostheses to ensure an adequate ratio of EOA to BSA. An EOA/BSA ratio of >0.75 cm(2)/m(2) may avoid residual left ventricular outflow tract obstruction and persistent transvalvular gradients. Careful prosthesis-patient matching will improve both early and late survival after AVR.

Aortic Valve↗
PubMed2000

Recombinant BCG approach for development of vaccines: cloning and expression of immunodominant antigens of M. tuberculosis.

In spite of major advances in our understanding of the biology and immunology of tuberculosis, the incidence of the disease has not reduced in most parts of the world. In an attempt to improve the protective efficacy of Mycobacterium bovis bacille Calmette-Guérin (BCG), we have developed a generic vector system, pSD5, for expression of genes at varying levels in mycobacteria. In this study, we have cloned and overexpressed three immunodominant secretory antigens of M. tuberculosis, 85A, 85B and 85C, belonging to the antigen 85 complex. All the genes were cloned under the control of a battery of mycobacterial promoters of varying strength. The expression was analysed in the fast-growing strain M. smegmatis and the slow-growing vaccine strain M. bovis BCG. The recombinant BCG constructs were able to express the antigens at high levels and the majority of the expressed antigens was secreted into the medium. These results show that by using this strategy the recombinant BCG approach can be successfully used for the development of candidate vaccines against infections associated with mycobacteria as well as other pathogens.

Antigens, Bacterial↗
PubMed2000

The benefits and risks of ECT for patients with primary dementia who also suffer from depression.

BACKGROUND: Major depression afflicts 20-25% of patients with dementia. Of these, about a third do not improve with antidepressant therapy and may be suitable candidates for electronconvulsive treatment (ECT). However, the use of ECT is dementia patients is concerning due to possible adverse effects on memory and cognition. Outcome studies of ECT in patients with primary dementia and depression are very rare. OBJECTIVE: To determine the effectiveness and complications of ECT treatment for depression in dementia. METHOD: A chart review was conducted of all 31 patients wit ha discharge diagnosis of 'Dementia with depression' treated with ECT at the Johns Hopkins Hospital, over a five-year period. Admission and discharge ratings were made on the Mini-Mental State Examination (MMSE) and the Montgomery-Asberg Depression Rating Scale (MADRS) as part of the clinical routine. RESULTS: All patients suffered from dementia: 55% had vascular dementia, 13% Alzheimer's disease, and 32% degenerative dementia of uncertain etiology. The admission MADRS mean score was 27.5 (SD 8.1) and the MMSE mean score was 18.8 (SD 5. 5). The patients received between 1 and 23 ECT treatments (mean 9, SD 5.7). At discharge, there was a statistically significant mean decline on the MADRS of 12.28 points (p<0.01). Forty percent had scores less than 10 (normal) on the MADRS. While 49% of patients developed delirium, by discharge there was also a significant mean increase (improvement) in MMSE of 1.62 points (p<0.02). CONCLUSIONS: ECT is an effective treatment for depression in dementia, leading to improvements in both mood and cognition. Multiple ECT treatments may be necessary before a significant improvement in mode is achieved.

Aged↗
PubMed2000

Effects of gene deletion of the tissue inhibitor of the matrix metalloproteinase-type 1 (TIMP-1) on left ventricular geometry and function in mice.

Alterations in the expression and activity of the matrix metalloproteinases (MMPs) and the tissue inhibitors of the MMPs (TIMPs) have been implicated in tissue remodeling in a number of disease states. One of the better characterized TIMPs, TIMP-1, has been shown to bind to active MMPs and to regulate the MMP activational process. The goal of this study was to determine whether deletion of the TIMP-1 gene in mice, which in turn would remove TIMP-1 expression in LV myocardium, would produce time-dependent effects on LV geometry and function. Age-matched sibling mice (129Sv) deficient in the TIMP-1 gene (TIMP-1 knock-out (TIMP-1 KO), n=10) and wild-type mice (n=10) underwent comparative echocardiographic studies at 1 and 4 months of age. LV catheterization studies were performed at 4 months and the LV harvested for histomorphometric studies. LV end-diastolic volume and mass increased (18+/-4 and 38+/-3%, respectively, P<0.05) at 4 months in the TIMP-1 KO group; a significant increase compared to wild-type controls (P<0.05). At 4 months, LV and end-diastolic wall stress was increased by over two-fold in the TIMP-1 KO compared to wild type (P<0.05). However, LV systolic pressure and ejection performance were unchanged in the two groups of mice. LV myocyte cross-sectional area was unchanged in the TIMP-1 KO mice compared to controls, but myocardial fibrillar collagen content was reduced. Changes in LV geometry occurred in TIMP-1 deficient mice and these results suggest that constitutive TIMP-1 expression participates in the maintenance of normal LV myocardial structure.

Animals↗
PubMed2000

Repair of isolated multiple muscular ventricular septal defects: the septal obliteration technique.

BACKGROUND: Isolated multiple ventricular septal defects (mVSDs) remain a surgical challenge. The dilemma of whether to perform a complete repair ultimately rests with the surgeon, who must decide if all significant septal defects can be located. Avoidance of a pulmonary arterial band (as part of a two-stage repair) will negate the need for future pulmonary arterial reconstruction and will reduce the incidence of late right ventricular diastolic dysfunction. METHODS: We performed a retrospective analysis of hospital and echocardiographic data of eight children who underwent a septal obliteration technique (SOT) as part of their correction of mVSDs (with and without coarctation of the aorta). RESULTS: Eight children with a mean age of 10.5 months (range 1.5 to 36 months), and weight of 6.2 kg (range 2.1 to 13.5 kg), respectively, underwent correction of mVSDs. All had a single, large, perimembranous defect, additional VSDs within the muscular trabecular septum (juxtaposed to the moderator band), and apical mVSDs. All VSDs were repaired via the right atrium, with avoidance of either a right or left ventriculotomy. The posterior and apical defects were excluded from the right ventricular cavity with a pericardial patch (SOT). The follow-up period remains limited to a mean of 20.9 months (8 to 39 months). Two children repaired with SOT had previous pulmonary artery bands (neonatal coarctation repair). All children were successfully discharged home with a mean postoperative Qp:Qs of 1.09:1. One pacemaker was required, but this child has since reverted back to normal sinus rythm. CONCLUSIONS: Our initial experience using the SOT in the treatment of apical VSDs as a component of isolated mVSDs has been rewarding. All children are currently alive, in normal sinus rhythm, and have no residual significant left-to-right shunts.

Cardiac Surgical Procedures↗