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Biomedical subjects

B S Goldman

Publications and source records attributed to B S Goldman.

At least 19 recordsLinked to original sources
PubMed1995

Intermittent warm blood cardioplegia. Warm Heart Investigators.

BACKGROUND: Warm heart surgery implies continuous perfusion with normothermic blood cardioplegia. Interruption of cardioplegia, however, facilitates construction of distal coronary anastomoses and is the method practiced by many surgeons. To determine whether intermittency is harmful, we present results from 720 coronary bypass patients, protected with intermittent antegrade warm blood cardioplegia, that were derived from a previous study of normothermic versus hypothermic cardioplegia. METHODS AND RESULTS: Mean +/- SD age was 60.8 +/- 9.0 years; 27% of cases were urgent; 16% of patients had > 50% left main stenosis, and 19% had grade III or IV ventricles. A mean of 3.2 +/- 0.9 grafts was constructed. The average aortic cross-clamp time was 61.8 +/- 22.2 minutes. The longest single time off cardioplegia (LTOC) averaged 11.4 +/- 4.0 minutes per patient. The cumulative time off cardioplegia as a percentage of the cross-clamp time (PTOC) was 48.2 +/- 18.6% per patient. LTOC and PTOC were divided into quartiles (LTOC, < 10, 10 to 11, 12 to 13, and > 13 minutes; PTOC, < 36%, 36% to 49%, 50% to 62%, and > 62%) and related to the prespecified composite outcome of mortality, myocardial infarction according to serial CK-MB sampling, and low-output syndrome (LOS). Longer LTOC was harmful (event rates per quartile, 13.5%, 10.3%, 10.9%, and 19.0%; P = .046), whereas longer PTOC was protective (16.1%, 17.2%, 9.4%, and 10.6%; P = .07). Stepwise logistic regression was performed, controlling for demographic and angiographic predictors. In the multivariate models, LTOC remained detrimental (P = .07) and PTOC remained beneficial (P = .053). Additional modeling after entering surgeon identity (P < .001) into the risk equation eliminated the PTOC effect, whereas LTOC remained predictive of adverse outcomes (P = .053; odds ratio, 1.06; 95% CI, 1.00, 1.13). CONCLUSIONS: The data indicate that a reasonable margin of safety exists with intermittent, antegrade warm blood cardioplegia. Repeated interruptions of warm blood cardioplegia are unlikely to lead to adverse clinical results if single interruptions are < or = 13 minutes.

Aged↗
PubMed1995

Is body size the cause for poor outcomes of coronary artery bypass operations in women?

Although small body size and coronary artery diameter are recognized as major contributors to the increased risk of coronary artery bypass grafting in women, few studies have established the independent influence of body size and gender on outcome. We studied 7025 consecutive patients (5694 men, 1331 women) undergoing isolated coronary artery bypass grafting between 1990 and 1994. Women were older, had higher preoperative prevalences of urgent operation because of unstable angina, diabetes, peripheral vascular disease, hypertension, and single-vessel coronary artery disease (p < 0.0001), and a lower prevalence of left ventricular ejection fraction 40% or less (p < 0.0001). The prevalences of operative mortality (men, 1.8%; women, 3.5%), low-output syndrome (men, 6.6%; women, 14.8%), and myocardial infarction (men, 2.8%; women, 5.5%) were higher in women (p < 0.0001). Patients were divided into quartiles for body surface area, weight, height, and body mass index. For both men and women, there was no difference in operative mortality between the highest and lowest quartiles of body size. Women, however, had a higher prevalence of operative mortality than men in the lower quartiles of body surface area, height, and weight and in the higher quartiles of body mass index. Among men, the prevalence of low-output syndrome increased (p < 0.0001) with decreasing body surface area, weight, and body mass index, suggesting that body size did influence the prevalence of low-output syndrome. However, women had a higher prevalence of low-output syndrome than men in every category and quartile of body size (p < 0.0001). Multivariable analysis identified gender as a significant determinant of operative mortality (odds ratio 1.83, 95% confidence interval 1.27 to 2.64) and low-output syndrome (odds ratio 2.52, 95% confidence interval 2.05 to 3.11). When multivariable adjustments were made for body size and preoperative risk factors, gender remained a predictor of both operative mortality and low-output syndrome. Multivariable assessment of risk for men and women separately identified that urgent operation was a predictor of operative mortality (odds ratio 2.52, 95% confidence interval 1.32 to 5.61) and low-output syndrome (odds ratio 1.57, 95% confidence interval 1.14 to 2.17) in women but not men. In conclusion, the increased risk of coronary artery bypass grafting in women may be explained in part by dramatic differences in preoperative risk factors between men and women. In both men and women, small body size did not increase the risk of operative mortality, but may have contributed to the risk of low-output syndrome.(ABSTRACT TRUNCATED AT 400 WORDS)

Aged↗
PubMed1995

The technique of radial artery bypass grafting and early clinical results.

There is renewed interest in the use of the radial artery as a conduit for coronary artery bypass. Fifty patients underwent bypass surgery using the radial artery in addition to other conduits between November 24, 1992 and November 8, 1994 at our institution. The mean age was 54.4 +/- 9.1 years (mean +/- SD) and 47 of the patients were male. There were 3.6 +/- 0.9 and stomses per patient, of which 2.2 +/- 0.4 were arterial anastomoses. The most common target vessel for the radial artery has been the obtuse marginal (58.8%), with the aorta as the usual site for proximal anastomosis (80.4%). There have been no ischemic hand complications and no radial nerve deficits. There have been no early or late deaths and no myocardial ischemic complications related to the use of the radial artery. We present the techniques used at our institution for the use of the radial artery as a conduit for coronary artery bypass.

Anastomosis, Surgical↗
PubMed1994

Metaanalysis of prophylactic drug treatment in the prevention of postoperative bleeding.

Prophylactic drug treatment is one of several strategies to reduce postoperative blood loss and potentially limit homologous blood use in open heart surgery. A computerized MEDLINE search supplemented with manual bibliography reviews was performed for randomized clinical trials published in peer-reviewed English-language journals from January 1980 to June 1993. A metaanalysis was conducted of trials evaluating desmopressin (group DD, n = 13), epsilon-aminocaproic acid or tranexamic acid (group EA, n = 4), and aprotinin (group AP, n = 16). Eligible studies used placebo controls and administered the drug in a prophylactic manner. The primary study end point was postoperative chest tube loss (mL, mean +/- standard deviation). There was a significant reduction in postoperative chest tube loss detected for each of the active treatments versus the placebo (DD versus controls: percent reduction 0.11, p = 0.0021; EA versus controls: percent reduction 0.30, p < 0.0001; and AP versus controls: percent reduction 0.36, p < 0.0001). Therapy with EA or AP was associated with a greater reduction in chest tube loss than DD (EA versus DD, p = 0.0033, and AP versus DD, p < 0.0001). Secondary study end points were transfusion requirements, chest reexploration, and perioperative mortality. The volume of postoperative red cell transfusion (mean +/- standard deviation) was reduced with EA (p < 0.0001) or AP treatment (p < 0.0001) compared with a placebo or DD, whereas the proportion of patients given transfusions was limited only in the AP-treated patients (odds ratio 0.23; 95% confidence interval, 0.16 to 0.33; p < 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Aminocaproic Acid↗
PubMed1992

A randomized study of the systemic effects of warm heart surgery.

The technique of warm heart surgery is defined as continuous warm blood cardioplegia and normothermic cardiopulmonary bypass. Although the systemic effects of traditional myocardial protection are well known, the effects of warm heart surgery are not. In a prospective trial, 204 patients undergoing coronary artery bypass grafting were randomized to the warm heart surgery technique (normothermic group) or traditional intermittent cold blood cardioplegia and cardiopulmonary bypass (hypothermic group). The groups had similar heparin sodium requirement, activated clotting times, urine output, hematocrit, and blood product utilization. There were no differences in hemodynamics immediately after cardiopulmonary bypass. The normothermic patients had a higher incidence of spontaneous defibrillation at cross-clamp removal (84%) than the hypothermic patients (33%) (p less than 0.01). An increase in the flow rate of low K+ cardioplegia was necessary to eradicate electrical activity during aortic occlusion more often in the normothermic patients (20%) than in the hypothermic patients (3%) (p less than 0.01). When low K+ cardioplegia was ineffective, high K+ cardioplegia was necessary to eradicate electrical activity in 31% of the normothermic patients compared with 10% of the hypothermic patients (p less than 0.05). The total cardioplegia volume delivered to the normothermic group (4.7 +/- 1.9 L) was higher than that delivered to the hypothermic group (2.6 +/- 0.8 L) (p less than 0.01). Although urine output was similar in both groups, the serum K+ levels were higher in the normothermic group (5.7 +/- 0.8 mmol/L) than in the hypothermic group (5.3 +/- 0.8 mmol/L) (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Pressure↗
PubMed1992

Rapid mapping in Salmonella typhimurium with Mud-P22 prophages.

A new method for mapping mutations in the Salmonella typhimurium chromosome is described and applied to the localization of novel regulatory mutations affecting expression of the nirB (nitrite reductase) gene. The mapping technique is also illustrated by the mapping of mutations in genes affecting carbohydrate catabolism and biosynthetic pathways. The new mapping method involves use of the hybrid phage MudP and MudQ (together referred to as Mud-P22), originally constructed by Youderian et al. (Genetics 118:581-592, 1988). This report describes a set of Mud-P22 lysogens, each member of the set containing a different Mud-P22 insertion. The insertions are scattered along the entire Salmonella genome. These lysogens, when induced by mitomycin C, generate transducing lysates that are enriched (45- to 1,400-fold over the background, generalized transducing particle population) for transducing particles containing bacterial DNA that flanks one side of the insertion. We demonstrate that within the set of lysogens there can be found at least one Mud-P22 insertion that enriches for any particular region of the Salmonella chromosome and that, therefore, all regions of the chromosome are discretely enriched and represented by the collection as a whole. We describe a technique that allows the rapid and facile determination of which lysate contains enriched sequences for the repair of a mutant locus, thereby allowing the determination of the map position of the locus. This technique is applicable to those mutations for which the wild-type allele is selectable. We also describe a procedure whereby any Tn10 insertion can be mapped by selecting for the loss of Tetr.

Bacteriophages↗
PubMed1992

Coronary artery bypass grafting in patients with poor ventricular function. Cardiovascular Surgeons of the University of Toronto.

Although patients with severe ventricular dysfunction have improved long-term survival times after coronary bypass procedures, operative morbidity and mortality rates remain high. This study was designed to identify the contemporary risk factors for isolated coronary artery bypass grafting in this high-risk subgroup. Between January 1982 and December 1990, a total of 12,471 patients underwent isolated coronary artery bypass grafting. The 9445 patients with preoperative ejection fractions greater than 40% had a lower operative mortality rate (2.3%) than that of the 2539 patients with ejection fractions between 20% and 40% (4.8%) and that of the 487 patients with ejection fractions less than 20% (9.8%; p less than 0.001). However, patients with ejection fractions of less than 20% were demographically distinct from those with higher ejection fractions. This group was older, with fewer women, a higher frequency of left main stenosis, and more frequent requirement of urgent operation for unstable angina. The risk factors for operative death also varied with preoperative ejection fraction. The traditionally accepted risk factors--urgency of operation, left main coronary artery stenosis, reoperation, sex, and age--were predictive of risk of operative death for patients with ejection fractions greater than 40%. The risk of operative death for patients with ejection fractions between 20% and 40% was predicted by urgency of operation, reoperation, sex, myocardial protection, and age. The only predictor of risk of operative death for patients with ejection fractions less than 20% was urgency of operation. Patients undergoing isolated coronary artery bypass grafting who have severe ventricular dysfunction are therefore a highly selected, high-risk subgroup of patients who risk depends on the urgency of operation. Strategies to improve the results in these patients should be focused on patient selection, improvement of myocardial protection, and more aggressive preoperative treatment of myocardial ischemia.

Age Factors↗
PubMed1991

Current risk of coronary bypass for unstable angina.

The risk associated with surgical revascularization for unstable angina is critically dependent upon the clinical presentation of the patient. For this study, between January 1982 and December 1987, clinical, angiographic, operative and hospital outcome data were collected prospectively for 6539 patients undergoing surgery for unstable angina. Urgent surgery was performed in 1523 patients (23.3%), while 5016 (76.7%) underwent semielective revascularization. The mean age was 58.9 +/- 9.2 years and 805 patients (12.3%) were aged 70 years or above. The male:female ratio was 3.6:1. Depressed left ventricular function (left ventricular ejection fraction less than 40%) was present in 27.2% of the population. Preoperative myocardial infarction (within 30 days of surgery) had occurred in 588 patients (9.0%). Operative mortality was 4.6% (301 deaths). Stepwise logistic regression analysis was performed to determine the independent predictors of operative mortality. The following variables were selected in descending order: urgent surgery (P less than 0.001), coronary reoperation (P less than 0.001), depressed left ventricular (P less than 0.001), female gender (P less than 0.001), increasing age (P less than 0.001), left main stenosis (P = 0.002), and preoperative myocardial infarction (P less than 0.001). Predicted operative mortality varied between 0.5 +/- 0.3% and 82.6 +/- 12.7%. The most important determinant for patients with a preoperative myocardial infarction was left ventricular dysfunction, whereas urgent surgery for unstable angina was the most important risk variable in those without preoperative necrosis.

Adult↗
PubMed1991

Recent preoperative myocardial infarction increases the risk of surgery for unstable angina.

Patients with postinfarction angina undergoing surgery for unstable angina face an increased risk of operative mortality. Between January 1982 and December 1987, clinical, angiographic, and operative data was collected prospectively in 588 unstable patients with a prior myocardial infarction within 30 days of surgery (MI) and 5951 unstable patients without preoperative damage (NONMI). MI patients were characterized as being older (age greater than or equal to 70 years: MI, 19.7%; NONMI, 11.6%; p less than 0.001) and having more left ventricular dysfunction (left ventricular ejection fraction less than 40%: MI, 34.8%; NONMI, 26.4%; p less than 0.001). Semi-elective surgery was performed in 82.0% of NONMI patients while 76.9% of MI patients underwent urgent surgery. Operative mortality was increased in MI patients (MI, 11.1%; NONMI, 4.0%; p less than 0.001) which was related to the extent of preoperative MI (non-Q wave, 8.3%; Q wave, 17.5%; p less than 0.001). Stepwise logistic regression analysis identified preoperative MI as an independent risk variable of operative mortality for unstable angina. Separate multivariate analyses were performed to identify the independent predictors for MI and NONMI patients. The multivariate predictors of operative death for MI patients were left ventricular dysfunction, reoperative coronary surgery, nonuse of the internal mammary, age, transmural MI (relative risk 2.11 vs non-Q wave infarction) and left main stenosis. For NONMI patients, the independent variables were urgent operation, left ventricular dysfunction, reoperation, female gender, left main stenosis, and age. The results of this study indicate that recent preoperative MI adversely influences the surgical results in patients with unstable angina. Alternative treatment strategies are warranted for high risk patients, particularly those with transmural MIs and impaired ventricular function.

Adult↗
PubMed1991

Survey of cardiac pacing in Canada.

UNLABELLED: The status of cardiac pacing in Canada in 1989 was determined from data provided by 62 of 128 physicians surveyed (48% response) and four major manufacturer/distributors. A questionnaire designed for the IXth World Symposium on Cardiac Pacing was used. DEMOGRAPHICS: There were five implant hospitals per million population, 65% community based and 35% university affiliated; 63% of implanters were surgeons. There were 279 new implants and 46 replacement procedures per million population. INDICATIONS: Sinus node disorders accounted for 44.6% of implants, atrioventricular block 43.2% (fixed 24.4%, intermittent 12.0%, incomplete 6.8%), tachycardias 2.9%, drug-induced bradycardia 3.1%, and other (including automatic implantable cardioverter defibrillators) 6.2%. TECHNOLOGY: Single chamber units were implanted in 78.6% of patients, and dual chamber in 22.7%, and 19.5% of the total were rate-adaptive. Unipolar leads were used in 57.1% of atrial and 53.2% of ventricular insertions; 40.4% of atrial and 5.8% of ventricular leads were active fixation. The pervenous sheath introducer technique was used in 64.9% of lead insertions. PERIOPERATIVE: Major complications occurred in 2.6% of single and 6.8% of dual chamber primary implants, but mortality was less than 0.1%; 8.4% of replacements were unanticipated; there was no known death from malfunction. Mean hospital stay was 2.7 days for primary implants and 1.4 days for replacement/revisions. CONCLUSIONS: Comparison with prior surveys (1979, 1981, 1985) reveals: increased physician response to the survey questionnaire; relatively stable electrocardiographic indications for implant; a modest increase of new implants per million; continued decrease in replacements; an increase in dual chamber and rate-adaptive pacing; and increased use of active fixation and bipolar electrodes in both atrium and ventricle.

Arrhythmias, Cardiac↗
PubMed1991

Assigning priority to patients requiring coronary revascularization: consensus principles from a panel of cardiologists and cardiac surgeons.

In light of lengthy waiting lists for coronary surgery in Canada, a panel of 16 cardiologists and cardiac surgeons was convened to derive guiding principles for ranking how urgently diverse patients with angiographically proven coronary disease require revascularization. Factors likely to affect urgency were agreed upon by the panelists and incorporated into a case scenario questionnaire. Each panelist then rated 438 case scenarios with respect to maximum acceptable waiting time on a scale with seven time frames ranging from emergency surgery ('level 1') to delays of up to six months ('level 7'). The scenario rating process facilitated attainment of a panel consensus. The purpose of the principles is to assist in assigning priorities to patients according to both symptoms and risk of death or additional morbidity from ischemic events. The pattern or severity of the patient's anginal symptoms and the response of those symptoms to medical therapy emerged as the single most important determinant of the level of urgency. Anatomy and noninvasive tests of ischemic risk were the other key determinants of priority. All other factors were less important, and operated largely within a given level of urgency on the seven-point scale. The principles, including explicit ranking criteria divided according to angina class, are outlined in this final report. The panel specifically cautioned that adoption of such principles is not designed to countenance delays in treatment, but if necessary, should help form more rational queues for coronary revascularization.

Canada↗
PubMed1991

Thoracic aortic surgery.

Between 1982 and 1989, 119 patients had repair of thoracic aortic pathology. Thirty-seven had repair of ascending aortic aneurysms, with an 11% hospital mortality. Forty-one patients had urgent repair of acute type A aortic dissections, with a 32% hospital mortality. The independent predictors of mortality were the use of crystalloid cardioplegia, aortic dissection, and the use of an intraluminal prosthesis or the inclusion surgical technique. Better grafts and the resection technique has reduced mortality since 1986. Seventeen patients had their primary pathology in the aortic arch, with a 47% hospital mortality. The urgency of the procedure and crystalloid cardioplegia predicted an unsuccessful outcome. Seventeen patients had descending aortic aneurysms repaired, with an 18% mortality. The urgency of surgery was the predictor of mortality. Seven patients had a descending thoracic aortic disruption repaired, with one death (14%). Better graft materials, surgical techniques, and methods of myocardial protection have contributed to the improved results of thoracic aortic surgery in recent years.

Aortic Dissection↗
PubMed1990

Assessment of priority for coronary revascularisation procedures. Revascularisation Panel and Consensus Methods Group.

To develop guidelines for ranking the urgency with which patients with angiographically proven coronary disease need revascularisation procedures, factors that a panel of cardiac specialists agreed were likely to affect urgency were incorporated into 438 fictitious case-histories. Each panelist then rated the cases on a 7-point scale based on maximum acceptable waiting time for surgery; 1 on the scale represented emergency surgery and 7 delays of up to 6 months. For only 1% of cases was there agreement on a single rating by at least 12/16 panelists. Results of this ranking exercise were used by the panel to draw up triage guidelines. The three main urgency determinants were severity and stability of symptoms of angina, coronary anatomy from angiographic studies, and results of non-invasive tests for risk of ischaemia. Together these three factors generally gave an urgency rating for any given case to within less than 0.25 scale points of the value predicted with all factors. A numerical scoring system was derived to permit rapid estimation of the panel's recommended ratings.

Adult↗
PubMed1990

Placing patients in the queue for coronary revascularization: evidence for practice variations from an expert panel process.

A panel of 16 cardiologists and cardiac surgeons rated 438 case scenarios for the maximum acceptable delay prior to revascularization, using a scale with seven interventional time frames and two nodes for designating dubious or inappropriate cases. If consensus was defined as agreement by 12 or more panelists, only 1.4 percent of the case scenarios showed consensus on a single rating. Dividing the scale into three broad clinical categories (revascularize promptly, place on a waiting list, or no intervention), 11.4 percent of scenarios showed all 16 panelists agreeing on a single category, rising to 59.4 percent of scenarios if agreement by 12 panelists was accepted as a consensus. The mean difference between the panelists' highest and lowest urgency ratings yielded waiting time differences of two weeks for scenarios of very unstable angina, and more than three months for those with stable angina. However, in a regression model, individual panelist factors on average had less effect than clinical features such as severity and stability of angina, or stenosis of major coronary arteries. These findings strongly support the need for consensus criteria to ensure that triage practices are consistent and fair, and also suggest that widespread adoption of a standardized approach to revascularization priorities may be feasible.

Coronary Artery Bypass↗
PubMed1990

Single lung transplantation and closure of patent ductus arteriosus for Eisenmenger's syndrome. Toronto Lung Transplant Group.

A case report of the first single lung transplantation and closure of a patent ductus arteriosus for Eisenmenger's syndrome is presented. The operation was performed on Sept. 28, 1988. The patient was extubated on postoperative day 8, discharged from the intensive care unit on postoperative day 13, and discharged from the hospital on postoperative day 43, free of symptoms and without supplementary oxygen. Subsequent symptoms of dyspnea, presyncope, and fatigue recurred in association with subvalvular right ventricular outflow tract obstruction. Symptomatic improvement occurred gradually in association with reduction of the outflow tract obstruction. The patient is in New York Heart Association class I-II 12 months after the operation. The rationale, methods, and management of this patient are discussed, as well as the potential for application of this operation in similar settings.

Adult↗