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B W Lytle

Publications and source records attributed to B W Lytle.

At least 19 recordsLinked to original sources
PubMed1997

Is there an advantage to repairing infected mitral valves?

BACKGROUND: The therapy for native mitral valve endocarditis is in evolution. Antibiotics have significantly improved survival rates, but patients with complications of endocarditis may require surgical treatment. METHODS: Between January 1985 and December 1995, 146 patients underwent surgical therapy (repair or replacement) for native mitral valve endocarditis. All patients had documented bacterial endocarditis. Univariate and multivariate analyses were performed to determine predictors of hospital death, long-term event-free survival, and probability of repair. Patients were evaluated in three groups: all patients, patients with acute endocarditis, and patients with chronic endocarditis. RESULTS: There were ten hospital deaths (6.8%). Patients undergoing repair had a lower hospital mortality rate (p = 0.008) then those having replacement. Event-free survival was improved after mitral valve repair in the overall group (p = 0.02) and in the group with healed (chronic) endocarditis (p = 0.05). Although the acute endocarditis group demonstrated an improved event-free survival rate after mitral valve repair versus replacement (74% versus 20% at 6 years), this did not reach statistical significance. CONCLUSIONS: We conclude that mitral valve repair is preferable to mitral valve replacement when possible, in patients with complications of endocarditis, as repair results in a lower hospital mortality and an improved long-term survival.

Adolescent↗
PubMed1997

Intraoperative echocardiography is indicated in high-risk coronary artery bypass grafting.

BACKGROUND: Intraoperative echocardiography is a valuable monitoring and diagnostic technology used in cardiac surgery. This reports our clinical study of the usefulness of intraoperative echocardiography to both surgeons and anesthesiologists for high-risk coronary artery bypass grafting. METHODS: From March to November 1995, 82 consecutive high-risk patients undergoing coronary artery bypass grafting were studied in a four-stage protocol to determine the efficacy of intraoperative echocardiography in management planning. Alterations in surgical and anesthetic/hemodynamic management initiated by intraoperative echocardiography findings were documented in addition to perioperative morbidity and mortality. RESULTS: Intraoperative echocardiography initiated at least one major surgical management alteration in 27 patients (33%) and at least one major anesthetic/hemodynamic change in 42 (51%). Mortality and the rate of myocardial infarction in this consecutive high-risk study population using intraoperative echocardiography and in a similar group of patients without the use of intraoperative echocardiography was 1.2% versus 3.8% (not significant) and 1.2% versus 3.5% (not significant), respectively. CONCLUSIONS: We conclude that when all of the isolated diagnostic and monitoring applications of perioperative echocardiography are routinely and systematically performed together, it is a safe and viable tool that significantly affects the decision-making process in the intraoperative care of high-risk patients undergoing primary isolated coronary artery bypass grafting and may contribute to the optimal care of these patients.

Aged↗
PubMed1997

A profile of candidates for repeat myocardial revascularization: implications for selection of treatment.

OBJECTIVES: It is not known whether the results of randomized trials comparing coronary artery bypass grafting to percutaneous transluminal coronary angioplasty for initial revascularization apply to repeat revascularization in patients with prior bypass grafts. We studied the differences between the patients with prior bypass grafts referred for surgery or angioplasty to identify the clinical and angiographic characteristics that correlated best with either choice and to find clues that might aid in selecting one treatment over the other. METHODS: Between 1992 and 1994, 870 patients underwent first isolated reoperation and 793 patients underwent first balloon angioplasty after a previous operation. A jeopardy score (0 to 8 points) was derived for each patient on the basis of the relative size of the ischemic territory. Clinical and angiographic data were analyzed for association with the revascularization strategy. RESULTS: The following characteristics were more prevalent in the reoperation group: male sex, diabetes, hypertension, valvular disease, normocholesterolemia, and severe left ventricular systolic dysfunction; fewer functioning venous and arterial grafts; and a higher jeopardy score (p < 0.01 for all) than in the angioplasty group. A higher jeopardy score, diabetes, and a lower number of functioning arterial or venous grafts were strong, independent predictors of referral for reoperation (p < 0.01 for all). In hospital death and Q-wave infarction (p < 0.01 for both) were more frequent in the reoperation group. CONCLUSIONS: Reoperation was the revascularization procedure of choice when larger regions of myocardium were in jeopardy. Angioplasty was more frequently chosen in the presence of a patent arterial graft to the left anterior descending coronary artery or multiple functioning bypass grafts. Reoperation was associated with a higher risk of in-hospital complications than angioplasty.

Aged↗
PubMed1997

Reoperation for failure of mitral valve repair.

BACKGROUND AND OBJECTIVE: Mitral valve repair is the procedure of choice to correct mitral regurgitation of all types. Up to 10% of patients who undergo mitral valvuloplasty require late reoperation for recurrent mitral valve dysfunction. To determine the causes of failed mitral valve repair, we examined the surgical pathology of patients who underwent reoperation for failed mitral valve repair. PATIENTS AND RESULTS: From 1986 to 1994, 81 patients had 86 reoperations for recurrent mitral regurgitation after mitral valve repair. Mean age was 59.2 +/- 1.4 years; 55 were men. Primary valve disease was degenerative in 48 patients (59%), rheumatic in 16 (20%), ischemic in 13 (16%), endocarditic in 3 (4%), and congenital in 1 (1%). Mean time interval between initial mitral valve repair and reoperation was 15.6 +/- 2.5 months. Causes of repair failure were procedure-related (50 cases, 58%), valve-related (33 cases, 38%), or unknown (3 cases, 3%). Procedure-related valve failure was caused by suture dehiscence (21 cases), rupture of previously shortened chordae (19 cases), or incomplete initial correction (10 cases). Valve-related repair failure was caused by progressive primary valve disease (27 cases), endocarditis (5 cases), or extensive leaflet retraction (1 case). Repair failure was procedure-related in 70% of patients with degenerative valvular disease versus only 13% of patients with rheumatic valvular disease (p = 0.0001). At reoperation, mitral valve replacement was performed in 64 patients (79%) and repeat mitral valve repair in 17 (21%). CONCLUSION: We conclude that (1) most mitral valve repair failures are procedure-related in degenerative disease and valve-related in rheumatic disease; (2) rupture of previously shortened chordae is a common cause of late failure in patients with degenerative mitral valve disease; and (3) repeat mitral valve repair results in successful treatment for a minority of patients.

Adolescent↗
PubMed1997

Fungal prosthetic valve endocarditis in 16 patients. An 11-year experience in a tertiary care hospital.

Fungal prosthetic valve endocarditis (PVE) is an infrequent but serious complication of valve replacement surgery. To examine its long-term outcome, we retrospectively studied 16 patients with 19 episodes of definite fungal PVE. The mean age was 51 years (range, 27-71 yr). Onset of fungal PVE ranged from 8 days to 3.4 years after valve replacement. Candida albicans was the most common (56%) pathogen isolated. A portal of entry was identified in only 25% of the patients; the presence of intravascular catheters (50%) and prior bacterial endocarditis (38%) were leading predisposing factors. Fever (83%) was the most consistent clinical finding. Potentially serious embolic events, particularly strokes (32%), were common at presentation. Transesophageal echocardiography (sensitivity = 100%) was more useful than transthoracic echocardiography (sensitivity = 60%) in detecting lesions due to fungal PVE. Combined valve replacement surgery and amphotericin B (mean total dose of 1.8 g) in 15 patients resulted in an 87% in-hospital survival and 67% overall survival with a mean follow-up of 4.5 years (range, 5 mo to 16 yr). Two patients had 3 late relapses of fungal PVE up to 9 years after the preceding episode. Each relapse was treated with repeat valve replacement and amphotericin B; in addition, oral azole was utilized for chronic suppression, although the efficacy of this strategy remains unproven. Because of the possibility of relapse, long-term follow-up is essential even after surgical and prolonged antifungal therapy.

Adult↗
PubMed1997

Intramural hematoma of the thoracic aorta: MR image findings and their prognostic implications.

PURPOSE: To evaluate magnetic resonance (MR) imaging findings of intramural hematoma of the thoracic aorta and their relationship to prognosis. MATERIALS AND METHODS: MR images of 22 patients with intramural hematoma of the thoracic aorta were reviewed retrospectively. Site, thickness, degree of mural involvement, and signal intensity on spin-echo (SE) and cine gradient-echo (GRE) images of the hematoma were noted. MR findings of patients who did and those who did not develop complications were compared. RESULTS: Hematoma site was the only MR finding that correlated significantly with patient outcome. Complication frequencies in four (80%) of five patients with hematoma of the ascending aorta (type A) and in two (12%) of 17 patients with hematoma of the descending aorta (type B) were significantly different (P = .009). There were moderately strong correlations between days after symptom onset and signal intensity of the hematoma on SE (r = 0.78) and GRE (r = 0.72) images. MR images of two of three patients who developed early-subacute complications showed signal intensity changes of the hematoma that were consistent with recurrent bleeding. CONCLUSION: Patients with MR findings consistent with type A intramural hematoma of the thoracic aorta should undergo surgery. In cases of type B intramural hematoma of the thoracic aorta, MR imaging can be useful for detecting complete resolution or impending complications of the hematoma.

Aged↗
PubMed1996

Mechanisms of hemolysis with mitral prosthetic regurgitation. Study using transesophageal echocardiography and fluid dynamic simulation.

OBJECTIVES: The aims of this study were to define the hydrodynamic mechanisms involved in the occurrence of hemolysis in prosthetic mitral valve regurgitation and to reproduce them in a numeric simulation model in order to estimate peak shear stress. BACKGROUND: Although in vitro studies have demonstrated that shear stresses > 3,000 dynes/cm2 are associated with significant erythrocyte destruction, it is not known whether these values can occur in vivo in conditions of abnormal prosthetic regurgitant flow. METHODS: We studied 27 patients undergoing reoperation for significant mitral prosthetic regurgitation, 16 with and 11 without hemolysis. We classified the origin and geometry of the regurgitant jets by using transesophageal echocardiography. By using the physical and morphologic characteristics defined, several hydrodynamic patterns were simulated numerically to determine shear rates. RESULTS: Eight (50%) of the 16 patients with hemolysis had paravalvular leaks and the other 8 had a jet with central origin, in contrast to 2 (18%) and 9 (82%), respectively, of the 11 patients without hemolysis (p = 0.12, power 0.38). Patients with hemolysis had patterns of flow fragmentation (n = 2), collision (n = 11) or rapid acceleration (n = 3), whereas those without hemolysis had either free jets (n = 7) or slow deceleration (n = 4) (p < 0.001, power 0.99). Numeric simulation demonstrated peak shear rates of 6,000, 4,500, 4,500, 925 and 950 dynes/cm2 in these five models, respectively. CONCLUSIONS: The distinct patterns of regurgitant flow seen in these patients with mitral prosthetic hemolysis were associated with rapid acceleration and deceleration or high peak shear rates, or both. The nature of the flow disturbance produced by the prosthetic regurgitant lesion and the resultant increase in shear stress are more important than the site of origin of the flow disturbance in producing clinical hemolysis.

Aged↗
PubMed1996

New insights into the reduction of mitral valve systolic anterior motion after ventricular septal myectomy in hypertrophic obstructive cardiomyopathy.

To determine the mechanism of reduction of mitral valve systolic anterior motion by myectomy, we examined 33 patients with hypertrophic obstructive cardiomyopathy echocardiographically before and after myectomy. Measurements included outflow tract diameter, the direction of ejection streamline (the angle between the ejection flow and the mitral valve), midventricular fractional area change, and papillary muscle inward excursion in the short-axis image. After myectomy, the outflow tract was enlarged (from 1.2 +/- 0.3 cm to 2.1 +/- 0.4 cm; p < 0.001), and the ejection flow became more parallel to mitral leaflets (from 51 +/- 10 degrees to 28 +/- 8 degrees; p < 0.001), whereas hyperdynamic midventricular fractional area change was reduced (81% +/- 14% to 62% +/- 14%; p < 0.001), and papillary muscle excursion decreased (1.3 +/- 0.3 cm to 0.8 +/- 0.3 cm; p < 0.001). Outflow enlargement and reduced ventricular contraction would decrease the Venturi force. Change of ejection streamline and reduced contraction would decrease the drag force onto the mitral leaflets. Blunted papillary motion would increase the mitral leaflet tension and decrease the effect of drag force on both leaflets. Thus myectomy decreases Venturi and drag forces and appears to reduce systolic anterior motion of the mitral valve.

Cardiomyopathy, Hypertrophic↗
PubMed1996

Repair of anterior leaflet prolapse: chordal transfer is superior to chordal shortening.

UNLABELLED: Several techniques are currently used to repair anterior leaflets with elongated or ruptured chordae. To evaluate the efficacy of these techniques, we analyzed the case histories of 108 patients operated on from 1989 through 1992 with degenerative mitral valve disease and prolapse of the anterior leaflet. The mean age was 59 +/- 15 years (range 18 to 87 years) and 74 (69%) were male. METHODS: Chordal shortening was performed in 31 (29%) and chordal transfer in 77 (71%) of the repairs. Of the transfers, 58 (75%) were from the posterior to the anterior leaflet and 16 (21%) were from the secondary to the primary position of the anterior leaflet. Three patients had both types of transfers. Seventy-one (66%) patients had isolated repairs and the remainder had associated procedures. The degree of preoperative mitral regurgitation was 3+ or greater for 107 (99%) of the patients, mean 3.4 for shortening and 3.7 for transfer. RESULTS: Four (4.0%) hospital deaths occurred, none after isolated repair. Follow-up of hospital survivors was 100% complete at a mean of 4.0 years. A total of 421 patient-years of follow-up were available for analysis. There were seven late deaths, for a 5-year actuarial survival of 93%. Eleven patients underwent reoperation for recurrent mitral regurgitation. Five-year actuarial freedom from reoperation was 90%-96% after chordal transfer and 74% after chordal shortening, p = 0.003. Independent predictors for reoperation include chordal shortening and preoperative New York Heart Association functional class III or IV. The mechanism of valve failure in six of seven patients undergoing reoperation after chordal shortening was rupture of the previously shortened chordae. CONCLUSIONS: We conclude that chordal transfer is superior to chordal shortening, providing a more predictable correction of mitral regurgitation and a lower incidence of reoperation. Reoperations after chordal shortening are a result of rupture of the previously shortened chordae.

Actuarial Analysis↗
PubMed1996

Surgical treatment of prosthetic valve endocarditis.

From 1975 through 1992, we reoperated on 146 patients for the treatment of prosthetic valve endocarditis. Prosthetic valve endocarditis was considered to be early (< 1 year after operation) in 46 cases and active in 103 cases. The extent of the infection was prosthesis only in 66 patients, anulus in 46, and cardiac invasion in 34. Surgical techniques evolved in the direction of increasingly radical débridement of infected tissue and reconstruction with biologic materials. All patients were treated with prolonged postoperative antibiotic therapy. There were 19 (13%) in-hospital deaths. Univariate analyses demonstrated trends toward increasing risk for patients with active endocarditis and extension of infection beyond the prosthesis; however, the only variables with a significant (p < 0.05) association with increased in-hospital mortality confirmed with multivariate testing were impaired left ventricular function, preoperative heart block, coronary artery disease, and culture of organisms from the surgical specimen. During the study period, mortality decreased from 20% (1975 to 1984) to 10% (1984 to 1992). For hospital survivors the mean length of stay was 25 days. Follow-up (mean interval 62 months) documented a late survival of 82% at 5 postoperative years and 60% at 10 years. Older age was the only factor associated (p = 0.006) with late death. Nineteen patients needed at least one further operation; reoperation-free survival was 75% at 5 and 50% at 10 postoperative years. Fever in the immediate preoperative period was the only factor associated with decreased late reoperation-free survival (p = 0.032). Prosthetic valve endocarditis remains a serious complication of valve replacement, but the in-hospital mortality of reoperations for prosthetic valve endocarditis has declined. With extensive débridement of infected tissue and postoperative antibiotic therapy, the extent and activity of prosthetic valve endocarditis does not appear to have a major impact on late outcome, and the majority of patients with this complication survive for 10 years after the operation.

Adult↗
PubMed1996

Left ventricular outflow tract obstruction in hypertrophic cardiomyopathy: presurgical and postsurgical evaluation by computed tomography magnetic resonance imaging.

Along with hypertrophy of the left ventricle (LV), hypertrophic cardiomyopathy (HC) is characterized by LV outflow tract (LVOT) obstruction, partly from systolic anterior motion (SAM) of the anterior mitral leaflet; if obstruction is significant, excision of excess subaortic septal myocardium may be indicated. In this study, the ability of computed tomography magnetic resonance imaging (Cine MRI) to provide information about LVOT obstruction was assessed in a series of 37 HC cases undergoing evaluation, including echocardiography (0 to 14 days before), for possible septal myectomy; in 4 cases, Cine MRI was used postsurgically (5 to 25 months after). Blinded to echocardiography results, 3 reviewers analyzed by consensus the Cine-MRI LVOT-long-axis image-loops for SAM grade (none, mild, severe) and "aorta:LVOT signal ratio" (intensity in descending aorta/intensity in LVOT at maximum systolic-flow disturbance). Resting LVOT flow velocities were separately determined using Doppler analysis, permitting differentiation between insignificant (< 30 mm Hg) and significant (< or = 30 mm Hg) gradients. With echocardiography, significant resting obstruction was found in 62% of cases, including 92% treated surgically. A significant association between SAM grade and obstruction was found; all cases with a SAM grade of none had insignificant ([-] predictive value: 100%) and most with a severe grade had significant ([+] predictive value: 78%) obstruction. Signal ratio in the absence of a significant gradient was significantly lower than in its presence; a significant linear relationship between aorta:LVOT signal ratio and resting gradient was found: LVOT gradient = ([2.9] x [signal ratio]) + 22.8. SAM grade did not contribute significantly in obstruction categorization when signal ratio was known. In all cases studied after surgery, SAM grade had decreased from severe to insignificant levels and aorta:LVOT signal ratio had been significantly reduced. Insights into the dynamic nature of the LVOT in HC patients can be provided by Cine MRI, either during their evaluation for surgery or after their septal myectomy.

Cardiomyopathy, Hypertrophic↗
PubMed1995

Clinical markers, management, and long-term follow-up of early ischemia after coronary artery bypass grafting.

In summary, the occurrence of angina or myocardial infarction within 1 year after coronary bypass is associated with a high incidence of significant angiographic abnormalities. Early angiography is necessary to identify high-risk patients who could undergo revascularization. Patients with other markers of ischemia should have a noninvasive approach (stress imaging test) as initial evaluation, before coronary angiography is considered. When technically feasible, coronary angioplasty can be performed safely and with a high success rate. Repeat coronary bypass in this group of patients is associated with higher in-hospital complications. Patients with less compromised coronary anatomy can be treated medically with a good long-term outcome.

Aged↗
PubMed1995

Have PTCA failures requiring emergent bypass operation changed?

From 1980 through 1990, 9,145 patients had balloon angioplasty with failure of the procedure requiring emergent surgical revascularization within 24 hours occurring in 253 patients (2.8%). Patients were divided into two cohorts based on the date of the percutaneous transluminal coronary angioplasty (PTCA): 1980 to 1985 (n = 109) and 1986 to 1990 (n = 144). The incidence of PTCA failure was 3.8% during 1980 to 1985 (109/2,903) and decreased to 2.3% (144/6,242) for 1986 to 1990. Comparison of pre-PTCA patient characteristics between the two periods showed that only a history of a previous PTCA and class III or class IV symptoms were more common in the recent years (p < or = 0.05). In-hospital mortality after emergency operation was 4.6% (5/109) during 1980 to 1985 and 7.6% (11/144) from 1985 to 1990 (p = not significant). This trend toward increased mortality appeared to be related to an increased number of patients who underwent operation in a state of severe hemodynamic compromise in the more recent period. The in-hospital mortality rate for patients in shock or undergoing cardiopulmonary resuscitation was 28.3% (13/46) compared with 1.4% (3/207) for patients with less severe hemodynamic derangement (p < 0.001). Use of the intraaortic balloon pump preoperatively increased from 12.8% to 32.6% (p < 0.01). Late survival was 92% at 2 and 87% at 5 postoperative years. Although the incidence of PTCA failure necessitating emergent surgical intervention has decreased over time, there has been a trend toward an increased in-hospital mortality rate for those patients that does not appear to be related to more severe pre-PTCA characteristics.(ABSTRACT TRUNCATED AT 250 WORDS)

Angioplasty, Balloon, Coronary↗
PubMed1995

Surgical and long-term antifungal therapy for fungal prosthetic valve endocarditis.

BACKGROUND: Fungal prosthetic valve endocarditis is an uncommon but serious disease. We have developed a strategy of treatment that includes perioperative amphotericin B, radical debridement of infected tissue, reconstruction using biologic tissue when possible, and prolonged oral suppressive antifungal therapy. METHODS: We retrospectively reviewed the charts of 12 patients reoperated on for fungal prosthetic valve endocarditis involving the aortic valve (10 patients: six porcine valves, two mechanical valves, two homografts) and the mitral valve (2 patients, both porcine valves). Prosthetic valve endocarditis developed in 7 within 12 months after the first valve procedure. The organisms included Candida species (9 patients), Scopulariopsis brevicaulis (1), Saccharomyces cervisiae (1), and histoplasmosis (1). RESULTS: At operation, all patients had prosthetic vegetations, 8 had abscesses, and 4 had sinus tracts. Seven received aortic homografts, 4 received porcine valves (two mitral), and 1 received a mechanical prosthesis. Two patients died in the hospital after prolonged illnesses (83% hospital survival). Four patients had recurrence an average of 25 months later and 3 underwent further surgical intervention. One patient had recurrence and died 17 months postoperatively. One other late death occurred 96 months after operation, and there was no evidence of recurrence. Eight patients (67%) are alive and well 51.5 +/- 61.0 months (range, 1 to 189 months) after the first redo procedure for fungal prosthetic valve endocarditis. CONCLUSIONS: We conclude that preoperative treatment with amphotericin B, radical resection of all infected tissue, cardiac reconstruction using biologic tissue when possible, and life-long oral antifungal therapy is effective for fungal prosthetic valve endocarditis.

Abscess↗
PubMed1995

Surgical management of hypertrophic obstructive cardiomyopathy. Early and late results.

From 1975 through 1993, 178 patients underwent surgical management of hypertrophic obstructive cardiomyopathy. Operations included isolated septal myectomy (n = 95), septal myectomy and coronary artery bypass grafting (n = 41), septal myectomy plus a valve procedure (n = 25), septal myectomy, valve procedure, and coronary artery bypass grafting (n = 14), and mitral valve replacement without septal myectomy (n = 3). Recent myectomy results were monitored with transesophageal echocardiography. After initial myectomy, 32 patients (20%) underwent a second pump run for more extensive myectomy only (n = 22), mitral valve replacement only (n = 5), or both (n = 2). In-hospital mortality was 6% (n = 11) and 4% (n = 6) for patients undergoing septal myectomy or septal myectomy plus coronary artery bypass grafting, respectively. Heart block occurred in 17 patients (10%). Left ventricular outflow tract systolic gradients decreased from a mean of 93 mm Hg to 21 mm Hg after myectomy. Late survival was 86% and 70% at 5 and 10 postoperative years, respectively, and 93% and 79% for patients undergoing septal myectomy alone or septal myectomy plus coronary artery bypass grafting, respectively. Only 3 of 131 in-hospital survivors of septal myectomy or septal myectomy plus coronary artery bypass grafting died late cardiac deaths, for a yearly mortality of 0.6%. However, the 5-year late survival of patients undergoing valve operation plus septal myectomy was 51%, and multivariate testing confirmed the adverse influence on late survival (p = 0.008), as well as adverse influences of increasing age (p = 0.016) and return to cardiopulmonary bypass for mitral valve replacement (p = 0.038). At follow-up 136 patients (94%) had New York Heart Association class I or II symptoms. For patients with hypertrophic obstructive cardiomyopathy, septal myectomy alone or in combination with coronary artery bypass grafting produces effective symptom relief, excellent long-term survival, and a low risk of late cardiac death.

Aged↗
PubMed1995

The Carpentier-Edwards pericardial aortic valve. Ten-year results.

To evaluate the function of the Carpentier-Edwards pericardial valve in the aortic position, we analyzed the results of 310 aortic valve replacements performed between 1982 and 1985. Mean age was 64.2 +/- 10.8 years (range 22 to 95 years); 190 patients (61.3%) were male patients. There were 18 hospital deaths (5.8%), and none were valve related. Follow-up of the 292 survivors was 100% complete at a mean of 7.8 +/- 2.9 years; 2290 patient-years of follow-up were available for analysis. There were 133 late deaths (45.5%). Actuarial survivals at 5 and 10 years were 82.5% and 45.9%, respectively. The 10-year actuarial freedom from events was 88.7% +/- 2.1% for thromboembolism, 90.9% +/- 1.8% for hemorrhage, 94.3% +/- 1.6% for endocarditis, and 91.2% +/- 2.6% for structural deterioration. The 153 hospital survivors 65 years of age or older had an extremely low incidence of structural valve deterioration, with only four explants and 95.5% actuarial freedom from explantation at 10 years, and a linearized rate of 0.3 +/- 0.2 per patient-year compared with 88.6% and 0.7 +/- 0.2 for patients younger than 65 years of age. Twelve valves were explanted for structural deterioration. Of these, 11 (93%) had leaflet calcification causing stenosis and one had a wear-related leaflet tear. The Carpentier-Edwards pericardial valve has a low incidence of valve-related complications. The freedom from structural valve deterioration is low at 10 years, particularly in patients 65 years of age and older.

Actuarial Analysis↗
PubMed1995

Axillary artery: an alternative site of arterial cannulation for patients with extensive aortic and peripheral vascular disease.

The increasing number of patients with extensive aortic and peripheral vascular atherosclerosis or aneurysms who are undergoing cardiac operations present difficult decisions as to the optimal site of arterial cannulation for cardiopulmonary bypass. Femoral artery cannulation is the most common alternative to ascending aortic cannulation, but severe iliofemoral disease or the danger of atheroemboli caused by retrograde perfusion through an atherosclerotic or aneurysmal descending aorta may make this approach impossible or undesirable. We have used axillary artery cannulation for cardiac operations in 35 patients for indications including severe aortic atherosclerosis (n = 16), extensive aortic aneurysms (n = 11), and aortic dissection (n = 8). The cardiac operations performed were coronary artery bypass grafting (n = 9) aortic valve replacement (n = 1), aortic valve replacement and coronary artery bypass grafting (n = 5), repair of mitral valve periprosthetic leak (n = 1), and resection of ascending and/or aortic arch (n = 19). Deep hypothermia with circulatory arrest was used in 26 patients and retrograde cerebral perfusion in 18. All patients awoke from the operation and no patient had a cerebrovascular accident. One patient required axillary artery thrombectomy and one patient had a mild ipsilateral brachial plexus paresis after the operation. Four patients died in the hospital. We conclude that axillary artery cannulation is a safe and effective means of providing antegrade arterial flow during cardiopulmonary bypass in patients with severe atherosclerotic or aneurysmal disease. This strategy may lower the prevalence of stroke associated with cardiopulmonary bypass in these patients.

Adult↗