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Biomedical subjects

W L Holman

Publications and source records attributed to W L Holman.

At least 19 recordsLinked to original sources
PubMed2001

Alabama coronary artery bypass grafting project: results of a statewide quality improvement initiative.

CONTEXT: Efforts to improve quality of care in the cardiac surgery field have focused on reducing the risk-adjusted mortality associated with common surgical procedures, such as coronary artery bypass grafting (CABG). However, the best methodological approach to improvement is under debate. OBJECTIVE: To test an intervention to improve performance of CABG surgery. DESIGN AND SETTING: Quality improvement project based on baseline (July 1, 1995-June 30, 1996) and follow-up (July 1-December 31, 1998) performance measurements from medical record review for all 20 Alabama hospitals that provided CABG surgery. PATIENTS: Medicare patients discharged after CABG surgery in Alabama (n = 5784), a comparison state (n = 3214), and a national sample (n = 3758). INTERVENTION: Confidential hospital-specific performance feedback and assistance with multimodal improvement interventions, including the option to share relevant experience with peers. MAIN OUTCOME MEASURES: Duration of intubation, reintubation rate, aspirin therapy at discharge, use of the internal mammary artery (IMA), hospital readmission rate, and risk-adjusted in-hospital mortality. RESULTS: Proportion of extubation within 6 hours increased from 9% to 41% in Alabama, decreased from 40% to 39% in the comparison state, and increased from 12% to 25% in the national sample. Use of IMA increased from 73% to 84%, 48% to 55%, and 74% to 81%, respectively, in the 3 samples, but aspirin use increased only in Alabama (from 88% to 92%). The amount of improvement in all 3 of these process measures was greater in Alabama than in the other samples (IMA use for Alabama vs comparison state was P =.001 and for Alabama vs national sample, P =.02; and P<.001 for all other comparisons). Risk-adjusted mortality decreased in Alabama (4.9% to 2.9%), but this decrease was not statistically significantly different from mortality changes in the other groups (odds ratio, 0.76; 95% confidence interval, 0.54-1.07 vs national sample). CONCLUSION: Confidential peer-based regional performance feedback and process-oriented analysis of shared experience are associated with some improvement in quality of care for patients who underwent CABG surgery.

Aged↗
PubMed2001

Cardiomyopathy in a carrier of Duchenne's muscular dystrophy.

During the third trimester of her pregnancy, a 25-year-old carrier of Duchenne's muscular dystrophy developed severe cardiac failure and required mechanical circulatory support and transplantation. Her cardiac function improved during 311 days of circulatory support. However this improvement was not sufficient to allow removal of her left ventricular assist device before transplantation.

Adult↗
PubMed2000

Pneumoperitoneum after concomitant resection of the right middle and lower lobes (bilobectomy).

BACKGROUND: Removal of the right middle and lower lobes often leaves a pleural space problem that can cause prolonged air leaks. METHODS: A single surgeon prospectively randomized 16 patients who underwent bilobectomy. Eight patients had 1200 mL of air injected under the right hemidiaphragm after bilobectomy and 8 did not. The air was injected through a small transdiaphragmatic opening made in the right hemidiaphragm at the time of pulmonary resection. RESULTS: The age of the patients, preoperative pulmonary function, preoperative comorbidities, indications for surgery, and final pathology were not significantly different between the two groups. On postoperative day #1, a pneumothorax was present in 1 patient (13%) in the pneumoperitoneum group (P group) and in 4 patients (50%) in the nonpneumoperitoneum group (N-P group). On postoperative day 1, an air leak was present in 1 patient (13%) in the P group and 5 patients (63%) in the N-P group (p < 0.001). By the third postoperative day, no patient in the P group had an air leak; however, a leak was present in 4 patients (50%) in the N-P group (p < 0.001). Median hospital stay in the P group was 4 days (range, 3 to 6 days), compared with 6 days (range, 4 to 8 days) in the N-P group (p < 0.001). Three patients in the N-P group were sent home with a Heimlich valve. There was no operative mortality and no complications from the pneumoperitoneum. CONCLUSIONS: We conclude that pneumoperitoneum after bilobectomy is safe and easy to do. It decreases the incidence of air leaks and of pneumothoraces and shortens hospital stay without increasing morbidity. We recommend pneumoperitoneum after bilobectomy at the time of thoracotomy, especially if there are residual small air leaks that cannot be sealed before chest closure.

Aged↗
PubMed2000

Right thoracotomy for mitral reoperation: analysis of technique and outcome.

BACKGROUND: This report describes technical details of the right thoracotomy approach for mitral surgery, and analyzes our experience with this procedure for patients with a prior sternotomy. Three methods for myocardial management (hypothermic cardioplegic arrest, beating heart, and fibrillating heart) are compared. METHODS: Records were abstracted of patients who had a right thoracotomy between January 1, 1992 and July 1, 1999 for mitral surgery after at least one prior sternotomy. Demographic, operative, and outcome data were collected for analysis. Telephone follow-up was used to measure postoperative New York Heart Association functional status. RESULTS: Eighty-four patients (mean age 60 +/- 15 years) had reoperative mitral surgery via a right thoracotomy. Myocardial management included ventricular fibrillation in 10 patients, operation on the beating heart in 58 patients, and hypothermic blood cardioplegia arrest in 16 patients. The mean time in the operating room was 185 +/- 73 minutes, and the mean duration of cardiopulmonary bypass was 63 +/- 56 minutes. There were no perioperative strokes and the prevalence of death for patients who received cardioplegic arrest was significantly higher than the prevalence of death for patients who had mitral surgery with perfused fibrillating or beating heart techniques (p = 0.007; Fisher's exact test comparing risk-unadjusted mortality). CONCLUSIONS: Right thoracotomy provides efficient exposure for reoperative mitral surgery. Mitral valve procedures on the fibrillating or beating heart are feasible in most patients and are at least as safe as surgery using cardioplegic arrest.

Adult↗
PubMed2000

Controlled postcardioplegia reperfusion: mechanism for attenuation of reperfusion injury.

OBJECTIVE: Controlled reperfusion and secondary cardioplegia are used to minimize reperfusion injury. The mechanisms for their benefit are incompletely defined and may include attenuation of myocyte sodium uptake. METHODS: Pigs had 1 hour of cardioplegic arrest followed by reperfusion with blood (control) or warm cardioplegic solution followed by blood (test). Reperfusion injury in the control and test groups was quantified by measuring changes of intramyocyte ion content with atomic absorption spectrometry and by analyzing electrophysiologic recovery from recordings of reperfusion arrhythmias. RESULTS: Control animals had an increase in intramyocyte sodium content at 5 minutes after initiating reperfusion (+20.2 micromol/g dry weight, P <.04), whereas the test group had an insignificant decrease (-14.0 micromol/g dry weight, P =.33). The first rhythm after initiating reperfusion was more often ventricular fibrillation in the control group (100% vs 50%, P <.02), and the control group required more defibrillations to establish a nonfibrillating rhythm (4.5 +/- 1.2 vs 1.1 +/- 0.3, P <.03). CONCLUSIONS: Controlled reperfusion eliminated the increase in intramyocyte sodium that was observed in the control group at 5 minutes after cardioplegic arrest. This improvement in myocyte ion homeostasis during postcardioplegia reperfusion was associated with fewer reperfusion arrhythmias. These data support the hypothesis that attenuation of myocyte sodium gain during postischemic reperfusion is a mechanism by which controlled reperfusion and secondary cardioplegia are beneficial.

Animals↗
PubMed2000

Prophylactic value of preincision intra-aortic balloon pump: analysis of a statewide experience.

OBJECTIVE: The objective of this study was to determine whether preincision use of an intra-aortic balloon pump improves survival and shortens postoperative length of stay in hemodynamically stable, high-risk patients undergoing coronary artery bypass grafting. METHODS: A post hoc analysis of the Alabama CABG Cooperative Project database was performed by using propensity scores to model the likelihood of receiving a prophylactic preincision intra-aortic balloon pump. Every patient receiving a prophylactic preincision balloon pump was matched with another patient of similar propensity score who did not receive one. We then compared outcomes for matched pairs. RESULTS: There were 7581 patients of whom 592 received a prophylactic preincision balloon pump. Patients with preoperative renal insufficiency, heart failure, or left main coronary artery disease, or who had undergone previous bypass grafting were significantly more likely to receive a prophylactic preincision balloon pump. By using propensity scores, we matched 550 patients who received a prophylactic preincision balloon pump with 550 who did not. Survival did not significantly differ by whether a prophylactic preincision balloon pump was used. However, surviving patients who received a preincision balloon pump had a significantly shorter postbypass length of stay (7 +/- 7.3 days) than did matched patients not receiving a balloon pump (8 +/- 6.2 days; P <.05). CONCLUSIONS: No survival advantage was found for use of a prophylactic intra-aortic balloon pump in hemodynamically stable, high-risk patients undergoing bypass grafting, as opposed to placing a balloon pump on an "as needed" basis during or after the operation. However, the patients receiving the balloon pump had improved convalescence as shown by significantly shorter length of stay.

Aged↗
PubMed2000

Aortic dissection with intimal intussusception: diagnosis and management.

A man presented with acute chest and back pain with loss of consciousness. CT scan showed a mass in the arch that extended into the descending aorta. A diagnosis of type I aortic dissection was ultimately made by echocardiography. At surgery there was a circumferential intimal tear in the aortic root, and an intussuscepted dissection flap was retrieved from the arch and descending aorta.

Aortic Dissection↗
PubMed2000

Novel methods to evaluate controlled reperfusion techniques in cardiac surgery.

BACKGROUND: This manuscript describes two novel techniques that may be useful for comparing methods to reperfuse the heart during cardiac operations. These techniques are based on measurements of intra-myocyte ion content and the analysis of reperfusion arrhythmias. METHODS: Myocyte ion content was measured in normal porcine hearts before and after ischemia (cardioplegic arrest, CP arrest) using atomic absorption spectroscopy. A cobalt-EDTA complex served as the extra-cellular marker. Cobalt-EDTA was infused into the aorta together with blood or cardioplegia (CP) solution. Myocardial biopsies were taken prior to CP arrest and upon successful defibrillation 5 min after initiating reperfusion. Ventricular fibrillation (VF) was recorded prior to ischemia, and then during reperfusion. VF wavefront (WF) morphology and propagation patterns were analyzed using computer algorithms. Electrophysiologic variables for measuring VF included the multiplicity index (a descriptor of VF organization), the number of WFs detected (nwaves/s) and the mean peak first derivative of electrogram voltage with respect to time (mp d V/dt). RESULTS: Intra-cellular sodium content increased, while intra-cellular magnesium content decreased between control and reperfusion measurements (p < 0.05). Electrophysiologic recovery was characterized by increasingly rapid depolarization (i.e. more negative mp d V/dt) and an increasing nwaves/s during the first minute of post-CP reperfusion. CONCLUSIONS: Atomic absorption spectroscopy and computer-based analysis of reperfusion VF successfully measured metabolic and electrophysiologic events that occurred during controlled reperfusion. These methods may be useful for comparing controlled reperfusion techniques.

Animals↗
PubMed1999

Infection during circulatory support with ventricular assist devices.

BACKGROUND: This study is a retrospective analysis of infections in patients supported by ventricular assist devices (VADs) as a bridge to cardiac transplantation. METHODS: Infections were assigned to four classes. Class I were patient-related nonblood infections, class II were blood-borne infections, class III were percutaneous site infections, and class IV were infections of intracorporeal VAD components. RESULTS: The cumulative number and incidence of infections were higher during the early VAD experience than in more recent patients (p < 0.05), although the cumulative number and incidence of class II and IV infections were similar in earlier and later patients. There were 28 serious (ie, class II and IV) infections in 9 patients who died, and 35 serious infections in 11 patients who survived until transplantation. Three of 4 patients with class IV infections died. A larger cumulative number of infections (ie, total class I-IV) was associated with more fungal isolates (p < 0.001) and more class II and IV infections (p < 0.02). Positive fungal cultures were obtained in 16 patients, but there were only 3 class III and 1 class IV fungal isolates. CONCLUSIONS: Infection remains an important problem for patients with VADs. Bloodstream infections (class II) can often be controlled by appropriate therapy. However, intracorporeal device infections (class IV) are associated with substantial morbidity and mortality. Optimal implant techniques together with optimal wound care, appropriate use of prophylactic antibiotics, and avoidance of infection in indwelling catheters remain the most practical means for minimizing the risk of VAD infection.

Adult↗
PubMed1999

Management of wound and left ventricular assist device pocket infection.

Our patient developed a wound infection that involved an implanted left ventricular assist device. At surgery, the pump was washed with a detergent-containing bacteriocidal solution, then antibiotic-impregnated polymethylmethacrylate beads were placed around the pump. The wound was revised using rectus muscle to cover the pump. The incisions have healed and the patient is now at home. She is on no systemic antibiotics and has no evidence of infection 11 months postoperatively.

Adult↗
PubMed1999

Alabama coronary artery bypass grafting Cooperative Project: baseline data. Alabama CABG Cooperative Project Study Group.

BACKGROUND: The Alabama Cooperative CABG Project is a statewide process-oriented analysis of coronary artery bypass grafting (CABG). The purpose of this report is to present the first information generated by this analysis, which will serve as a baseline for subsequent quality improvement projects. METHODS: Medical records of Medicare beneficiaries from Alabama, a comparison state, and a national random sample who had isolated CABG between July 1, 1995, and June 30, 1996, were examined. Fifty-six demographic, procedural, and outcome variables were abstracted. Quality indicators identified by the Alabama Quality Assurance Foundation Study Group included: internal mammary artery use, prescription of aspirin at discharge, duration of postoperative intubation, use of intraaortic balloon pump, readmission to intensive care unit, hospital readmission within 30 days, return to the operating room for bleeding, and in-patient mortality. Benchmark performance rates for quality indicators reflecting care processes were calculated. RESULTS: Alabama, the comparison state, and the national sample consisted of 4,092, 2,290, and 1,119 patients, respectively. The processes of care and outcome, including risk-adjusted mortality, for CABG across the state of Alabama are generally similar to other states and nationwide samples. However, there was considerable variation at the local hospital level in Alabama for each quality indicator. CONCLUSIONS: The data provide a "snapshot" of practice patterns for CABG in Alabama. A specific quality indicator (duration of intubation) was identified as a focus for statewide improvement. Hospital-specific variations in quality indicators suggested opportunities for improvement in other indicators at a number of hospitals.

Aged↗
PubMed1999

Outcome after myocardial revascularization and renal transplantation: a 25-year single-institution experience.

BACKGROUND AND OBJECTIVE: Cardiac disease is a common cause of death in renal transplant recipients. This study retrospectively analyzes the results of myocardial revascularization procedures in these patients and makes recommendations for managing coronary atherosclerosis in patients with renal disease who already have a transplanted kidney or who may receive a kidney transplant. METHODS: Patients who had myocardial revascularization (coronary artery bypass grafting [CABG] or percutaneous transluminal coronary angioplasty [PTCA]) and renal transplantation at the authors' institution between 1968 and 1994 were analyzed. Patient, procedural, and institutional variables were used for actuarial analyses of survival, as well as multivariate analyses of risk factors for death. RESULTS: Eighty-three of 2989 renal transplant patients required myocardial revascularization either before or after their transplant, and diabetes mellitus was the cause of renal failure in 42% of these patients. Standard coronary angiography, CABG, and PTCA techniques were used without periprocedural renal allograft loss. Actuarial patient survival was 89%, 77%, and 65% at 1, 3, and 5 years after the last procedure (transplantation or revascularization). Cardiac disease was the most common mode of death. Early-phase risk factors for death by multivariate analysis included hypertension and revascularization before 1989. Late-phase risk factors for death included diabetes mellitus, higher number of pre-CABG myocardial infarctions, renal transplantation before 1984, older age, and unstable angina before CABG. CONCLUSIONS: Myocardial revascularization can be performed with acceptable short- and long-term results in patients with renal disease who have renal transplantation either before or after the revascularization procedure. Diabetes mellitus was a highly prevalent condition among these patients, and cardiac disease was their most common mode of death. PTCA and CABG, as performed at this institution, posed little risk for renal allograft loss. Modification of risk factors for coronary atherosclerosis, rigorous cardiac evaluation of patients at risk for coronary artery disease before renal transplantation, and aggressive use of revascularization procedures to decrease the incidence of myocardial infarction are proposed as ways to prolong the survival of renal transplant patients with ischemic heart disease.

Coronary Artery Disease↗
PubMed1998

Arrest duration influences postcardioplegia electrophysiologic recovery and reperfusion arrhythmias.

BACKGROUND: This study tests the hypothesis that postcardioplegia electrophysiologic recovery is influenced by the duration of cardioplegic arrest. METHODS: Pigs were randomized to various durations of cardioplegic arrest (group I, 15 minutes; group II, 60 minutes; group III, 120 minutes). Electrophysiologic data included limb lead, atrial and ventricular epicardial, and ventricular endocardial electrocardiograms. Variables included times for earliest electrical activity and sinus rhythm; number of defibrillations; mechanism for reperfusion ventricular fibrillation; and time until last ventricular fibrillation. RESULTS: Time to last ventricular fibrillation was 73+/-8, 134+/-23, and 238+/-23 seconds for groups I, II, and III (mean+/-standard error of the mean; p < 0.05 between group III versus groups I and II). The number of defibrillations was 1.0+/-0.3, 5.8+/-1.2, and 10.5+/-1.1 for groups I, II, and III (p < 0.05 between groups). The time to sinus rhythm was 66+/-8, 192+/-27, and 249+/-23 seconds for groups I, II, and III (p < 0.05 group I versus groups II and III). The most common mechanism for reperfusion arrhythmias was an accelerating ventricular tachycardia that initiated fibrillation (79 of 167 episodes). However, in many instances postdefibrillation amplifier saturation masked the initiation of reperfusion arrhythmias. CONCLUSIONS: Electrophysiologic recovery after cardioplegic arrest is influenced by the duration of cardioplegic arrest.

Animals↗
PubMed1998

A prospective algorithm for the management of air leaks after pulmonary resection.

BACKGROUND: Air leaks (ALs) are a common complication after pulmonary resection, yet there is no consensus on their management. METHODS: An algorithm for the management of chest tubes (CT) and ALs was applied prospectively to 101 consecutive patients who underwent elective pulmonary resection. Air leaks were graded daily as forced expiratory only, expiratory only, inspiratory only, or continuous. All CTs were kept on 20 cm of suction until postoperative day 2 and were then converted to water seal. On postoperative day 3, if both a pneumothorax and AL were present, the CT was placed to 10 cm H2O of suction. If a pneumothorax was present without an AL, the CT was returned to 20 cm H2O of suction. Air leaks that persisted after postoperative day 7 were treated with talc slurry. RESULTS: There were 101 patients (67 men); on postoperative day 1, 26 had ALs and all were expiratory only. Univariable analysis showed a low ratio of forced expiratory volume in 1 second to forced vital capacity (FEV1/FVC) (p = 0.005), increased age (p = 0.007), increased ratio of residual volume to total lung capacity (RV/TLC) (p = 0.04), increased RV (p = 0.02), and an increased functional residual capacity (FRC) (p = 0.02) to predict the presence of an AL on postoperative day 1. By postoperative day 2, 22 patients had expiratory ALs. After 12 hours of water seal, 13 of the 22 patients' ALs had stopped, and 3 more sealed by the morning of postoperative day 3. However, 2 of the 6 patients whose ALs continued experienced a pneumothorax. Five of the 6 patients with ALs on postoperative day 4 still had ALs on postoperative day 7, and all were treated by talc slurry through the CT. All ALs resolved within 24 hours after talc slurry. CONCLUSIONS: Most ALs after pulmonary resection are expiratory only. A low FEV1/FVC ratio, increased age, increased RV/TLC ratio, increased RV, and an increased FRC were predictors of having an ALs on postoperative day 1. Conversion from suction to water seal is an effective way of sealing expiratory AL, and pneumothorax is rare. If an expiratory AL does not stop by postoperative day 4 it will probably persist until postoperative day 7, and talc slurry may be an effective treatment.

Adult↗
PubMed1998

Evaluation of complex mediastinal masses by magnetic resonance imaging.

MRI was used to diagnose a mediastinal mass in a elderly patient with previous repair of aortic coarctation. MRI excluded aneurysm by demonstrating a homogeneous mass encasing aorta and the bypass graft. A second thoracotomy was avoided. Moreover, outpatient testing was performed, without exposure to contrast agents, ionizing radiation, or an invasive procedure.

Aged↗
PubMed1997

Replacement of an intracorporeal left ventricular assist device.

An intracorporeal left ventricular assist device was placed as a bridge to cardiac transplantation in a 51-year-old man after an acute myocardial infarction. After 126 days of support, the left ventricular assist device malfunctioned. The pump, which had a tear in its pneumatic drive line, was successfully replaced.

Equipment Design↗
PubMed1997

Simultaneous use of an implanted defibrillator and ventricular assist device.

A left ventricular assist device was placed as a bridge to cardiac transplantation in a 51-year-old man with cardiogenic shock. Placement of the left ventricular assist device occurred 5 years after implantation of an implantable cardioverter/defibrillator. The implantable cardioverter/defibrillator discharged appropriately during ventricular assist device support to terminate episodes of sustained ventricular tachycardia without causing malfunction of the ventricular assist device.

Defibrillators, Implantable↗