PubMed Health⌕ Search

Biomedical subjects

D M Cosgrove

Publications and source records attributed to D M Cosgrove.

At least 55 records · Page 3Linked to original sources
PubMed1999

Atrial fibrillation early postoperatively following minimally invasive cardiac valvular surgery.

We report a cohort of our first 100 minimally invasive cardiac valvular operations matched 1:1 by age and valvular surgery type with patients undergoing a traditional midline sternotomy approach. The prevalence of postoperative atrial fibrillation among patients with minimally invasive procedures versus traditional midline sternotomy was 26.3% versus 38.0%, respectively (p = 0.08). Neither multiple logistic regression nor Kaplan-Meier distribution analysis identified differences in postoperative atrial fibrillation between the 2 surgical techniques.

Adult↗
PubMed1999

Intra-arterial thrombolysis for perioperative stroke after open heart surgery.

Recent major surgery is an exclusion criterion for thrombolysis. Six patients with acute ischemic stroke underwent intra-arterial thrombolysis after recent open heart surgery without clinically significant bleeding complications, although one patient developed a small, asymptomatic cerebellar hemorrhage. Intra-arterial thrombolysis may be an option for patients with cerebral embolism in the perioperative period.

Aged↗
PubMed1999

Is minimally invasive heart valve surgery a paradigm for the future?

During the past 5 years, there has been considerable progress in the development of less invasive techniques for heart valve surgery. Both aortic and mitral valve surgery can now be performed through small chest wall incisions. Recent evidence confirms patient benefit with minimally invasive heart valve surgery. Although several approaches can be used, a partial upper sternotomy offers several advantages for minimally invasive heart valve surgery.

Aortic Valve↗
PubMed1999

Injury to a patent left internal thoracic artery graft at coronary reoperation.

BACKGROUND: The purpose of this study was to determine the prevalence, outcome, and operative strategies for patients having injury to a patent left internal thoracic artery (LITA) graft to the left anterior descending coronary artery (LAD) at coronary reoperation. METHODS: Of 655 patients with a patent LITA graft to the LAD undergoing coronary reoperation from 1986 to 1997, 35 (5.3%) sustained intraoperative injury to the LITA graft. RESULTS: Strategies to restore flow to the LAD included new saphenous vein graft to the LAD in 15 patients, saphenous vein graft to the LITA stump in 7, saphenous vein graft to the LAD and repair of the LITA graft in 6, and other strategies in 7. All or part of the LITA graft to the LAD was salvaged in 20 patients (57%). Fourteen patients (40%) sustained perioperative myocardial infarction, and 3 patients died (8.6%). The 3 patients who died all had stenosis or thrombosis of the graft to the LAD documented at autopsy. CONCLUSIONS: We conclude that (1) the prevalence of injury to a patent LITA graft is 5.3%; (2) a variety of techniques can be used to restore blood flow to the LAD; and (3) ineffective revascularization of the LAD in this situation is associated with operative mortality. At primary coronary artery bypass grafting, the LITA pedicle should be positioned in the left chest away from the posterior sternal table; this strategy may minimize the risk of LITA graft injury at coronary reoperation.

Adult↗
PubMed1999

Aortic valve replacement after substernal colon interposition.

A 60-year-old man with a history of esophageal resection and substernal colon interposition required aortic valve replacement for aortic stenosis. The aortic valve was approached through an 8-cm right parasternal incision over the third and fourth costal cartilages with cardiopulmonary bypass using cannulas in the right femoral artery and vein and the right atrium. The right parasternal approach provided safe exposure of the aorta and left ventricular outflow tract when substernal abnormalities precluded conventional median sternotomy.

Aortic Valve↗
PubMed1999

A prospective randomized trial of Duraflo II heparin-coated circuits in cardiac reoperations.

BACKGROUND: Heparin-coated circuits in cardiopulmonary bypass have been shown to decrease the systemic inflammatory responses associated with cardiopulmonary bypass. Previous clinical studies on low-risk patients who had coronary artery bypass grafting (CABG) and received full-dose systemic heparin did not have clearly improved clinical outcomes. We hypothesized that the beneficial effects of heparin-coated circuits might be seen in patients who had cardiac reoperations. METHODS: Three hundred fifty patients who had reoperation with CABG only (58%), or with valve operations (42%) were randomly assigned to receive either a heparin-coated (Duraflo II; study group) or uncoated (control group) circuit. Clinical outcomes were compared and the variables were analyzed using the following three groups: entire populations of study group and control group, subgroup of patients who had CABG reoperation only, and a subgroup who had valve reoperation or combined valve and CABG reoperation. RESULTS: Preoperative variables were the same in both groups. No difference in clinical outcomes could be demonstrated except that the percentage of patients with major bleeding episodes was significantly lower in the study group (1.2% versus 5.4%, p = 0.035). In the subgroup analysis of patients who had valve reoperations, lower blood transfusion requirements in the intensive care unit (p = 0.013) were found in the study group. When the subgroup of patients who had CABG reoperations was analyzed separately, there was a trend toward less reoperation for bleeding in the study group (0% versus 4.0%, p = 0.058). CONCLUSIONS: We conclude that the use of heparin-coated circuits was safe and imparted protection from reoperations for bleeding and major bleeding episodes. Material-independent blood activation (eg, blood-air interface and cardiotomy suction) blunted the total effect of the heparin-coated surface.

Aged↗
PubMed1999

Use of the anterior mitral leaflet to reinforce the posterior mitral annulus after debridement of calcium.

In mitral valve surgery, preservation of continuity between the papillary muscles, chordae, and annulus is associated with preservation of left ventricular function and reduced risk of postoperative left ventricular rupture. However, at mitral valve replacement, extensive annulus and leaflet calcification can necessitate resection of the posterior mitral leaflet. We describe a technique in which the anterior mitral leaflet and its subvalvular apparatus are used to reinforce the posterior mitral annulus after extensive debridement of calcium along the same annulus.

Calcinosis↗
PubMed1999

Is anterior leaflet repair always necessary in repair of bileaflet mitral valve prolapse?

BACKGROUND: Traditionally, bileaflet prolapse has been treated by posterior leaflet resection combined with one of a number of procedures designed to support the anterior leaflet. However, most patients with bileaflet prolapse do not have important anterior chordal pathology. This study was undertaken to evaluate the effectiveness of a strategy of posterior leaflet resection and annuloplasty alone for patients with bileaflet prolapse and no anterior chordal rupture or severe anterior chordal elongation. METHODS: From 1993 to 1997, 93 patients with transesophageal echocardiography (TEE) demonstrated bileaflet prolapse and without anterior chordal rupture or important anterior chordal elongation had primary isolated mitral valve repair consisting only of posterior leaflet resection (quadrangular in 28 and sliding in 65) and annuloplasty (Cosgrove-Edwards in 83, pericardial in 9, and Carpentier-Edwards in 1). All patients had severe mitral regurgitation documented by intraoperative TEE. Mean age was 55+/-13 years; 60% were men. RESULTS: Postrepair, mitral regurgitation was 0 to trace in 93% and 1+ in 7%. There were no operative deaths. Late follow-up was available in all patients, with 277 patient-years of follow-up available for analysis. Five-year actuarial survival was 95%. At a mean interval of 2.3+/-1.3 (SD) years, echocardiography demonstrated no or trace mitral regurgitation in 65%, 1+ in 28%, and 2+ in 7%. No correlates of late mitral regurgitation were identified by multivariable analysis. No patient has required reoperation. CONCLUSIONS: In the absence of significant anterior chordal pathology, a strategy of posterior leaflet resection and annuloplasty corrects anterior leaflet prolapse and mitral regurgitation, and provides a durable repair without the necessity of additional procedures on the anterior leaflet.

Aged↗
PubMed1999

Primary synovial sarcoma of the left heart.

Primary synovial sarcoma of the heart is extremely rare. This report adds another case to the literature and emphasizes that this tumor, although rare, should be considered in the differential diagnosis of left atrial tumors.

Adult↗
PubMed1999

Two internal thoracic artery grafts are better than one.

OBJECTIVE: Does the use of bilateral internal thoracic artery (ITA) grafts provide incremental benefit relative to the use of a single ITA graft? METHODS: We conducted a retrospective, nonrandomized, long-term (mean follow-up interval of 10 postoperative years) study of patients undergoing elective primary isolated coronary bypass surgery who received either single (8123 patients) or bilateral ITA grafts (2001 patients), with or without additional vein grafts. Multiple statistical methods including propensity score matching, and multivariable parsimonious and nonparsimonious risk factor analyses were used to address the issues of patient selection and heterogeneity. RESULTS: In-hospital mortality was 0.7% for both the bilateral and single ITA groups. Survival for the bilateral ITA group was 94%, 84%, and 67%, and for the single ITA group 92%, 79%, and 64% at 5, 10, and 15 postoperative years, respectively (P <.001). Death, reoperation, and percutaneous transluminal coronary angioplasty were more frequent for patients undergoing single rather than bilateral ITA grafting, and this observation remained true despite multiple adjustments for patient selection, sampling, and length of follow-up. The differences between the bilateral and single ITA groups were greatest in regard to reoperation. The extent of benefit of bilateral ITA grafting varied according to patient-related variables, but no patient subsets were identified for whom single ITA grafting could be predicted to provide an advantage. CONCLUSIONS: Patients who received 2 ITA grafts had decreased risks of death, reoperation, and angioplasty.

Aged↗
PubMed1999

Dissection of the ascending aorta after previous cardiac surgery: differences in presentation and management.

OBJECTIVE: This study was undertaken to determine the impact of previous cardiac surgery on the presentation, management, and outcome of late dissection of the ascending aorta. PATIENTS AND METHODS: From 1976 to 1998, type A dissection developed in 56 patients with a history of previous cardiac surgery. Interval from first operation to type A dissection was 49 +/- 47 months (0.3-180 months). Previous operations were coronary artery bypass grafting (n = 40), aortic valve replacement (n = 8), and other (n = 8). RESULTS: Type A dissection was acute in 34 patients and chronic in 22. In acute dissection, aortic insufficiency occurred in 50%, malperfusion in 12%, and rupture in 18%; 2 patients (6%) were in hemodynamically unstable condition because of rupture. Of patients with previous coronary bypass grafting, 98% had preoperative coronary angiography. Type A dissection was treated by supracoronary tube graft (84%), Bentall procedure (14%), or local repair (2%). Strategies for managing previous coronary bypass grafting included reimplantation of proximal anastomoses with a button of native aorta (29 patients), interposition graft to pre-existing saphenous vein grafts (9 patients), and new saphenous vein grafts (20 patients). Eight hospital deaths occurred (14%). CONCLUSIONS: We conclude that (1) patients having type A dissection late after cardiac surgery infrequently have cardiac tamponade and hemodynamic collapse; (2) patients with previous coronary bypass grafting require coronary angiography, because operative management must account for pre-existing coronary artery disease; and (3) operative mortality is low, and this may be attributable to preoperative hemodynamic stability, delineation of coronary anatomy in those with previous coronary bypass grafting, and operative treatment of coronary artery disease.

Aged↗
PubMed1999

The value of assessing pulmonary venous flow velocity for predicting severity of mitral regurgitation: A quantitative assessment integrating left ventricular function.

Although alteration in pulmonary venous flow has been reported to relate to mitral regurgitant severity, it is also known to vary with left ventricular (LV) systolic and diastolic dysfunction. There are few data relating pulmonary venous flow to quantitative indexes of mitral regurgitation (MR). The object of this study was to assess quantitatively the accuracy of pulmonary venous flow for predicting MR severity by using transesophageal echocardiographic measurement in patients with variable LV dysfunction. This study consisted of 73 patients undergoing heart surgery with mild to severe MR. Regurgitant orifice area (ROA), regurgitant stroke volume (RSV), and regurgitant fraction (RF) were obtained by quantitative transesophageal echocardiography and proximal isovelocity surface area. Both left and right upper pulmonary venous flow velocities were recorded and their patterns classified by the ratio of systolic to diastolic velocity: normal (>/=1), blunted (<1), and systolic reversal (<0). Twenty-three percent of patients had discordant patterns between the left and right veins. When the most abnormal patterns either in the left or right vein were used for analysis, the ratio of peak systolic to diastolic flow velocity was negatively correlated with ROA (r = -0.74, P <.001), RSV (r = -0.70, P <.001), and RF (r = -0.66, P <.001) calculated by the Doppler thermodilution method; values were r = -0.70, r = -0.67, and r = -0.57, respectively (all P <.001), for indexes calculated by the proximal isovelocity surface area method. The sensitivity, specificity, and predictive values of the reversed pulmonary venous flow pattern for detecting a large ROA (>0.3 cm(2)) were 69%, 98%, and 97%, respectively. The sensitivity, specificity, and predictive values of the normal pulmonary venous flow pattern for detecting a small ROA (<0.3 cm(2)) were 60%, 96%, and 94%, respectively. However, the blunted pattern had low sensitivity (22%), specificity (61%), and predictive values (30%) for detecting ROA of greater than 0.3 cm(2) with significant overlap with the reversed and normal patterns. Among patients with the blunted pattern, the correlation between the systolic to diastolic velocity ratio was worse in those with LV dysfunction (ejection fraction <50%, r = 0.23, P >.05) than in those with normal LV function (r = -0.57, P <.05). Stepwise linear regression analysis showed that the peak systolic to diastolic velocity ratio was independently correlated with RF (P <.001) and effective stroke volume (P <.01), with a multiple correlation coefficient of 0.71 (P <.001). In conclusion, reversed pulmonary venous flow in systole is a highly specific and reliable marker of moderately severe or severe MR with an ROA greater than 0.3 cm(2), whereas the normal pattern accurately predicts mild to moderate MR. Blunted pulmonary venous flow can be seen in all grades of MR with low predictive value for severity of MR, especially in the presence of LV dysfunction. The blunted pulmonary venous flow pattern must therefore be interpreted cautiously in clinical practice as a marker for severity of MR.

Aged↗
PubMed1999

Intraoperative transesophageal echocardiography in minimally invasive cardiac valve surgery.

The minimally invasive procedure is a new surgical technique that uses a small sternal incision. Because of limited surgical exposure, removal of intracavitary air and visual assessment of cardiac function are not possible. We studied the utility of intraoperative transesophageal echocardiography (IOE) before and after cardiopulmonary bypass in 112 patients (mean age 53.1 +/- 15.2 years, 74 males) who underwent minimally invasive valvular surgery. Surgical procedures included 52 isolated mitral valve procedures (49 repairs, 3 prostheses), 58 isolated aortic valve procedures (16 repairs, 26 prostheses, 16 homografts), and 2 combined aortic and mitral valve repairs. Prepump IOE was useful to confirm valve dysfunction and assist determination of arterial cannulation site. Postpump IOE identified intracardiac air in all patients, which was defined as extensive in 58 (52%) cases. Postoperatively, new left ventricular dysfunction was noted in 22 (20%) patients, more often in the group with extensive air by IOE (17 [30%] of 58 patients) compared with those without extensive air (5 [10%] of 54 patients, P =.01). Second pump runs were required in 7 (6%) of 112 patients: 3 cases of residual aortic regurgitation, 1 case of residual mitral regurgitation, and 3 cases with new ventricular dysfunction. No deaths occurred. We conclude that IOE is essential in minimally invasive valvular surgery because it detects problems that require immediate remedy. IOE allows real-time assessment of ventricular filling, ventricular and valvular function, and intracardiac air.

Air↗
PubMed1999

Intermediate-term durability of bicuspid aortic valve repair for prolapsing leaflet.

OBJECTIVE: To determine the durability of repair of a bicuspid aortic valve with leaflet prolapse, and to identify factors associated with repair failure. METHODS: From November 1988 to January 1997, 94 patients with a bicuspid aortic valve and regurgitation from leaflet prolapse had aortic valve repair. In 66 patients, the repair employed triangular resection of the prolapsing leaflet. The remainder underwent mid-leaflet plication of the prolapsing leaflet. Mean age was 38 +/- 10 years and 93% were male. Median follow-up was 5.5 years (range 0.2-9 years). Factors associated with aortic valve competence and durability were identified by multivariable logistic and hazard function analyses. RESULTS: Early valve competence was more difficult to achieve in patients with large, poor functioning ventricles (P = 0.02). Aortic valve reoperation was necessary in 12 patients that included three re-repairs and nine aortic valve replacements. Freedom from reoperation was 95, 87 and 84% at 1, 5 and 7 years, respectively. The instantaneous risk of reoperation was highest immediately after operation, and fell rapidly to approximately 2% per year and less after 2 years. The only risk factor identified was the presence of residual aortic regurgitation (trace to mild in 35 cases) on immediate intraoperative post-repair transesophageal echocardiography. Late aortic regurgitation did not progress detectably across time (P = 0.3). There were no deaths, early or late. CONCLUSION: Bicuspid aortic valve repair for prolapsing leaflet is a safe procedure with good intermediate-term outcome. However, any residual aortic regurgitation jeopardizes repair durability and initial repair achievement is more difficult in patients with dilated, poor functioning ventricles.

Adolescent↗
PubMed1999

Minimally invasive mitral valve surgery: mini-sternotomy with extended transseptal approach.

A partial upper sternotomy and an extended transseptal incision provide excellent exposure for mitral valve surgery. From March 1997 to December 1998, 462 patients had mitral valve surgeries using this minimally invasive approach. Eighty-seven percent had mitral valve repair, and 13% had mitral valve replacement. Thirteen patients (3%) required conversion to full sternotomy, and all other patients had the procedure completed using the initial approach. Forty-eight percent of patients were extubated within 6 hours of surgery, and 47% of patients spent less than 24 hours in the intensive care unit (ICU). Mean hospital length of stay was 7.2 +/- 5.4 days. Eighty-six percent of patients received no blood products. There was 1 hospital death (0.2%). Morbidity included reexploration for bleeding (4%), respiratory insufficiency (1%), stroke (1%), myocardial infarction (0.2%), and wound infection (0.2%). We conclude that virtually all mitral valve procedures, including complicated repairs, can be accomplished via partial upper sternotomy with an extended transseptal incision. This approach provides excellent exposure of the mitral valve and results in a low rate of wound complications, low transfusion requirements, and excellent cosmesis.

Adult↗