Biomedical subjects
Publications and source records attributed to D A Cooley.
An unusual case of a large, prolapsing atrial septal aneurysm in a patient with an otherwise normal heart is described. The aneurysm caused right atrial obstruction and resulted in a "tumor effect." The patient experienced debilitating symptoms for years before receiving an appropriate diagnosis and curative surgical treatment.
Ischemic injury to the spinal cord and kidneys continues to be the major complication after resection of aneurysms involving the descending and proximal abdominal aorta. Our recent surgical experience with use of only a proximal clamp on the aorta to perform an "open" distal anastomosis has proved this technique to be safe and expeditious. We therefore compared our results using the technique of open distal anastomosis for aneurysm repair with those of the conventional two-clamp technique. Since January 1989, we have used the conventional two-clamp technique in 31 patients (group 1) and the technique of open distal anastomosis in 24 patients (group 2). No significant differences were noted between the two groups in terms of age, sex, cause of aneurysm, extent of aneurysm, or site of proximal cross-clamp. The average distal ischemic time was 31 minutes in group 1 patients and 26 minutes in group 2 patients. Renal insufficiency occurred in 8 of 31 patients in group 1 and in 0 of 24 patients in group 2 (p = 0.01). Neurologic complications occurred in 4 patients in group 1 and in 1 patient in group 2. Early mortality rates were similar for both groups (4 of 31 [13%], group 1; 4 of 24 [17%], group 2). Deaths were attributed to multiorgan failure and sepsis in 6 patients and coexisting coronary artery disease in 2 patients. Based on these results, we believe the technique of open distal anastomosis is safe and may improve the outcome in patients undergoing operation for descending thoracic aneurysms.(ABSTRACT TRUNCATED AT 250 WORDS)
Bentall's technique for repair of annuloaortic ectasia has been associated with postoperative bleeding and with false aneurysms at the anastomotic site between the coronary orifices and valve-containing graft. To reduce the incidence of these complications, we modified the Bentall procedure, using a simplified technique to implant the graft and to create a fistula between the closed perigraft space and right atrium to control bleeding. A continuous suture of monofilament polypropylene was used to implant the prosthetic valve ring and to anastomose the coronary orifices to the Dacron fabric. In some instances, a brief period of hypothermic circulatory arrest was needed to perform the distal aortic anastomosis. Among 562 patients undergoing operation for aneurysm of the ascending aorta between January 1, 1980, and February 28, 1990, 280 underwent graft replacement with a valve-containing composite conduit. Most (82%) had annuloaortic ectasia. In 267, we performed a classic Bentall procedure with direct anastomosis between the coronary orifices and fabric graft. The remaining 13 patients underwent other procedures for coronary connection. Early mortality was 5.0%. Reoperation for bleeding was needed in 13.2% of patients who underwent operation before we used the right atrial fistula technique and in 4.4% after we began to use the technique (p = 0.044). Actuarial survival was 71% at 5 years and 65% at 7 years. For hospital survivors, it was 76% at 5 years and 70% at 7 years. During follow-up, only 9 patients have required reoperation. A false aneurysm at the coronary anastomosis, which was associated with prosthetic valve endocarditis, developed in 1 patient. No permanent fistulas have developed.(ABSTRACT TRUNCATED AT 250 WORDS)
Coronary artery anomalies, some of which are considered clinically insignificant, can be associated with other congenital heart defects, myocardial ischemia, and reduced life expectancy. We conducted a retrospective study to determine the efficacy of surgical treatment in 191 patients who had a total of 202 coronary artery anomalies, which were classified as anomalies of origin (88 patients), termination (93), or distribution (10). Of the 88 patients with anomalies of origin, 60 had a coronary artery arising from the pulmonary artery, 18 had a right coronary artery arising from the left anterior descending artery, and 10 had a coronary artery arising from the contralateral sinus of Valsalva. All patients with an anomaly of termination had a coronary arteriovenous fistula, and all patients with an anomaly of origin had a single coronary artery. The diagnostic and operative techniques for each of the defects are evaluated. Based on our experience, early diagnosis and surgical intervention can yield satisfactory results in patients with coronary artery anomalies, with most experiencing relief of symptoms. The operative procedures were associated with a low early and late mortality; in addition, few patients experienced complications.
Posterior disruption of the left ventricle is a difficult injury to repair and is associated with a high intraoperative mortality. We report a case of posterior disruption that occurred during a mitral valve operation. A conventional approach to repair failed after sutures tore through the myocardium. Intraventricular decompression to reduce ventricular wall tension and allow for successful suture repair of the injury was accomplished by insertion of a BioMedicus left ventricular assist device.
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Myocardial damage after infarction is a common sequela in patients with coronary occlusive disease. The extent of injury varies and may be localized or diffuse. Since March 1989, the authors have used a new surgical repair technique that employs an intracavitary patch of Dacron fabric or glutaraldehyde-treated pericardium to exclude the hypokinetic or fibrotic myocardial segment. An elliptical configuration preserves the contour and volume of the ventricular cavity. After securing the patch, the ventriculotomy is closed with a simple continuous suture. Through July 31, 1991, 136 patients underwent repair using this technique. Of these patients, 100 (group I) had neither sustained an acute myocardial infarction (within 30 days before surgery) nor had undergone previous cardiac surgery, whereas 36 (group II) had sustained an acute myocardial infarction or had undergone previous cardiac surgery. In group I, four (4%) died within 30 days of surgery, and seven died later, resulting in a 6-month survival of 90.5% and a 1-year survival of 85.3%. In group II, 11 (30.6%) died within 30 days of surgery, and three died later. Functional class improved after repair in 95.7% of patients in group I and all patients in group II. In both groups, ejection fraction improved significantly (p less than 0.0001, group I; p less than 0.0001, group II). By eliminating the need for epicardial buttresses to repair the ventriculotomy, myocardial revascularization has been possible in most patients. This method of intraventricular repair is also appropriate for patients with calcified aneurysms, acquired ventricular septal defects, and acute ventricular rupture.
After an extensive trial of many different suture techniques for implanting valvular prostheses, we have recently returned to using a simple, continuous suture of monofilament polypropylene. We believe this technique has many theoretical and practical advantages. Valvular implantation takes less time and is even more secure than when individual sutures are used. In addition, the need for porous felt pledgets, which may harbor bacteria, is eliminated. This simple technique facilitates implantation in the mitral and aortic positions.
The purpose of this study is to determine the effects of ischemia in the spinal cord when a calcium channel blocker, nimodipine, is administered intravenously before, during, and after crossclamping of the thoracic aorta. In this series of experiments, 18 pigs underwent thoracotomies and had 17.5 to 18.0 cm of the thoracic aorta clamped for 30 minutes. By random selection, nine animals received intravenous nimodipine (2 micrograms/kg per minute) and nine control animals received only a carrier solution. Of the nine animals that received nimodipine, eight walked after the operation. In contrast, in the control group only two of nine animals walked. The ninth nimodipine-treated animals walked but had a severe delayed deterioration response. All animals, except one control animal, had a negative central spinal perfusion pressure. Morphologic examination of serial sections of spinal cords from control animals showed diffuse neuronal necrosis. In comparison, cords from the nimodipine group had swollen neurons accompanied by an inflammatory infiltrate and only occasional necrotic neurons. With this data, we conclude that certain calcium channel blockers, when administered in sufficient doses, can lend a protective effect to the spinal cord during ischemic events even when cord perfusion pressure has dropped to dangerously low levels.
Studies were done on the structural changes that develop in Ionescu-Shiley valves that are used as replacement heart valves for 4 to 8 years. These changes were compared with those found in similarly used porcine aortic valve (PAV) bioprostheses. A variety of morphologic differences were observed between bovine pericardial valve (BPV) and PAV bioprostheses after orthotopic implantation including: primary tissue failure associated with the use of an alignment suture, thickening of valve leaflet, leaflet tissue delamination, leaflet calcification, and dystrophic alterations of collagen. These findings indicate that valve design criteria directly influence the durability of pericardial valves. However, other factors unique to pericardial tissue also affect the durability and performance of BPVs. These factors include the inability of pericardial tissue to accommodate dynamic stresses; the extensive insudation of plasma proteins and lipids; and the inability to reduce leaflet calcification using agents that effectively mitigate calcification in PAV bioprostheses.
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A new surgical technique for bypassing subclavian vein thromboses in patients undergoing hemodialysis is presented. Subclavian vein stenosis or occlusion can occur after the use of temporary access catheters in subclavian vein dialysis. If this occurs in a patient with an arteriovenous access fistula of an ipsilateral upper extremity, venous hypertension, massive edema of the arm, and dysfunction of the access graft may result. In 2 patients with this condition, we successfully performed axillary vein-to-right atrial bypass, which resolved swelling and restored function of the access graft. This may be an appropriate surgical option for symptomatic venous hypertension in such patients.
During a 27-year-period, 663 adults of the Jehovah's Witness faith underwent open heart procedures at the Texas Heart Institute. To determine the effect of recent changes in operative techniques and in the patient population itself on early mortality, we reevaluated the surgical outcome in this special group of patients. We reviewed the charts of 88 consecutive Jehovah's Witness patients who had an open heart operation between January 1986 and March 1989 and compared demographic variables in this group with those of 575 patients who underwent operation between May 1963 and January 1986. In our recent series, patients were older (mean age, 61 years versus 54 years), and 16% were seen for repeat procedures. Early mortality (less than or equal to 30 days postoperatively) was lower in the recent series than in the earlier series (7.0% versus 10.7%), but the difference between the groups was not statistically significant. We identified several important factors associated with an increased risk of early death in the recent group of patients. These factors included repeat cardiac operations (p less than 0.01), especially for valvar dysfunction, severe left ventricular dysfunction (defined as an ejection fraction less than 0.35) (p less than 0.01), and a hemoglobin level lower than 80 g/L (8 g/dL) (p less than 0.01) on postoperative day 1. Although blood loss remains the leading cause of death in these patients, cardiac operations can be performed with an acceptable mortality.
In marked contrast to benign cardiac tumors, primary cardiac sarcomas occur infrequently. Moreover, there is no uniform approach to treating such patients, and the benefits of postoperative chemotherapy are unclear. Between 1964 and 1989, 21 patients with primary cardiac sarcomas underwent surgical resection alone (n = 7), chemotherapy alone (n = 1), or combined operation and postoperative chemotherapy based on adriamycin (n = 13). Twenty-four operations were performed on 20 patients with relief of symptoms in all. Eleven patients had complete resection. Operative mortality was 8.3% (2/24). Histology and originating chamber(s) included angiosarcoma (n = 7; 6/7 in right atrium, 1 in left atrium), malignant fibrous histocytoma (7; all in left atrium), fibrosarcoma (2; 2/2 in left atrium), rhabdomyosarcoma (2; 1 in left atrium, 1 in right ventricle), leiomyosarcoma (2; 1 in left atrium, 1 in left ventricle); and one undifferentiated sarcoma (right atrium). Overall actuarial survival was 14% at 24 months after resection. Patients with complete resection had a median survival of 24 months compared with only 10 months in all other patients (p = 0.035). Postoperative chemotherapy did not enhance survival in patients with incomplete resection. At this time, aggressive and complete surgical resection seems to offer the best hope for palliation and survival in an otherwise fatal disease.
Between February 1960 and August 1989, 73 consecutive patients underwent surgical correction for supravalvar aortic stenosis (SVAS) at the Texas Heart Institute. There were 43 male (59%) and 30 female patients (41%) ranging in age from 5 days to 27 years (mean age, 12 years). Preoperatively, 8 patients were in New York Heart Association functional class I, 43 in class II, 18 in class III, and 4 in class IV. Of the 73 patients, 62 had localized SVAS and 11 (15%), diffuse SVAS. For all procedures, patients were placed on cardiopulmonary bypass. Those with localized SVAS were successfully treated with patch aortoplasty, whereas those with diffuse SVAS required either an apicoaortic conduit or extensive end-arterectomy with extended patch aortoplasty. There were eight early deaths (less than or equal to 30 days postoperatively) (11%) and four late deaths (greater than 30 days postoperatively) (6%) in a follow-up period ranging from 2 months to 28 years. Sixteen patients (25%) underwent one or more additional operations in the follow-up period. Postoperatively, there were 44 patients in New York Heart Association functional class I and 17 in class II. Preoperative functional class III and class IV (p less than 0.0005), diffuse SVAS (p = 0.05), and the presence of associated congenital defects (p less than 0.01) were important determinants of death.
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We reviewed the surgical results of 21 patients who had infected abdominal aortic grafts to determine the efficacy of in-situ graft replacement and extra-anatomic bypass in the management of these patients. Twelve patients had a primary perigraft infection, and nine had an infection secondary to an aortoenteric fistula (AEF). Whereas the infected graft was replaced with a new aortic prosthesis in 18 patients, an axillobifemoral bypass operation followed graft excision in three patients. Twelve of the graft replacement patients (two AEF patients) had a low-grade infection, with negative perigraft and blood cultures. All 12 patients were alive at a mean follow-up of 8 years. Two had required above-knee amputation because of severe occlusive disease, and one had required an axillobifemoral bypass because of reinfection. The remaining six graft replacement patients (five AEF patients) had severe graft infections, with positive perigraft fluid and blood cultures in which one or more bacteria were present. Five died of sepsis within 1 month of operation. The remaining patient, who later required an axillobifemoral bypass because of reinfection, was alive at follow-up 4.3 years after operation. The three patients (two AEF patients) who had axillobifemoral bypasses had severe graft infections, with positive perigraft fluid and blood cultures. They survived the extra-anatomic bypass operation and were alive at a mean follow-up of 4.5 years. We conclude that patients who have a low-grade graft infection and negative blood and perigraft cultures can be treated safely by graft excision and in-situ replacement with a new prosthesis.(ABSTRACT TRUNCATED AT 250 WORDS)