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PubMed1994

[Mechanism and prevention of postoperative hemolysis in the corrective surgery of subarterial ventricular septal defects].

Intravascular hemolysis following the repair of subarterial ventricular septal defects (VSD) was studied in 34 patients. The VSD was closed through a main pulmonary arteriotomy with a Dacron double-velour patch (Meadox, Oakland, NJ) in 17 cases (Group B) and with a Dacron single-velour patch covered by autologous pericardium facing toward the right ventricular outflow tract (RVOT) in 17 cases (Group A). No significant intergroup difference in age, weight, Qp/Qs, Pp/Ps, and Rp/Rs was found. There were no significant differences in the preoperative values of serum LDH, total bilirubin, and flow velocity at the RVOT (Group A: 1.7 +/- 0.4 m/sec vs Group B 1.8 +/- 1.0 m/sec). The severity of hemolysis was evaluated by serum LDH levels, total bilirubin levels, and hemoglobinuria on the morning of the first operative day. Postoperative LDH levels were significantly lower in the Group A (812 +/- 205 IU/L) than in the Group B (1098 +/- 427 IU/L) (p < 0.05). Hemoglobinuria developed in 2 patients in Group B (12%) and none in Group A. These data suggest that the pericardium apparently protects against postoperative hemolysis. The intensity of the turbulence at the RVOT was graded as follows using color-doppler echocardiography (0: none; Grade 1: turbulence was detected near the patch only; Grade 2: turbulence was detected halfway to the RVOT; Grade 3: turbulence extended to the anterior wall of the RVOT). The relationship between the presence of hemolysis and the degree of turbulence was examined. Turbulence at the RVOT appeared in 73% of those in Group A and in 82% of those in Group B.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1996

Prosthetic-vein composite graft with remote popliteal arteriovenous fistula.

BACKGROUND: Inadequate autogenous vein is often the limiting factor in femoral-distal reconstruction. Sequential grafts, distal arteriovenous fistulae (AVF), and autogenous cuffs have been recommended in this setting. This paper describes a new method of composite reconstruction, enhanced with a popliteal AVF. PATIENTS AND METHODS: Data was collected prospectively on 13 patients (14 limbs) who presented with severe ischemia (rest pain or ulcer 6, gangrene 8). The average age was 75 years. Eleven of the reconstructions were to tibial outflow tracts. The novelty of the technique is in the construction of a controlled AVF between the upper end of an autogenous vein graft and the popliteal vein. An uncomplicated autogenous anastomosis is created distally. The synthetic graft is placed between the common femoral artery and the vein graft distal to the AVF. The flow is balanced between the fistula and the outflow tract by narrowing the fistula while monitoring the pressure in the graft system. RESULTS: Patency was assessed by color duplex scan. Two grafts occluded (at 5 and 7 months) and 1 was revised at 12 months. Mean peak systolic velocity in the synthetic portion was 130 cm/s. Limb edema has not been a problem. There were 2 perioperative cardiac deaths. Mean follow up is 15 months (range 6 to 36). CONCLUSION: The addition of a controlled AVF below the synthetic portion of a composite graft appears promising when vein is in limited supply.

Aged↗
PubMed1995

Aortic root replacement with a pulmonary autograft.

A series of 42 consecutive patients with exclusively aortic root replacement using the pulmonary autograft is presented. The mean age at operation was 19.3 years (range 0.3-41.4). Two patients died in hospital (4.8%; 70% CL: 0.0-8.2). This mortality was not related to the autograft procedure. The mean follow-up time was 30 months (range 3-70; SD: 20). Late mortality consisted of two patients; in one of these severe autograft failure occurred due to chronic juvenile rheumatoid arthritis. The estimated survival rate at 4 years was 88.8% (70% CL: 83.3-94.5). Morbidity involved three patients. One had a total heart block after operation, requiring pacemaker implantation and two patients were reoperated: one for severe autograft failure due to recurrent acute rheumatic fever and the other for severe stenosis at the distal anastomosis of the pulmonary allograft. Thromboembolic complications and endocarditis were not registered. Reoperations for technical or degenerative reasons were not necessary. The estimated event-free survival rate at 4 years was 78.7% (70% CL: 71.0-86.4). Serial echocardiography (n = 28) showed a significant increase of the autograft annulus diameter of 2.9 mm (SD: 2.7). Thirty-five of the 37 patients with an autograft in situ were in NYHA class I, and 2 in class II. At last follow-up precordial color Doppler echocardiography showed moderate aortic regurgitation in one patient and no, trivial or mild aortic regurgitation in 36 patients. Stenosis of the autograft was not observed. These medium-term results are promising with respect to mortality, morbidity and functional results.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed2005

Is the valve OK or not? Immediate evaluation of a replaced aortic valve.

Transesophageal echocardiography is a crucial tool in intraoperative evaluation of newly implanted/repaired heart valves because suspected valvular malfunction needs to be identified and sometimes surgically corrected. Although color Doppler is often adequate in evaluating the expected regurgitant jets, as well as excluding pathologic paravalvular leaks, spectral Doppler techniques are the most commonly used methods for estimating transvalvular gradients in the operating room. However, these methods are subject to a variety of confounding factors, including subvalvular gradients and pressure recovery. Other methods of valve area estimation should also be used when evaluating a prostethic aortic valve, including the continuity equation and the left ventricular outflow tract/aortic valve velocity ratio.

Aortic Valve↗
PubMed2004

Submammary flap for correction of severe sequelae from augmentation mammaplasty.

A submammary flap was used in 20 patients with severe cicatricial retractions and loss of the inferior pole of the breast caused by inadequately treated mammary implant infections. This axial flap can be used with a medial pedicle, based on the perforating branches of the epigastric artery or the distal part of the internal mammary artery, or laterally based, nourished by the intercostal perforators. After 6 months, reimplantation was performed in 15 patients. The authors' follow-up ranged between 8 months and 6 years. This transverse adipocutaneous flap procedure is very simple to perform, the donor site is sutured primarily without additional undermining, and the resultant scar lies hidden within the submammary fold. It provides tissue with similar skin texture and color match. Its versatility allows it to be used as a full-thickness tissue replacement or partially or totally de-epithelialized for soft-tissue reconstruction. It can also be used as an island flap. For all of these reasons, in emotionally distressed patients with low compliance with surgical treatments and additional scars, this flap is the authors' flap of choice for reconstruction.

Adult↗
PubMed1992

Mitral valve repair using Carpentier techniques in patients more than 70 years old. Early and late results.

BACKGROUND: Mitral valve incompetence in elderly patients raises the problem of whether to replace or to repair the mitral valve. The purpose of this study is to review our experience with mitral valve repair in patients > 70 years old. METHODS AND RESULTS: Between 1986 and 1991, 79 consecutive patients > 70 years old underwent mitral valve repair by Carpentier techniques. The most frequent cause was degenerative valve disease (65 of 79). Preoperative echocardiography showed that 6% of the patients had type I, 88% type II, and 5% type III mitral valve dysfunction. Anatomic lesions encountered at surgery confirmed the preoperative echocardiographic findings, with 88% of the patients with a leaflet prolapse either of the posterior leaflet (56%) or of both the anterior and posterior leaflets (32%). Multiple surgical procedures were required in each patient. Posterior leaflet resection was the most common technique used (76%). Prosthetic ring annuloplasty was used in 96% of patients. Associated procedures were performed in 21.5% of cases. Three patients died, for an operative mortality of 3.8%. One patient (1.3%) required reoperation for residual mitral insufficiency. Nonfatal complications related to the patients' preoperative condition were noted in more than half of the patients. Echocardiography obtained before discharge revealed absent or minimal mitral insufficiency in 91% of patients and mild mitral insufficiency (2+/4+) in 9%. Follow-up was available for 74 of 76 patients (97.3%) and ranged from 3 months to 6 years (mean, 22 months). Two patients (2.6%) were lost to follow-up. Sixty patients (89%) were in New York Heart Association functional class I or II. Seven patients died and one required reoperation. Actuarial analysis of the results showed overall survival at 5 years 81 +/- 11%; freedom from thromboembolism, hemorrhage, and reoperation 97 +/- 5%, 97 +/- 5%, and 98 +/- 4%, respectively. Color-coded echo Doppler studies obtained in 67 patients at the time of follow-up showed absent or minimal MI (91%) (n = 61), and mild MI in 9% (n = 6). CONCLUSIONS: These data suggest that mitral valve repair using Carpentier techniques should now be considered as the procedure of choice in patients of any age referred for mitral insufficiency.

Actuarial Analysis↗
PubMed2005

New intraocular lens technology.

PURPOSE: To review the current status of phakic intraocular lenses (IOLs), intraocular treatment of presbyopia, and IOLs that filter some blue light. DESIGN: Review of current information on the subject from numerous sources. METHODS: Medline search and Internet search engines on the topics of phakic IOLs, presbyopia or multifocal IOLs, and blue light and macular degeneration. RESULTS: An iris fixated phakic IOLs is now approved in the United States (US). There are concerns for corneal endothelial stability and late dislocation. Other approaches include anterior chamber fixation with concerns of corneal endothelial stability and pupil elongation, and posterior chamber fixation with concerns of cataract formation, IOL dislocation, and pigment dispersion. Intraocular treatment of presbyopia includes monovision, multifocal, and accommodative IOLs. Which approach is superior today is still not clear. There are IOLs designed to block some blue light to potentially lessen the risk of age-related macular degeneration (ARMD). While there is presumptive evidence of this, no definitive study shows such a correlation. Color perception issues are unlikely to be a problem. While decreased scotopic vision has been proposed, there is no study that proves this is an issue of clinical significance. CONCLUSIONS: The IOL field is dynamic with many new choices. Phakic IOLs and treatment of presbyopia will be an increasingly important part of ophthalmology; however, there are important unresolved issues. With better evidence that blue light is an important variable in ARMD, such an approach could rapidly become the standard.

Biomedical Technology↗
PubMed1992

Left atrial V waves following mitral valve replacement are not specific for significant mitral regurgitation.

Left atrial or pulmonary capillary wedge pressure V waves are used immediately after mitral valve replacement to evaluate valve competence. However, their correlation with hemodynamically significant regurgitation has not been established. Transesophageal echocardiography (TEE) was used to prospectively examine whether left atrial V waves represented significant mitral regurgitation in 11 patients undergoing mitral valve replacement. Left atrial pressure V waves were measured in the immediate postcardiopulmonary bypass period by direct cannulation of the right superior pulmonary vein and recorded on a paper chart recorder. In each patient, three evaluations of mitral regurgitation by Doppler TEE were made at 15-minute intervals. In 22 of 33 evaluations, left atrial V waves with peak V wave height more than 5 mm Hg above the mean left atrial pressure were present. However, only in 3 of these periods did transesophageal echocardiography show evidence of more than trace mitral regurgitation by pulsed Doppler and color flow mapping. As indicators of mild-to-severe mitral regurgitation diagnosed by TEE, left atrial V waves had a specificity for the three evaluation periods of 40%, 30%, and 40%. Left atrial V waves with peak height greater than 5 mm Hg above mean left atrial pressure frequently appear following mitral valve replacement, but these V waves are nonspecific signs of mitral regurgitation.

Aged↗
PubMed2002

Characterization of visual phenomena with the Array multifocal intraocular lens.

PURPOSE: To characterize the visual sensations reported after bilateral implantation of the Array multifocal intraocular lens (IOL) (Allergan Surgical) and evaluate the means to mitigate unwanted visual sensations. SETTING: Surgery centers in Kansas City, Missouri, and Lake Worth, Florida, USA. METHODS: A retrospective parallel-group assessment of subjective nighttime visual sensations was conducted in 22 patients who had bilateral implantation of the Array multifocal IOL. Thirteen patients were recruited from a small subset of patients who were dissatisfied with the Array because of unwanted visual sensations (UVS group). The parallel group included 9 patients who were satisfied with the Array and not bothered by visual sensations (satisfied group). The primary endpoint was the patient's characterization of visual phenomena under simulated nighttime conditions. The secondary endpoint was the effect of adding trial lenses of -0.50 diopter (D) and -1.00 D to the patient's distance spectacle correction. RESULTS: Most patients reported that the simulation produced visual sensations similar to their real-life experiences. Patients in the UVS group reported the visual sensations as large starbursts and somewhat spoke-like starbursts with fine lines. Patients in the satisfied group reported them as blurred large or small starbursts. A few reported a color variance and finer quality to the starburst in real life. Visual phenomena were generally mitigated by the addition of a -0.50 D or -1.00 D lens. CONCLUSIONS: Both study groups reported similar visual phenomena. The difference between those who were bothered by the visual sensations and those who were not appears to be a function of individual tolerance. The visual sensations may be mitigated with minus-lens overcorrection.

Aged↗
PubMed1996

The clinical performance of CAD-CAM-generated ceramic inlays: a four-year study.

The authors conducted a long-term clinical study of 50 CEREC (Siemens AG) CAD-CAM inlay restorations in 28 patients. After four years, they found the inlays to rate very highly in color matching, interfacial staining, secondary caries, anatomic contour, marginal adaptation, surface texture and postoperative sensitivity. They monitored cement loss along the occlusal margins and found it to be relatively low, with an unusual decrease in measured cement wear from the third to the fourth year. The favorable results of this long-term clinical study of these CAD-CAM restorations portend significant success for this restorative approach.

Analysis of Variance↗
PubMedDate not supplied

[Experimental rationale for the use of a new model of the artificial iridolens stop for reconstructive surgery].

A new-design artificial iridolens stop (ILS) has been constructed, which is monolithic, elastic, universal by possible implantation modalities in relation to the degree of a damage to the anatomy of the anterior segment of the eye, adapted to surgery of minor incisions, and alleviating intra- and postoperative complications. The color spectrum of the haptic part of an ILS yields a good cosmetic effect. The ILS is made from a hydrophobic spatially sutured polymer based on polyoxypropylene. The experimental findings suggest that the proposed ILSs show a chemical and biomedical safety. The stops exert no locally irritant, sensitizing, and toxic effects, they are sterile, apyrogenic and meet the specifications of the items permanently contacting the internal environment of the eye.

Aniridia↗
PubMed2004

Mitral valve repair without cardiopulmonary bypass or atriotomy using the coapsys device: device design and implantation procedure in canine functional mitral regurgitation model.

BACKGROUND: Myocor developed a unique system, the Coapsys annuloplasty system, to treat functional mitral regurgitation (MR) without cardiopulmonary bypass (CPB). This study was conducted to test the feasibility of the Coapsys implantation procedure in a canine functional MR model. METHODS: Functional MR with heart failure was induced in 9 dogs by rapid ventricular pacing (230 beats/min for 30 +/- 4 days). The Coapsys device, which consists of anterior and posterior epicardial pads connected by a subvalvular chord, was then surgically implanted. Under epicardial echocardiographic guidance, we placed the Coapsys device across the left ventricular chamber using the delivery instrument and needle assembly. We sized the Coapsys device by drawing the posterior leaflet and annulus toward the anterior leaflet with the sizing instrument. Final device size was selected when MR was minimized or eliminated as assessed by 2-dimensional color Doppler echocardiography. RESULTS: In all cases, we successfully implanted the Coapsys device without CPB or atriotomy. MR was reduced an average of 2 grades. No adverse events, such as hemodynamic compromise or structural valve damage, were noted. CONCLUSION: Coapsys device implantation was feasible and safe on a beating canine heart. All accessory tools used for device implantation were found useful.

Animals↗
PubMed1995

Transesophageal echocardiography in the evaluation of prosthetic valves.

Biplane and multiplane TEE, with its relatively low risk, has become an invaluable complement to a comprehensive transthoracic two-dimensional Doppler and color flow examination. It should be undertaken in all instances when the transthoracic information is not adequate or if there is suspicion of abnormality that is not detected by TTE. One can advocate the use of TEE in the operating room in all instances wherein a patient is going to be implanted with a prosthetic valve because it will permit one to obtain baseline information that may be valuable in the management of patients seen subsequently with questionable findings when comparison is valuable. The role of cardiac catheterization is limited. Hemodynamic cardiac catheterization should only be used in instances in which there is discrepancy between echocardiographic findings and clinical presentation. Visualization of coronary arteries may be indicated in some situations, and a limited coronary arteriogram could be performed, the procedure being less morbid if separated from hemodynamic right and left heart catheterization. Echocardiography represents the state of the art in evaluation of patients with valvular prosthesis. Biplane TEE and multiplane TEE are valuable complementary technology to be used in conjunction with TTE, when the situation dictates its use, because it provides useful information that alters management of the patient.

Aortic Valve↗
PubMed2004

[Type A dissection caused by aortic cannulation during coronary artery bypass grafting; report of a case].

A 71-year-old woman who had severe stenosis in the origin of the left anterior descending coronary artery with large diagonal branch was scheduled for coronary artery bypass grafting (CABG). After harvesting of bypass conduits, aortic cannulation was performed into the ascending aorta. Immediately after insertion of the cannula, however, the ascending aorta changed to a bluish color. Epiaortic ultrasonography revealed aortic dissection. Replacement of the ascending aorta was carried out using circulatory arrest under deep hypothermia. The intimal tear was located at the cannulation site. After this procedure, scheduled CABG the left internal thoracic artery to the left anterior descending coronary artery and the saphenous vein graft to the diagonal branch was performed. The proximal site of the saphenous vein graft was anastomosed to the replaced graft. The postoperative course was uneventful. Rapid identification and appropriate surgical management are necessary to minimize patient morbidity and mortality.

Aged↗
PubMed1996

Dental ceramic restorative systems.

Esthetic restorative materials have rapidly grown in number and use. Ceramic materials are often the restorative of choice because they can replicate the color and shape of the natural dentition. Metalceramic restorations are still the most widely used type of ceramic system. However, there has been rapid development of all-ceramic restorative systems that do not require a metal substructure. The intent is to create a translucent restoration that mimics the appearance of the natural tooth. A variety of systems with different methods of fabrication, translucency, and strength are available for use. This article reviews the conventional metal-ceramic system and discusses all-ceramic systems with an eye to clinical selection based on material properties.

Aluminum Oxide↗
PubMed1993

[New procedures in transesophageal echocardiography: multiplane transesophageal echocardiography and transesophageal stress echocardiography].

Multiplane transesophageal echocardiography is a new development in transducer technology, which allows by rotation of the transducer to obtain not only transverse and longitudinal planes but also all intermediate planes. Exterior control allows continuous rotation of the scanning plane from the conventional transverse plane, corresponding to 0 degree, to the longitudinal plane, corresponding to 90 degrees and further to a left-right inverted transverse plane, corresponding to 180 degrees. Although the echoscope tip, which houses the rotatable transducer, is slightly larger than conventional probes, in our clinical experience of well over 400 cases, intubation of the esophagus is not more difficult than with the mono- or biplane probe. In comparison with the biplane technique the adjustment of intermediate planes is easier and less unpleasant for the patient, since mechanical irritation due to sideward flexion of the probe is less often necessary. Plane rotation, effected by control buttons in the echoscope handle, takes eight seconds from 0 degree to 180 degrees. The probe incorporates a 5 MHz phased array transducer, which alternatively works at 3.7 MHz. Pulsed, continuous and color Doppler are also integrated. Multiplane transesophageal echocardiography was used to investigate several clinical questions. In 41 patients with aortic valve stenosis the valve area was determined by planimetry. The valve area was measured in an individually aligned short axis view (between 50 degrees and 70 degrees). A high correlation (r = 0.95; Y = 0.9 X + 0.1; p < 0.01) with invasively determined valve areas by the Gorlin formula was found.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMedDate not supplied

Treatment of secondary stent-graft collapse after endovascular stent-grafting for iliac artery pseudoaneurysms.

We report the case of a patient who developed an asymptomatic pseudoaneurysm in the left external iliac artery after transplant nephrectomy. The pseudoaneurysm most probably arose as a suture aneurysm from the external iliac artery after removal of the graft renal artery. Obviously we can not exclude the possibility it was a true aneurysm, although this seems much less likely. The pseudoaneurysm was detected during a routine CT scan and was treated interventionally with a stent-graft. One month later the asymptomatic patient underwent a vascular ultrasound examination including color Doppler, power Doppler, and B-flow as a routine control. An endoleak with collapse of the stent-graft was diagnosed. There was no evidence of stent infection. At a reintervention, the pseudoaneurysm was successfully treated using two uncovered Palmaz stents at the proximal and distal edge of the stent graft. Peri- and post-interventional ultrasound and CT angiography confirmed the exclusion of the aneurysm without an endoleak.

Adult↗
PubMed1993

Adjustable tricuspid valve annuloplasty assisted by intraoperative transesophageal color Doppler echocardiography.

Intraoperative transesophageal echocardiography (TEE) can play a major role in active guidance of cardiac surgery. This study describes a new application of TEE for assisting tricuspid suture annuloplasty. Twenty-five patients (aged 52 +/- 11 years) who underwent mitral valve replacement and tricuspid valve annuloplasty were studied intraoperatively by TEE. After cardiopulmonary bypass, the suture annuloplasty was adjusted on the beating heart until palpable regurgitation was eliminated. Further adjustment of the suture was performed under echocardiographic guidance until color Doppler flow imaging showed the most adequate correction of tricuspid regurgitation (TR). A significant decrease in the semiquantitative grade of TR, of regurgitant jet area and of the ratio jet area/right atrial area was obtained when the suture was adjusted under echocardiographic guidance. The peak inflow velocity and the gradient across the tricuspid valve did not show significant changes throughout the procedures. The results showed that the tricuspid suture annuloplasty guided by TEE enables a substantial reduction in residual TR without creating valve stenosis.

Adult↗