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Biomedical subjects

C W Akins

Publications and source records attributed to C W Akins.

At least 19 recordsLinked to original sources
PubMed1992

Intraoperative aortic dissection.

Intraoperative aortic dissection is a rare but potentially fatal complication of open heart operations. If the dissection is promptly recognized and repaired, however, the outcome may be significantly better. In this study, we reviewed the hospital records of patients with dissection of the aortic arch occurring as a complication of a cardiac operation at Massachusetts General Hospital and Mt. Auburn Hospital from January 1980 through June 1990. During this period, 14,877 surgical procedures with the use of cardiopulmonary bypass and aortic cannulation were performed, and 24 patients (0.16%) with iatrogenic aortic dissection were identified. Dissection was discovered intraoperatively in 20 patients and postoperatively after complications developed in 4. Of the 20 patients whose injuries were discovered intraoperatively and repaired, 4 (20%) died. Of the 4 whose injuries were discovered after operation, 2 (50%) died. The primary cause of death was ventricular dysfunction resulting from myocardial ischemia. Dissections originated at the aortic cannulation site in 10 patients, at the cross-clamp site in 8, at the site of the partial-occlusion clamp in 7, at the proximal anastomosis in 1 patient, and as a result of direct injury in 1. Three of these patients had simultaneous injuries at the aortic cannulation site and at the heel of the partial-occlusion clamp. Two techniques of repair were used: primary repair and patch or tube graft insertion. There were two deaths in the patients who underwent primary repair and four deaths in patients requiring graft replacement. Although it is uncommon, intraoperative aortic dissection can be a lethal complication of cardiac operations.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1992

Postinfarct ventricular septal defect repair: effect of coronary artery bypass grafting.

Between June 1968 and April 1991, 75 patients who had undergone coronary angiography underwent repair of a postinfarction ventricular septal defect. Group 1 (n = 33) includes patients who had two- or three-vessel serious (> 75% narrowing) proximal coronary artery disease and underwent complete revascularization in addition to repair of the ventricular septal defect. Group 2 (n = 19) patients also had two- or three-vessel coronary artery disease but bypass grafting was not performed; only the ventricular defect was repaired. Group 3 (n = 23) patients had only single-vessel coronary artery disease that corresponded to the region of the infarct; they underwent ventricular septal defect repair only. Follow-up of hospital survivors was 96% complete at a mean of 86.2 months (range, 1 to 288 months). Hospital mortality after ventricular septal defect repair was 21.2% in the cohort with bypassed coronary artery disease (group 1), 26.3% in those with unbypassed disease (group 2), and 26.1% in those with only single-vessel coronary artery disease (group 3) (p = 0.88). With follow-up after 5 and 10 years, the actuarial survival was 72.2% +/- 8% and 47.8% +/- 10%, respectively, in the bypassed group, 29.2% +/- 11% and 0%, respectively, in the unbypassed group, and 52.2% +/- 10% and 36.5% +/- 11%, respectively, in the cohort with single-vessel disease. Bypassing associated coronary artery disease significantly increased long-term survival when compared with patients with unbypassed coronary artery disease (p = 0.0015).

Aged↗
PubMed1992

Blunt injuries of the thoracic aorta.

We managed 51 patients with thoracic aortic injuries caused by blunt trauma between 1977 and 1990. Forty-nine injuries were located in the upper descending aorta and one each in the ascending aorta and aortic arch. Three patients arrived moribund and underwent thoracotomy for resuscitation, and all died. The diagnosis was confirmed by aortography in 48. One patient died of aortic rupture, 1 died of hypoxemia, and 1 refused operation and died. Forty-four patients had aortic repair, 42 with graft insertion. Gott shunts were placed in 23 with 3 cases of paraplegia (13%). Simple cross-clamping was used in 19 with 1 case of paraplegia (5.2%). We found statistically significant differences between the cross-clamp times of patients without paraplegia compared with those in whom paraplegia developed in both the shunt and no-shunt groups. Logistic regression analysis showed that the only factor significantly associated with paraplegia was cross-clamp time. There were two postoperative deaths (4.4%). Seven patients had medical therapy initially and aortic repair was delayed to allow other injuries to stabilize. Before aortic repair, 18 patients had intraarterial pressure monitoring and 34 received beta-blockers or antihypertensive drugs. We conclude that aortic repair with graft insertion is usually successful in nonmoribund patients, simple cross-clamping is associated with a relatively low risk of paraplegia, the incidence of paraplegia is directly associated with the duration of cross-clamp time, and selected patients can be managed medically while awaiting aortic repair.

Adolescent↗
PubMed1992

Acute traumatic disruption of the thoracic aorta: emergency department management.

STUDY OBJECTIVE: To evaluate the safety and effectiveness of temporary IV antihypertensive therapy in patients with acute traumatic thoracic aortic disruption. DESIGN: Retrospective chart review of all patients treated for proven traumatic aortic disruption during the ten-year period of 1980 through 1989. SETTING: Emergency department of a large, urban, Level I trauma center. INTERVENTIONS: Preoperative IV beta-blockade and nitroprusside after initial resuscitation in hemodynamically stable patients. RESULTS: Thirty-seven patients with angiographically proven aortic disruption were separated retrospectively into one of three groups. Group 1 (15 patients without preoperative antihypertensive therapy) had two deaths. Group 2 (15 patients treated for two to seven hours [mean, 3.8 hours] before surgery with antihypertensives) had one death. Group 3 (seven patients treated with antihypertensives for 24 hours to four months before surgery to allow recovery from associated severe injuries) had one death. There were no complications resulting from antihypertensive therapy. CONCLUSION: Temporary antihypertensive therapy appears to be safe and effective in patients with aortic disruption.

Adolescent↗
PubMed1992

Hypothermic fibrillatory arrest for coronary artery bypass grafting.

Hypothermic fibrillatory arrest is a technique of myocardial preservation that has a long history of use in cardiac surgery. Numerous studies have documented its efficacy in various subgroups of patients with coronary artery disease. This report reviews the research support of the tenets of the technique and reports the results with its utilization in 2,801 consecutive patients having isolated myocardial revascularization.

Aged↗
PubMed1992

Review of the global experience with the Medtronic-Hall valve.

The Medtronic-Hall cardiac valvular prosthesis has been available for insertion since 1977. This report reviews the English language literature concerning that valve published during the last 14 years. The review is focused on three modes of assessment. First, experience with valve implantation techniques and their results has demonstrated that with careful attention to education of the implanting cardiac surgeon and increasing experience in the clinical use of the prosthesis, the incidence of occluder impingements has steadily fallen to 0.2% of total valve implantations in the United States in 1989. Secondly, hemodynamic assessment of the prosthesis with both invasive catheterization and Doppler echocardiography has demonstrated rest and exercise transvalve gradients and functional valve areas that are as good or better than those in other mechanical cardiac valvular prostheses. Finally, review of the long-term follow-up reports of the Medtronic-Hall prosthesis has demonstrated an acceptably low incidence of late valve-related complications and their consequences.

Actuarial Analysis↗
PubMed1991

Mechanical cardiac valvular prostheses.

Mechanical cardiac valvular prostheses currently enjoy a 60% to 40% market-share advantage over tissue prostheses in the United States and worldwide. Only the Starr-Edwards caged Silastic (Dow Corning) ball, Medtronic-Hall, St. Jude Medical, and Omniscience valves remain available in the United States. Although each valve has certain advantages and disadvantages, no design has achieved functional mechanical perfection. Late follow-up of valve-related complications from the literature favors the St. Jude Medical and Medtronic-Hall valves.

Adolescent↗
PubMed1991

The safety of intraaortic balloon pump catheter insertion through suprainguinal prosthetic vascular bypass grafts.

To determine the safety of intraaortic balloon pump catheter insertion for critical coronary ischemia through suprainguinal prosthetic bypass grafts, we examined our experience of 19 intraaortic balloon pumps placed through grafts in 17 patients by means of surgical exposure (8) or the percutaneous (11) approach. Fourteen intraaortic balloon pumps were placed through matured grafts at a time remote (2 to 13 years; mean, 7 years) from their vascular bypass surgery. Five were inserted through nonmatured grafts during the same hospitalization as their vascular reconstructive surgery (1 to 12 days; mean, 4 days). One patient, a day after an aortoiliac bypass, died during an urgent, surgical intraaortic balloon pump insertion for cardiogenic shock. All other patients had prompt reversal of their cardiac ischemia. Decreased limb perfusion developed during use of the intraaortic balloon pump in three patients, all of whom had their intraaortic balloon pump placed percutaneously through mature grafts. Two of these required surgical thrombectomy. Ten intraaortic balloon pump insertions in eight patients survived the hospitalization and were followed for a mean of 24 months (range, 2 weeks to 64 months). No localized groin or graft infections were identified. No bleeding complications or pseudoaneurysms occurred. Thus in patients with unstable, severe, cardiac disease, intraaortic balloon pumps can be safely placed through indwelling suprainguinal bypass grafts.

Aged↗
PubMed1990

Late results with Carpentier-Edwards porcine bioprosthesis.

From 1977 to 1984, 429 patients underwent aortic valve replacement (AVR), and 339 underwent mitral valve replacement (MVR) with a Carpentier-Edwards bioprosthesis. Early mortality for AVR was 4.6% (isolated AVR, 1.9%) and for MVR was 5.3% (isolated MVR, 4.1%). Follow-up was 99.3% complete at a mean of 5.9 years. Actuarial event-free rates at 10 years for AVR and MVR were, respectively, 1) for structural valve deterioration, 91.4 +/- 3.2% versus 75.1 +/- 4.0% (p less than 0.01); 2) for nonstructural dysfunction, 100% versus 97.8 +/- 1.6% (p = NS); 3) for thromboembolism, 90.6 +/- 2.3% versus 87.3 +/- 2.6% (p = NS); 4) for anticoagulant-related bleeding, 95.3 +/- 1.1% versus 88.6 +/- 2.4% (p = 0.05); 5) for endocarditis, 87.8 +/- 5.7% versus 90.6 +/- 2.4% (p = NS); 6) for reoperation, 91.0 +/- 2.5% versus 74.4 +/- 3.7% (p less than 0.01); 7) for valve-related mortality, 76.1 +/- 6.9% versus 71.4 +/- 5.2% (p = 0.01); 8) for permanent physical impairment, 85.0 +/- 3.0% versus 71.5 +/- 3.6% (p less than 0.01); and 9) for combined operative mortality, valve-related mortality, and reoperation, 68.7 +/- 6.4% versus 51.5 +/- 4.9% (p = 0.01). No structural valve dysfunction was observed in any AVR patient whose valve was inserted after age 70. Age at operation was the only factor that predicted structural valve deterioration (p less than 0.01).

Actuarial Analysis↗
PubMed1989

Comparison of coronary artery bypass grafting and percutaneous transluminal coronary angioplasty as initial treatment strategies.

Early and late results of primary nonemergency coronary artery bypass grafting in 1,000 consecutive patients and primary nonemergency percutaneous transluminal coronary angioplasty performed concurrently in 389 patients were retrospectively compared. The coronary bypass population was significantly older and more symptomatic and had more prior myocardial infarctions, more left main and multiple-vessel coronary artery disease, and poorer ventricular function. Hospital mortality rates for coronary bypass grafting and angioplasty were 0.4% and 0.5%, respectively, and infarction rates were 1.7% and 5.1%, respectively (p less than 0.01). Including hospital events for the coronary bypass and angioplasty populations, actuarial survival at 5 years was 92.3% versus 96.3% (p = 0.04), freedom from myocardial infarction was 94.6% versus 88.1% (p less than 0.001), freedom from subsequent angioplasty was 99.5% versus 75.2% (p less than 0.001), freedom from subsequent coronary bypass grafting was 98.8% versus 84.9% (p less than 0.001), and freedom from all morbidity and mortality was 87.1% versus 66.0% (p less than 0.001), respectively. By Cox regression analysis for all 1,389 patients, only diminished ejection fraction and advanced age predicted poor long-term survival (p less than 0.001). The only significant predictor of nonfatal late events was having had coronary angioplasty.

Angioplasty, Balloon↗
PubMed1986

Histamine antagonists and d-tubocurarine-induced hypotension in cardiac surgical patients.

Hemodynamic effects and histamine release by bolus injection of 0.35 mg/kg of d-tubocurarine were studied in 24 patients. H1- and H2-histamine antagonists or placebo were given before dosing with d-tubocurarine in a randomized double-blind fashion to four groups: group 1--placebo; group 2--cimetidine, 4 mg/kg, plus placebo; group 3--chlorpheniramine, 0.1 mg/kg, plus placebo; and group 4--cimetidine plus chlorpheniramine. Histamine release occurred in most patients, the highest level 2 minutes after d-tubocurarine dosing. Group 1 had a moderate negative correlation between plasma histamine change and systemic vascular resistance (r = 0.58; P less than 0.05) not present in group 4. Prior dosing with antagonists partially prevented the fall in systemic vascular resistance. These data demonstrate that the hemodynamic changes associated with d-tubocurarine dosing are only partially explained by histamine release. Thus prior dosing with H1- and H2-antagonists provides only partial protection.

Blood Pressure↗
PubMed1979

Preoperative evaluation of subvalular fibrosis in mitral stenosis. A predictor factor in conservative vs replacement surgical therapy.

To assess the degree of mitral subvalvular fibrosis (SVF) in patients with mitral stenosis, left ventriculograms were reviewed, and a mitral subvalvular distance ratio (DR) was determined by dividing the distance from the papillary muscle tips to the closed mitral leaflets in systole by the distance from the aortic valve to the left ventricular apex in diastole. In 15 patients with normal ventricles, the mean DR was 0.244 +/- 0.017. In nine patients with minimal SVF, the mean DR was 0.181 +/- 0.025. In 10 patients with moderate SVF, the mean DR was 0.148 +/- 0.033. In 5 patients with severe SVF, the mean DR was 0.087 +/- 0.009. All mean DRs were mutually distinguishable at p less than 0.01. The clinical results and preoperative DR of 28 patients who had mitral commissurotomy were reviewed. A DR of less than 0.140 precluded a good longterm result from mitral commissurotomy alone. The DR reliably predicts the degree of SVF preoperatively and identifies patients with mitral stenosis who require valve replacement or a direct surgical attack on the subvalvular mechanism.

Angiocardiography↗
PubMed1977

Total anomalous pulmonary venous connection and severe pulmonic stenosis in a 52-year-old man.

Total anomalous pulmonary venous connection (TAPVC) is a rare cardiac congenital abnormality which usually results in death in infancy or early childhood. We describe a 52-year-old man with TAPVC and severe calcific pulmonic stenosis. Both diagnoses were suspected clinically and from the chest X-ray. Cardiac catheterization was confirmatory, and the patient underwent surgery. His initial postoperative course has been unremarkable. The hemodynamic factors relevant to long survival and relative freedom from symptoms in TAPVC are considered based on findings in this patient.

Heart Defects, Congenital↗
PubMed1977

Anomalous origin of left coronary artery from pulmonary artery. Case report and review of literature concerning teen-agers and adults.

An adult with angina was found to have anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Review of the literature regarding this anomaly in teen-agers and adults disclosed only 25 cases diagnosed during life. Eighteen additional cases of ALCAPA in this age group have been diagnosed post mortem. In this report, we will review the management of teen-agers and adults in whom ALCAPA was correctly diagnosed during life. We shall also describe the eighth case of successful aorta-left coronary artery grafting with the saphenous vein in this age group. This case brings the total in the literature to 44. Of those patients offered surgical therapy, 13 underwent successful ligation of the anomalous artery. Saphenous vein grafts were employed in 8. Five did not undergo ligation or saphenous vein grafting. There was one death. It would appear that saphenous vein grafting is the definitive means of surgically correcting ALCAPA, because it restores the dual coronary circulation.

Adolescent↗
PubMed1976

Pulmonary valve replacement. Report of an operation performed for calcific pulmonic stenosis associated with total anomalous pulmonary venous drainage and atrial septal defect.

Calcification of the pulmonic valve is an uncommon lesion that is usually associated with other congenital cardiac defects. Prior attempts at valvotomy or partial excision of the puolmonic valve have carried a high mortality rate. Pulmonary valve replacement itself is an equally uncommon surgical procedure and, in the past, has been performed only during reconstruction of the right ventricular outflow tract, when the pulmonic valve itself had to be utilized as an aortic prosthesis, and in one patient in whom pulmonary regurgitation following valvotomy was not well tolerated. A case of calcific pulmonic stenosis in association with an atrial septal defect and total anomalous pulmonary venous drainage is reported. The patient was treated successfully by pulmonary valve replacement with a Hancock stented porcine xenograft aortic prosthesis in association with correction of the other congenital cardiac lesions.

Heart Septal Defects, Atrial↗