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Biomedical subjects

C R Hatcher

Publications and source records attributed to C R Hatcher.

At least 19 recordsLinked to original sources
PubMed1992

Emergency coronary artery bypass surgery for failed percutaneous coronary angioplasty. A 10-year experience.

Six hundred ninety-nine patients have required emergency coronary artery bypass after failed elective percutaneous coronary angioplasty during the decade September 1980 through December 1990. This represents 4% of 9860 patients having 12,146 elective percutaneous coronary angioplasty procedures during this interval. Emergency coronary artery bypass was required for acute refractory myocardial ischemia in 82%. Hospital mortality rate for all patients was 3.1%; 3.7% in patients with refractory myocardial ischemia but 0.8% in patients without refractory myocardial ischemia, p = 0.08. Postprocedural Q-wave myocardial infarctions were observed in 21% versus 2.4%, p less than 0.0001, and intra-aortic balloon pumping was required in 19% with versus 0.8% without refractory myocardial ischemia, p less than 0.0001. Multivessel disease, p = 0.004, age older than 65 years, p = 0.005, and refractory myocardial ischemia, p = 0.08, interacted to produce the highest risk of in-hospital death. Follow-up shows that there have been 28 additional late deaths, including 23 of cardiac causes for a 91% survival at 5 years. Freedom from both late death and Q-wave myocardial infarction at 5 years was 61%. In the group going to emergency coronary artery bypass with refractory myocardial ischemia, the late cardiac survival was 90%, and in those without ischemia, 92% at 5 years, p = not significant. The MI--free survival in the group with refractory ischemia, however, was 56% versus 83% in the group without ischemia, p less than 0.0001. Multivariate analysis showed the highest late event rates for patients with Q-wave myocardial infarction at the initial emergency coronary artery bypass, age older than 65 years, angina class III or IV, and prior coronary bypass surgery. In spite of a continuing high incidence of early acute myocardial infarction and an increasing operative mortality rate (7%) in the latest 3 years cohort of patients, excellent late survival and low subsequent cardiac event rates demonstrate the lasting effectiveness of prompt, successful emergency coronary bypass surgery for failed percutaneous coronary angioplasty.

Actuarial Analysis↗
PubMed1992

Inhibition of human internal mammary artery contractions. An in vitro study of vasodilators.

The internal mammary artery is currently the preferred conduit for myocardial revascularization; however, perioperative vasospasm of the internal mammary artery may limit its use as a bypass graft. The ability of various vasodilators to inhibit internal mammary artery contraction was investigated with the use of discarded segments of human internal mammary artery not used in coronary artery bypass grafting. Ring segments of human internal mammary arteries were suspended on strain gauges in muscle baths containing 37 degrees C Krebs solution for measurement of isometric tension in vitro. Arterial contraction was stimulated by elevating the extracellular potassium concentration to 70 mmol/L or by exposure to a 10 mumol/L concentration of norepinephrine, and inhibition of contraction by vasodilators was measured. The order of potency to inhibit potassium-induced contraction was as follows: nifedipine > verapamil > nitroprusside > papaverine. At maximal effective doses, nifedipine, verapamil, and papaverine almost completely inhibited potassium-induced contraction, whereas nitroprusside inhibited contraction by only 55%. When norepinephrine was used to contract the arteries, a biphasic relaxation curve was seen with nifedipine, but not with other vasodilator drugs. The order of potency to inhibit norepinephrine-induced contraction was as follows: nifedipine > nitroprusside > verapamil > papaverine. Maximal inhibition of norepinephrine contraction by these vasodilators ranged from 68% to 95%. Nitroglycerin, isoproterenol, and adenosine produced little or no inhibition of internal mammary artery contraction caused by potassium or norepinephrine. Although nifedipine was the most potent vasodilator, papaverine produced the greatest maximal inhibition of both potassium- and norepinephrine-induced contraction of human internal mammary artery.

Adenosine↗
PubMed1979

Carcinoma of the superior pulmonary sulcus.

From January, 1971, to January, 1977, 26 patients underwent surgical resection of a carcinoma of the superior pulmonary sulcus. They ranged from 33 to 77 years old. All but 1 had symptoms characteristic of Pancoast's syndrome. The site of involvement was the right superior sulcus in 17 patients and the left superior sulcus in 9. All patients were treated by lobectomy and extended en bloc resection. Twenty-five patients survived operation. There was 1 early postoperative death. Twenty-two patients had been followed for at least 3 years, and 8 had survived for 5 years, at the time of writing. Nine patients died of recurrent disease from five months to 3 years after operation. Important considerations in postoperative care include routine use of continuous positive airway pressure and intermittent mandatory ventilation.

Adenocarcinoma↗
PubMed1979

Esophageal carcinoma: an aggressive approach.

During a 3-year period, 45 patients with esophageal carcinoma (18 of the lower and 27 of the middle third) underwent esophagectomy and esophagogastrostomy. All patients were considered to be in Stage I and Stage II preoperatively, but at the time of operation, 66% were found to have Stage III disease. All patients underwent mobilization of the stomach through a laparotomy, and resection of the esophagus and reconstruction of the continuity of the gastrointestinal tract through a separate right lateral thoracotomy incision. Following operation, 22 patients (10, Stage I and II and 12, Stage III) received no radiotherapy and 23 patients (5, Stage I and II and 18, Stage III) received radiotherapy. Two patients died in the immediate postoperative period, for a surgical mortality of 4.8%. Because of the acceptable survival and enhancement of quality of life, esophagectomy and esophagogastrostomy should be offered not only to Stage I and II patients with esophageal carcinoma but also to selected patients with Stage III disease and those with lower and middle third esophageal lesions.

Adult↗
PubMed1979

What role should the intra-aortic balloon have in cardiac surgery.

Intra-aortic balloon pumping (IABP) to assist the failing circulation has become widely applied and accepted since its introduction in 1968. The elective, preoperative use of IABP for patients undergoing cardiac surgery has now become the controversy. The purposes of this report are to examine our experience with IABP and to determine its appropriate role in high-risk patients. IABP was utilized in 75 of 2333 (3.2%) adult cardiac surgical patients at Emory University Hospital from January 1976 through June 1978. IABP was required for refractory shock following cardiopulmonary bypass (CB) in 53 patients, for preoperative cardiogenic shock after acute myocardial infarction (CSMI) in nine and was electively placed prior to CB in 13. Sixty-two patients (81%) were able to separate from CB with IABP and pharmacologic support and were assisted 24-432 hours (median 64 hours). Fifty-five (73%) were weaned from IABP. Fifty (67%) are hospital survivors; late deaths have occurred in six patients (8%). Hemodynamic effect of IABP was demonstrated by comparison of pumping 1:1 to 1:8 mode in five balloon-dependent patients after CB. IABP was found to decrease systolic blood pressure, left ventricular filling pressure and peripheral resistance (p < .05). It increased diastolic and mean blood pressure, cardiac index and the endocardial viability ratio (p < .05). The post-CB use of IABP resulted in highest salvage when utilized to support failing hearts that required surgery despite recent preoperative infarction or when intraoperative ischemic injury had occurred. Poorest results were in patients with extensive chronic myocardial damage. Except in the case of preoperative cardiogenic shock, it was impossible to establish statistically reliable criteria for patients in whom elective preoperative insertion was found to be necessary. Careful surgical and anesthesia management with good monitoring can be used instead of preoperative IABP in the majority of (if not all) hemodynamically stable patients regardless of risk classification.

Adult↗
PubMed1979

Late hemodynamic evaluation of Hancock Modified orifice aortic bioprosthesis.

Nineteen patients with Hancock Modified Orifice prosthesis (HMO-250), size 19 to 23 mm, were recatheterized 6 to 16 months following aortic valve replacement (AVR). Although hemodynamic characteristics varied widely, HMO-250 compared favorably to the standard model 243 (less than 0.05). Mean peak resting gradient across HMO-250 was 14.8 torr at rest and rose to 26.8 torr with exercise. Systolic gradients for HMO-250, both resting and exercise, were improved for 21 mm (p less than 0.01), but not for 23 mm. Increasing the patient's body surface area (BSA) correlated with increasing gradients for 23 mm (p less than 0.05), but was unrelated to 21 mm. Effective orifice areas were similarly found to be improved with 21 mm HMO-250 but unchanged for 23 mm. Use of the 21 or 23 mm size HMO for AVR is supported only when the patient's body surface area is less than 1.8 m2. If the body surface area is greater than 1.8 m2, annulus enlargement and a larger size bioprosthesis should be employed. Use of 19 mm porcine xenograft for AVR is not supported.

Aortic Valve Insufficiency↗
PubMed1979

Further evaluation of the sutureless, screw-in electrode for cardiac pacing. Experience with first 300 implantations.

This report details our experience with 300 sutureless epicardial electrode implantations performed in the past 6 years. Indications for pacing, surgical approaches, implantation sites and complications are presented. The subxiphoid approach was valuable in obtaining safe, reliable, and long-term impulse generation. Complications have been few and of short duration. In general, pacing thresholds have been lower and sensitivity thresholds higher with left ventricular implantation than with right ventricular implantation. Endocarcial pacing is reserved for the very aged and debilitated patients, patients requiring implantation within 4 to 6 weeks of acute myocardial infarction, and for atrial or atrioventricular sequential pacing.

Adolescent↗
PubMed1978

Aortic root dissection complicating coronary bypass surgery.

Four cases are presented of aortic root dissection after aortocoronary bypass surgery in which the origin of the intimal tear was at or very near the aortic site of saphenous vein anastomosis. Two cases were documented at autopsy. In one of two cases diagnosed with aortography, the patient underwent surgical correction and survived. All patients had long-standing severe hypertensive cardiovascular disease or severe generalized atherosclerotic disease, or both. Clinical awareness of aortic dissection after coronary bypass surgery in this group of patients should make early diagnosis with successful surgical correction feasible.

Aged↗
PubMed1978

Value of coronary bypass surgery. Controversies in cardiology: Part I.

The value of coronary bypass surgery has been studied carefully during the last decade. Four methods, none perfect, have been used to compare the results of such surgery with the results of medical therapy. New data are likely to be merely supportive rather than the outcome of a definitive study with a new and a acceptable experimental design. It is therefore time to analyze the available data in light of the treacherousness of the disease and to determine if a clear trend is evident. There appears to be sufficient evidence to state that properly performed coronary bypass surgery will increase coronary blood flow and relieve angina pectoris in 90 percent of patients; total relief of angina can be expected in 60 percent and partial relief in 30 percent. Compared with modern medical therapy, properly performed coronary bypass surgery appears to prolong the life of patients who have obstruction of the left main coronary artery or triple or double vessel disease. There is not adequate evidence to state that the procedure will prolong the life of patients with single vessel obstruction. However, patients with single vessel obstruction and unacceptable angina pectoris should be considered for bypass surgery (especially patients with obstruction of the left anterior descending coronary artery). In practice, at Emory University Hospital, Atlanta, bypass surgery is recommended for young people with few symptoms if compelling obstructing lesions are present and in older patients only if their symptoms require it. Medical therapy is given before and after bypass surgery. When bypass surgery is performed in an excellent fashion (operative risk 1 percent) a great deal of "controversy" about this problem vanishes.

Angina Pectoris↗
PubMed1978

Criteria for operability and reduction of surgical mortality in patients with severe left ventricular ischemia and dysfunction.

A series of 188 patients who were operated on for left ventricular ischemia and dysfunction is presented. Angina was a prominent symptom in all patients, and a history of congestive heart failure could be elicited in 20%. Mean ejection fraction for the series was 0.35, with 67% having an ejection fraction of 0.35 or less 24%, 0.20 or less. Complete revascularization was accomplished whenever possible; more than 70% of the patients had triple-vessel disease, and single bypass was performed infrequently (5%). Factors thought to be important in achieving a low operative mortality (2.1%) were: precise prebypass monitoring, particularly with the V5 precordial lead; maintaining a low rate-pressure product (less than 12,000) prior to bypass; myocardial preservation with cold hyperkalemic or hyperkalemic-hyperosmolar solution; and careful titration of inotropic and vasodilator drugs. Inotropic drugs and intraaortic balloon pumping were used frequently in this series. The late mortality was 4.3%. Angina was completely relieved or improved in 94% of the patients. Those having a history of congestive heart failure had an increased late mortality rate, four times that of the entire series.

Angina Pectoris↗
PubMed1978

Thoracoscopy: a useful tool in the diagnosis of thoracic disease.

During a 12-month period, 11 patients underwent diagnostic thoracoscopy for previously undiagnosed thoracic disease. In all patients, the diagnosis had been unobtainable by the usual diagnostic modalities of bronchoscopy, scalene node biopsy, mediastinoscopy, thoracentesis, or closed pleural biopsy. Thoracoscopy was diagnostic in 10 of the 11 patients. There was no morbidity or mortality. In all patients the indication for thoracoscopy was suspected malignancy. The majority of patients had recurrent pleural effusions in which routine cytological studies and tissue biopsies had been nondiagnostic. Pathological findings were mesothelioma in 3 patients, primary carcinoma of the lung in 4, congestive heart failure with pleural effusion in 1, metastatic carcinoma in 2, and inflammatory disease in 1 patient. Indications, techniques, and results are discussed. Thoracoscopy is a valuable tool in the diagnosis of thoracic disease; with it, unneccessary thoracotomy can often be avoided.

Aged↗
PubMed1978

Spontaneous rupture of the esophagus.

Spontaneous rupture of the esophagus remains a medical and surgical challenge. Its diagnosis is often missed or delayed resulting in increased morbidity and mortality, and controversy exists as to the mode of therapy for the cases seen later than 12 hours after rupture. During the last seven years, nine patients were treated at Grady Memorial Hospital. Four patients, "early group," were operated upon within 12 hours from the onset of their symptoms and five, "late group," were operated upon between 20-76 hours (average 41) after rupture. All four patients in the "early group" had primary repair of the rupture and two had, in addition, fundoplication. From the two patients with primary repair alone, one developed postoperative leakage at the esophageal suture line, which closed spontaneously; whereas, in the two patients with fundoplication, no leakage occurred. Three of the four patients recovered and one died from renal failure, gastrointestinal bleeding, and gastric perforation. In the "late group" one patient had T-tube drainage of the esophagus and died. Two had primary repair alone with one death and the other two had primary repair with fundoplication 20 and 76 hours postrupture and both recovered. The two deaths in the "late group" were due to leakage at the site of the rupture. This study suggests that even in patients diagnosed late as having rupture of the esophagus, primary repair can be implemented with reasonable success. Good mediastinal, pleural and gastric drainage, high levels of appropriate antibiotics, and provision of good nourishment are of paramount importance for the successful management of these desperately ill patients.

Adult↗
PubMed1978

Physicians' assistants on a university cardiothoracic surgical service. A five-year update.

In 1973 two physicans' assistants (P.A.'s) were employed on a cardiothoracic surgical service at Emory University Hospital. In 1974 our initial experience with these paramedical personnel was presented to this Association. Since that time eight additional P.A.'s have been added to our service. They are now employed in four hospitals of the Emory University Woodruff Medical Center. New guidelines and regulations have been imposed at both the state and federal levels regarding P.A.'s, and their role in our center has become rather well defined. With over 1,700 cardiac cases and 600 thoracic cases per year to cover on our service, the P.A. has assumed a position of increasing importance both in operating room assistance and in preoperative and postoperative care. Since the university has maintained a constant number of residents and fellows during this interval, P.A.'s have filled needs of expanded clinical service in the various hospitals. In the pediatric and community hospitals associated with a university, the P.A. now functions as a junior house officer. In our university center, with a large resident staff, their role has become narrowed with definite guidelines. A Credentials Committee now governs the hiring of all P.A.'s by the University. When properly utilized and supervised, the P.A. can be a vital member of the cardiothoracic team. This report details our experience with P.A.'s for the past 5 years--culminating in a staff of ten P.A.'s working on our service in four types of hospitals within our university medical center.

Georgia↗
PubMed1978

Potassium-induced cardioplegia. Additive protection against ischemic myocardial injury during coronary revascularization.

Potassium-induced cardioplegia during anoxic arrest was utilized in a study of 190 consecutive patients undergoing revascularization (average 2.8 grafts per patient) from August, 1975, through August, 1976. Surgical technique, moderate systemic hypothermia with intermittent anoxic arrest, and the surgeon were the same for all patients. One hundred thirty-five patients (KC1-treated) received a bolus (150 ml.) of potassium solution injected into the proximal aortic root whenever the aortic cross-clamp was applied; 55 others served as control subjects. The mortality rate was 2.2% (three of 135) in the KCl-treated group and one of 55 in the control group. New Q waves appeared in 5.9% (eight of 135) of the KCl-treated patients and 11% (6 of 55) of control subjects (p = N.S.). Catecholamine drips were required after bypass in 4.4% (six of 135) of patients given potassium and 18% (10 of 55) of control patients (p less than 0.05). Profound myocardial relaxation was of added technical value with potassium. It is our impression that hearts treated with potassium exhibited more prompt cardioversion, separated from cardiopulmonary bypass with less need for inotropic support, and exhibited less myocardial injury during the revascularization procedure.

Cardiopulmonary Bypass↗