Continuous tissue plasminogen activator infusion to maintain patency of recurrently narrowing coronary artery.
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Coronary Disease↗
Biomedical subjects
A Smolinsky
Publications and source records attributed to A Smolinsky.
Preservation of the posterior leaflet during mechanical valve replacement for ischemic mitral regurgitation and complete myocardial revascularization.
Between 1980 and 1987, 40 patients with ischemic mitral insufficiency underwent mitral valve replacement (with a mechanical prosthesis) and coronary bypass grafting, 3.5 grafts per patient. The posterior mitral leaflet was preserved in 17 and resected in 23. Five arrived at operation in cardiogenic shock, 15 after recurrent episodes of pulmonary edema, and 20 electively, but in congestive heart failure. Twenty-five had unstable angina, and the remaining had chronic angina. Perioperative and early deaths occurred only in patients with an ejection fraction less than 35%. None of the 21 patients with an ejection fraction greater than 35% died, whereas eight of 19 with an ejection fraction less than 35% died, whereas eight of 19 with an ejection fraction less than 35% died (p less than 0.001). When causes of death in patients with an ejection fraction less than 35% were studied, operative and early mortality was zero of seven with preservation of the posterior mitral leaflet versus eight of 11 with excision of the leaflet (p = 0.035). We concluded that the high mortality in mitral valve replacement for ischemic mitral insufficiency is linked to an ejection fraction less than or equal to 35% and, in this particular group of patients, is due to the surgical destruction of the left ventricular chordae tendineae supportive apparatus. Preservation of this apparatus by preservation of the posterior mitral leaflet drastically reduces operative and early mortality. Preoperative cardiogenic shock, left ventricular aneurysmectomy, and multiple grafting (up to five grafts per patient) did not increase the risk of operation. Extensive revascularization (3.5 grafts per patient) provides improved long-term results.
Aged↗
Infundibular septal resection: surgical anatomy of the superior approach.
A technique for extensive resection of the infundibular septum through the superior transarterial approach is proposed. Infundibular septal resection facilitates intraventricular rerouting for anatomic correction of transposition of the great arteries with ventricular septal defect and double-outlet right ventricle. This technique also may be used to enlarge progressively obstructive but physiologically advantageous ventricular septal defects, for example, with tricuspid atresia. Through the superior transaortic or transpulmonary approach, the landmarks of the infundibular septum are the intercoronary commissure of the aortic valve and the septal commissure of the pulmonary valve, both of which are directly above the middle of the infundibular septum. With this exposure, the infundibular septum may then be resected easily and relatively completely and a large opening created immediately beneath the semilunar valves. The feasibility of infundibular septal resection by the superior approach was assessed post mortem in 25 cases of transposition of the great arteries with ventricular septal defect and in 20 autopsied cases of double-outlet right ventricle. This technique was subsequently applied successfully to enlarge the obstructive ventricular septal defect of a 2-year, 11-month-old girl with D-transposition of the great arteries. The advantages of the proposed technique include technical ease, relative completeness of infundibular septal resection, and the facilitation of intraventricular repair of transposition of the great arteries with ventricular septal defect and double-outlet right ventricle.
Adolescent↗
Relationship of right and left ventricular negative diastolic pressures, hypercontractility, and relief of outflow tract obstructions.
Continuous postoperative right and left ventricular diastolic pressures were measured in 12 consecutive patients undergoing pulmonic valvotomy and in 13 consecutive patients undergoing membranectomy and myectomy for discrete subaortic stenosis. All 25 patients had positive preoperative diastolic ventricular pressures. Negative ventricular diastolic pressure was detected immediately postoperatively in all 25. The lowest left ventricular negative diastolic pressure was -38 mm Hg, and the lowest right ventricular negative diastolic pressure was -28 mm Hg. Intravenous administration of volume (blood) reduced the right ventricular negative diastolic pressure significantly (from -14.8 +/- 9.2 to -6.4 +/- 6.8 mm Hg, p less than 0.001) and decreased right ventricular rate of pressure rise from 1100 +/- 320 to 380 +/- 180. Left ventricular negative diastolic pressure was not significantly affected (from -17 +/- 11 to -14.7 +/- 11 mm Hg). Left ventricular negative diastolic pressure disappeared spontaneously 6 to 9 hours postoperatively in association with a spontaneous decrease of left ventricular rate of pressure rise (from 3450 +/- 610 to 2100 +/- 660 mm Hg/sec). We conclude that negative right and left ventricular pressures are common findings immediately after surgical relief of outflow obstructions. Hypercontractility is the main reason for these phenomena. Volume load reduces the right ventricular negative diastolic pressure, but has insignificant effect on left ventricular negative diastolic pressure. The pathogenesis of the hypercontractility is discussed.
Aortic Valve Stenosis↗
The perioperative fate of residual gradients after repair of discrete subaortic stenosis and time-related blood levels of catecholamines.
UNLABELLED: The fate of the residual peak systolic left ventricular-aortic gradient was studied perioperatively in 14 patients with membranous discrete subaortic stenosis. In nine (group A) the initial postrepair left ventricular-aortic gradient was greater than 35 mm Hg (mean 56.8 +/- 13.4), and in five (group B) there was no significant postoperative gradient (mean 15.3 +/- 3.2 mm Hg). The operation included membranectomy and myectomy. Peak left ventricular-aortic pressure gradient, endogenous levels of norepinephrine, peak rate of rise of left ventricular pressure, cardiac index, systemic vascular resistance, heart rate, and central venous pressure were recorded at the end of cardiopulmonary bypass and in 3-hour intervals for the next 9 hours. In group A during that period there was a 67% reduction in peak systolic left ventricular-aortic gradient (from 56.8 +/- 13.4 to 18 +/- 14 mm Hg, p less than 0.001). Concomitant reduction in the initial endogenous norepinephrine level was observed (from 982.1 +/- 181 to 422.6 +/- 109 pg/ml, p less than 0.001). A consistent linear relationship between norepinephrine levels and peak systolic left ventricular-aortic gradient was found (r = 0.78). Systolic left ventricular pressure decreased from 174.2 +/- 24.8 to 113.8 +/- 14.7 mm Hg (p less than 0.001). Marked reduction in peak rate of rise of left ventricular pressure (from 3455 +/- 636 to 2161 +/- 680 mm Hg/sec, p less than 0.001) was observed. Cardiac index increased and systemic vascular resistance decreased during the study period (from 2.11 +/- 0.2 to 3.07 +/- 0.26 L/min, p less than 0.001, and from 2172 +/- 331 to 1233 +/- 202 dynes/sec/cm-5, p less than 0.001, respectively). There were no significant changes in heart rate (p = not significant) and central venous pressure p = not significant). CONCLUSION: Some of the residual perioperative left ventricular-aortic gradients in patients with discrete subaortic stenosis undergoing repairs are dynamic and transient, and are probably related to increased postoperative sympathetic activity.
Adolescent↗
Obstructed pulmonary venous drainage with total anomalous pulmonary venous connection to the coronary sinus.
Obstructed pulmonary venous drainage is generally considered extremely rare with total anomalous pulmonary venous connection (TAPVC) to the coronary sinus (CS). A retrospective review of 27 operated patients with TAPVC to CS revealed 6 cases of obstruction (22%). Two of 6 patients who died early had evidence of obstruction at the pulmonary vein confluence at autopsy. Among the 21 hospital survivors, obstruction proximal to the point of CS unroofing developed in 4 (19%), necessitating reoperation and resulting in death in 3. One other patient died late. Mean follow-up of the 17 long-term survivors, who are generally doing well, is 85 months (range 2 to 212). There have been no cases of late obstruction at the site of unroofing among 10 patients who underwent the fenestration procedure suggested by Van Praagh. The incidence of early bradyarrhythmias (60%) does not appear to be decreased by this procedure. Review of 13 autopsy specimens suggests that if the right and left pulmonary veins did not drain directly to the CS but converged to form a short common vertical vein (4 cases), obstruction was likely. When pulmonary artery pressure approaches systemic levels preoperatively, careful echocardiographic and intraoperative assessment of the junction of the pulmonary vein confluence with the CS should be made. If there is evidence of obstruction, consideration should be given to anastomosing the horizontal right and left pulmonary veins directly to the left atrium rather than performing a simple unroofing procedure.
Coronary Vessel Anomalies↗
Pericardial patch enlargement of Blalock-Hanlon atrial septectomy.
A modified Blalock-Hanlon operation is described, in which both the right and left atriotomies were bridged by a generous pericardial patch. This patch significantly enlarged the interatrial communication and markedly increased arterial blood saturation.
Child, Preschool↗
Negative right ventricular diastolic pressure after operation for pulmonary valve stenosis: the phenomenon and its relation to volume load and conal contraction.
The phenomenon of negative right ventricular diastolic pressure immediately after operation for relief of isolated pulmonary valve stenosis was investigated in 11 patients. Pressures in the right ventricle and pulmonary artery were measured with a catheter tip micromanometer. One patient had a negative right ventricular diastolic pressure before operation. At the end of operation right ventricular diastolic pressure was negative in all 11 patients. The greater the right ventricular hypertrophy, the lower were these diastolic pressures. Negative right ventricular diastolic pressure is thus common in patients after pulmonary valvotomy, but fluid administration may eliminate it. Negative right ventricular diastolic pressure may be the result of hypercontraction and reduced volume of the hypertrophied right ventricle after relief of right ventricular outflow tract obstruction.
Adolescent↗
Changes in systemic vascular resistance detected by the arterial resistometer: preliminary report of a new method tested during percutaneous transluminal coronary angioplasty.
A recently developed apparatus provides on-line continuous monitoring of systemic vascular resistance (SVR) by means of simple computer analysis of the peripheral arterial waveform. The fundamental equation of this method is Ri = P'/(dP/dt), where dP/dt is the peak dP/dt of the peripheral arterial waveform, P' is the pressure at time of peak dP/dt, and Ri is a resistance index that bears a direct relation to SVR. Eleven patients undergoing percutaneous transluminal coronary angioplasty (PTCA) were studied to evaluate the changes in SVR associated with myocardial ischemia (angina detection). There were 49 balloon inflations, all of which were associated with an increase in Ri (from 38.4 +/- 12 to 81.2 +/- 36 X 10(-3) sec; p less than .01) and a decrease in dP/dt (from 2076 +/- 257 to 1327 +/- 326 mm Hg/sec; p less than .01). In 42 of the balloon inflations these changes were associated with electrocardiographic ST-T changes and in 23 it was also associated with anginal pain. When angina was present, a further increase in Ri (to 97.5 +/- 43 X 10(-3) sec; p less than .01) and a decrease in dP/dt (to 1218 +/- 338 mm Hg/sec; p less than .01) was observed. It was found that myocardial ischemia is associated with an increase in the resistance index and a decrease in dP/dt and can be detected by the resistometer.
Angioplasty, Balloon↗
Myectomy versus myotomy as an adjunct to membranectomy in the surgical repair of discrete and tunnel subaortic stenosis.
The results of membranectomy and deep myectomy in the left ventricular outflow tract were compared to those of membranectomy and myotomy in 42 patients who underwent surgical repair of discrete and tunnel subaortic stenosis. Fifteen consecutive patients (Group A) underwent membranectomy and myotomy, and 27 consecutive patients (Group B) underwent membranectomy and myectomy. Two patients of Group A and nine of Group B had tunnel subaortic stenosis. The preoperative mean (+/- standard deviation) peak systolic gradients across the left ventricular outflow tract in patients with discrete subaortic stenosis types I and II were 64 +/- 29 mm Hg in Group A and 52 +/- 3 mm Hg in Group B (p = not significant). In the patients with tunnel subaortic stenosis the preoperative mean gradients were 97 +/- 74 mm Hg in Group A and 73 +/- 26 mm Hg in Group B (p = not significant). In patients with discrete subaortic stenosis types I and II, postoperative catheterization at a mean follow-up of 21 months revealed residual mean gradients of 29 +/- 24 mm Hg in Group A and 10 +/- 13 mm Hg in Group B (p less than 0.01). In the patients with tunnel subaortic stenosis, the postoperative mean gradients were 25 +/- 7 and 30 +/- 30 mm Hg in Groups A and B, respectively (p = not significant). We conclude that in the surgical management of discrete subaortic stenosis types I and II, deep myectomy (in addition to membranectomy) produces better relief of the left ventricular outflow obstruction than do membranectomy and myotomy. In patients with tunnel subaortic stenosis myectomy is less effective than in the non-tunnel type but still produces acceptable results and may delay radical procedures to a later age.
Adolescent↗
Dysplastic aortic valve with absence of aortic valve cusp: an unreported cause of congenital aortic insufficiency.
Three patients are described in whom dysplasia of the aortic valve was associated with total absence of one of the semilunar aortic cusps and congenital aortic insufficiency. Two of the three survived aortic valve replacement.
Adolescent↗
The effect of low-dose intravenous nitroglycerin on pulmonary hypertension immediately after replacement of a stenotic mitral valve.
The postoperative effect of infusion of nitroglycerin on pulmonary vasomotor dynamics was studied in 28 patients undergoing valve replacement for mitral valve stenosis. A 30% reduction in mean pulmonary arterial pressure (38.74 +/- 8.3 to 26.92 +/- 7.72 mm Hg, p less than .001) and a 48.4% reduction in pulmonary vascular resistance index (12.08 +/- 4.19 to 5.61 +/- 1.61 U/m2, p less than .001) were observed after nitroglycerin. While pulmonary driving pressure (mean pulmonary arterial pressure minus left atrial pressure) dropped by 50.8%, cardiac and stroke volume indexes increased by 25.5% and 24.2%, respectively. The ratio pulmonary/systemic vascular resistance decreased from 34.14% to 20.9% (p less than .001). There were no significant changes in mean systemic arterial pressure (86.89 +/- 13.5 to 83.5 +/- 9.3 mm Hg, p = NS) or heart rate (97.43 +/- 20.45 to 99.36 +/- 20.9 beats/min, p = NS); left and right atrial pressures decreased by 19.5% and 9.5%, respectively. Systemic vascular resistance index decreased by 18.8%. We conclude that low-dose infusion of nitroglycerin reduces the pulmonary vascular resistance in patients with pulmonary hypertension, and consequently results in improvement in immediate postoperative hemodynamics after replacement of a stenotic mitral valve.
Adolescent↗
Staged surgical treatment of early bacterial endocarditis after surgical repair of tetralogy of Fallot and discrete subaortic stenosis: report of a case.
An unconventional method of managing infection of the interventricular Teflon patch in a patient with tetralogy of Fallot is reported. The patch was initially replaced by a new patch. After reinfection, however, removal of the patch and pulmonary banding eradicated the infection, and at a later stage the defect was re-repaired successfully.
Cardiomyopathy, Hypertrophic↗
Percutaneous closure of a Blalock-Taussig shunt.
The technique used in the percutaneous closure of a Blalock-Taussig shunt in a 4-year-old child is described. After selective catheterization of the subclavian artery leading to the shunt, a spring coil was inserted which completely occluded the shunt.
Child, Preschool↗
Chemical reduction of oxidized human lymphocytes inhibits interleukin 2 production but not induction of interleukin 2 responsiveness.
Treatment with neuraminidase (NA) plus galactose oxidase (GalOxase) does not cause stimulation of human thymocytes. However, stimulation can be achieved by addition of exogenous interleukin 2 (IL-2). The IL-2-induced stimulation was inhibited with anti-Tac antibody, indicating that NA/GalOxase-oxidized cells can serve as inducers of functional IL-2 receptors on IL-2-responding T cells. The induction of IL-2 receptors by the oxidized cells was not inhibited by subsequent reduction with borohydride, since the cells could still be stimulated with IL-2. The presence of IL-2 receptors was also confirmed by flow cytometry using indirect immunofluorescence. Peripheral blood lymphocytes can be stimulated by NA/GalOxase treatment, and the conditioned medium from this treatment can support the growth of an IL-2-dependent line. This stimulation can be inhibited with borohydride and restored with IL-2. The conditioned medium derived from the borohydride-reduced cells cannot support the growth of the IL-2-dependent line, indicating that borohydride inhibits the oxidation-induced IL-2 production. The results suggest that NA/GalOxase-oxidized sites can be modified chemically without losing the potential to induce IL-2 receptors.
Cell Line↗
Pericardial-mechanical valved conduits in the management of right ventricular outflow tracts. Preliminary report.
Over the 3 year period from 1980 to 1982, mechanical prosthetic valves were implanted in the pulmonary pathway in seven patients. In two the procedure was a pulmonary valve replacement. In two it was an implantation of a pulmonary valve with transannular pericardial patching, and in three, complete pericardial (tube) conduits, which included mechanical valves, were constructed. There were neither perioperative nor late complications. Four patients were recatheterized. In three residual right ventricular hypertension was observed. In one of the three the cause of obstruction was not verified, but in the remaining two it was unrelated to the mechanical valve. No thromboembolic phenomena were observed.
Adolescent↗
Cardiac complications in vascular procedures: comparison of percutaneous angioplasty and surgery.
Percutaneous transluminal angioplasty (PTA) is currently recommended to high risk cardiac patients as a relatively safer procedure compared to reconstructive peripheral vascular surgery (RPVS). In order to evaluate this approach we studied the incidence of cardiac complications in 86 consecutive patients undergoing peripheral vascular procedures. 45 patients (Group I) underwent RPVS and 41 (Group II) PTA. The two groups were comparable regarding age, sex, the location of vascular lesions, the incidence of previous MI (Group I--40%, Group II--46%), and the incidence of angina pectoris (I--25%, II-29%). No special treatment or monitoring was used for patients with ischemic heart disease (IHD) in the PTA group. Successful revascularization was achieved in 36 (80%) of the surgical patients and 25 (61%) of the patients who underwent PTA. There were two anginal attacks, two MIs, and one cardiac death in group I compared to six anginas, three MIs, and one death in Group II. These differences are not statistically significant. It is concluded that PTA carries a definite risk of cardiac complications in patients with known IHD.
Aged↗
Beneficial effects of feet-down bed position in nocturnal angina.
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Angina Pectoris↗