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Biomedical subjects

D M Cosgrove

Publications and source records attributed to D M Cosgrove.

At least 73 records · Page 4Linked to original sources
PubMed1999

Surgical correction for sinus of Valsalva aneurysm.

BACKGROUND: To evaluate the efficacy of surgical correction of sinuses of Valsalva aneurysms, 24 patients operated on from 1974-1994 were reviewed. Mean age was 42.2+/-16.7 years; 17 were males. METHODS: Right coronary sinus was affected in 13 patients and noncoronary sinus in 8. Intracardiac fistula was detected in 16 patients: into the right atrium in 8; right ventricle in 5; left ventricle in 2; and left atrium in 1. Repair was performed via an aortic approach in 11 patients and a combined aortic and intracardiac approach in 13 patients. Suture closure of the fistula was via the aortic side in 10 cases and the intracardiac side in 6. Ten patients had patch closure via the aortic side. RESULTS: Follow-up was 92% complete at a mean of 8.4 years with 3 late cardiac and 1 noncardiac deaths. Eighty-eight percent of patients are in New York Heart Association functional class I or II; none underwent reoperation. CONCLUSIONS: Sinuses of Valsalva aneurysm repair have low operative mortality and morbidity risks with excellent early and late results. Surgical approach is dependent upon the presenting pathology.

Adolescent↗
PubMed1998

Analysis of risk factors for development of atrial fibrillation early after cardiac valvular surgery.

Atrial fibrillation (AF) commonly develops after cardiac valvular surgery. The objective of this study was to identify risk factors for postoperative AF following valvular surgery. A cohort of 915 consecutive adult patients undergoing isolated valvular surgery with preoperative sinus rhythm was analyzed. Univariate and independent multivariate risk factors for postoperative AF were determined. A second cohort of 305 patients with the same inclusion criteria was used to validate the multivariate predictors. Patients studied had a mean age of 56.1 +/- 14.7 years, 57.9% were men, 79.6% had a normal left ventricular ejection fraction, and their mean left atrial size was 46.2 +/- 9.3 mm. The incidence of postoperative AF was 36.7%. Independent predictors of postoperative AF included: advanced age (odds ratio [OR] 1.506 per decade, 95% confidence interval, [CI] 1.35 to 1.68, p = 0.0001); mitral stenosis (OR 2.066, CI 1.21 to 3.52, p = 0.0077); left atrial enlargement (OR 1.468, CI 1.07 to 2.01, p = 0.0165); use of systemic hypothermia (OR 0.572, CI 0.422 to 0.776, p = 0.0003); and a history of cardiac surgery (OR 0.676, CI 0.465 to 0.981, p = 0.0393). Among these variables, advanced age, mitral stenosis, and left atrial enlargement were confirmed as independent risk factors in the validation cohort.

Atrial Fibrillation↗
PubMed1998

Secular trends in nosocomial bloodstream infections in a 55-bed cardiothoracic intensive care unit.

BACKGROUND: Although bloodstream infections (BSIs) occur more frequently in intensive care unit patients than in ward patients, most studies of nosocomial BSIs in critically ill patients have not distinguished between intensive care unit populations beyond surgical, medical, and pediatric patients. METHODS: The primary objective of this study was to characterize the secular trends in rates of nosocomial BSIs for all pathogens among patients admitted to a busy cardiothoracic intensive care unit in a single tertiary care institution between January 1986 and December 1995. Patients with nosocomial BSIs were identified through continual prospective surveillance. RESULTS: A total of 40,207 patients were admitted to the cardiothoracic intensive care unit during the 10-year study period, and 804 episodes of nosocomial BSIs among 681 patients were identified. The mean crude BSI infection rate was 6.0 per 1,000 patient-care days and increased linearly during the study period (range, 4.4 to 8.1 per 1000 patient-care days), and approached statistical significance (p value = 0.07). The most common organisms causing BSIs were Staphylococcus aureus (12%), coagulase-negative staphylococci (11%), Candida albicans (11%), Pseudomonas aeruginosa (10%), and Enterococci (9%). The leading sources of nosocomial BSIs were primary BSIs (33%), intravascular devices (27%), lower respiratory tract infections (17%), and surgical wound infections (12%). The etiologic fraction or the proportion of deaths in cardiothoracic intensive care unit patients with BSIs was 15-fold higher than those patients without BSIs (37% versus 2.5%, p < 0.001). CONCLUSIONS: Rates of nosocomial BSIs among patients in our cardiothoracic intensive care unit have increased linearly during the past decade and patients with nosocomial BSIs have an increased risk of in hospital mortality.

Candida albicans↗
PubMed1998

Increased risk and decreased morbidity of coronary artery bypass grafting between 1986 and 1994.

BACKGROUND: The collective impact of advances in medical, surgical, and anesthetic care on the characteristics and outcomes of patients who undergo coronary artery bypass grafting was assessed. METHODS: We compared the demographic and clinical characteristics, preoperative risk factors, morbidity, and mortality of two groups of patients who underwent coronary artery bypass grafting in isolation or in combination with other procedures between July 1, 1986, and June 30,1988 (group 1, n = 5,051), and between January 1, 1993, and March 31, 1994 (group 2, n = 2,793). The patients were stratified according to their preoperative risk level. Outcome measures consisted of changes in preoperative risk categories; hospital mortality rates; overall and risk-adjusted major cardiac, neurologic, pulmonary, renal, and septic morbidity rates; and intensive care unit length of stay. RESULTS: Changes in the distribution of risk categories, from a median of 2 to 4 on a 9-point scale (p < 0.001), indicated that patients in group 2 were at significantly higher risk than those in group 1. The risk-adjusted mortality rate did not change (2.8% to 2.9%; p = 0.15), but the risk-adjusted morbidity rate decreased significantly (14.5% to 8.8%; p < 0.001). CONCLUSIONS: At our institution, patients who undergo coronary artery bypass grafting are now at greater preoperative risk at the time of hospital admission. However, their morbidity rate is significantly lower and their mortality rate is unchanged, results that we attribute to the collective impact of changes in our medical and surgical procedures.

Aged↗
PubMed1998

Optimizing mitral valve exposure with conventional left atriotomy.

The standard surgical approach to the mitral valve is accomplished through a longitudinal incision in the left atrium, posterior and parallel to the interatrial groove. Many other surgical approaches have evolved. This report describes a technique of optimizing mitral valve exposure via the standard approach. These modifications are simple, do not lengthen the procedure, and usually obviate the need for more complex maneuvers.

Cardiac Surgical Procedures↗
PubMed1998

Minimally invasive valve operations.

BACKGROUND: To reduce the morbidity from valvular heart operations, a right parasternal approach was introduced. We report our initial experience with the procedure. METHODS: From January 1996 through July 1996, 115 patients underwent primary isolated valve procedures. One hundred (85%) patients underwent the operation through a right parasternal incision. RESULTS: There was one hospital death secondary to a stroke on the fifth postoperative day. Three patients (two with aortic valve operations and one having a mitral valve procedure) required conversion to sternotomy. Mean aortic occlusion time was 71 minutes; mean cardiopulmonary bypass time was 93 minutes. Mean stay in the intensive care unit was 27 hours and mean hospital postoperative stay was 5.7 days. Seventy-seven percent of the patients did not receive blood transfusions. Comparison with median sternotomy demonstrated a reduction in both postoperative length of stay and direct hospital costs. CONCLUSIONS: We conclude that this minimally invasive approach is safe for a variety of valve procedures and is effective in reducing surgical trauma and cost.

Adult↗
PubMed1998

Aortic valve replacement for octogenarians: are small valves bad?

BACKGROUND: As the population ages, more octogenarians become candidates for aortic valve replacement. Many octogenarians, particularly women, have a small aortic annulus and there is uncertainty as to the optimal management of this situation in that age group. METHOD: To examine this issue, we reviewed 248 octogenarians (mean age, 82.6 +/- 2.3 years; 58% men) who underwent primary isolated aortic valve replacement (n = 99), or aortic valve replacement and coronary revascularization (n = 149), between 1980 and 1995. Nineteen-millimeter valves were used in 26% of the patients. RESULTS: In-hospital mortality was 8.9%, 5% for aortic valve replacement alone and 11.4% for aortic valve replacement and coronary revascularization. It was 12.5% for the 19-mm size valves compared with 7.7% for the bigger size valves (p = 0.24). Follow-up (mean interval, 4.4 years) demonstrated survival for all patients of 85%, 60%, and 30% and survival free from cardiovascular events of 80%, 45%, and 21% at 1, 5, and 10 postoperative years, respectively. Multivariate analysis identified triple-vessel disease and preoperative congestive heart failure as associated with increased risk for both in-hospital and late mortality (p < 0.05). Valve size did not influence late survival or event-free survival regardless of body surface area. CONCLUSIONS: The use of small aortic valve prostheses in octogenarians does not adversely affect the incidence of early or late mortality or cardiac events.

Aged↗
PubMed1998

Long-term results of the Carpentier-Edwards pericardial aortic valve: a 12-year follow-up.

BACKGROUND: Pericardial valves have excellent hemodynamic function; however, long-term durability is questionable. To determine the function of the Carpentier-Edwards pericardial valve in the aortic position, the results of 310 aortic valve replacements performed between 1982 and 1985 were analyzed. Mean age was 64.2+/-10.8 years (range, 22 to 95 years); 190 (61.3%) were men. Isolated valve replacement was performed in 135 patients (43.5%). There were 18 hospital deaths (5.8%), none of them valve related. METHODS: Follow-up of 292 survivors was 100% complete at a mean of 8.8 years; 2,556 patient-years of follow-up were analyzed. There were 150 late deaths (51.4%). Survival at 5, 10, and 12 years were 83%+/-2%, 47%+/-3%, and 34%+/-3%, respectively. The 12-year actuarial and actual freedom from thromboembolism was 87%+/-2% and 89%+/-2%, respectively. Freedom from hemorrhage was 91%+/-2% and 92%+/-2%; freedom from endocarditis was 93%+/-2% and 95% +/- 1%; and freedom from structural deterioration was 82%+/-4% and 91%+/-2%, respectively. RESULTS: Actuarial freedom from structural deterioration at 12 years was considerably higher for 153 hospital survivors 65 years or older, 93% (5 explants) compared to 76% (19 explants) for patients younger than 65 years, p = 0.03. Of 24 explanted valves for structural deterioration, leaflet calcification resulting in stenosis occurred in 20 (83%) and 4 were wear-related leaflet tears. CONCLUSIONS: We conclude that the Carpentier-Edwards pericardial valve has a low incidence of valve-related complications, that structural deterioration is infrequent and results from leaflet calcification, and that the low incidence of structural deterioration in patients 65 years or older makes this an increasingly appropriate option in this age group.

Actuarial Analysis↗
PubMed1998

Durability of mitral valve repair for degenerative disease.

BACKGROUND: Degenerative mitral valve disease is the most common cause of mitral regurgitation in the United States. Mitral valve repair is applicable in the majority of these patients and has become the procedure of choice. OBJECTIVE: This study was undertaken to identify factors influencing the durability of mitral valve repair. PATIENTS AND METHODS: Between 1985 and 1997, 1072 patients underwent primary isolated mitral valve repair for valvular regurgitation caused by degenerative disease. Repair durability was assessed by multivariable risk factor analysis of reoperation. It was supplemented by a search for valve-related risk factors for death before reoperation. Three hospital deaths occurred (0.3%); complete follow-up (4152 patient-years) was available in 1062 of 1069 hospital survivors (99.3%). RESULTS: At 10 years, freedom from reoperation was 93%. Among 30 patients who required reoperation for late mitral valve dysfunction, the repair failed in 16 (53%) as a result of progressive degenerative disease. Durability of repair was adversely affected by pathologic conditions other than posterior leaflet prolapse, use of chordal shortening, annuloplasty alone, and posterior leaflet resection without annuloplasty. Durability was greatest after quadrangular resection and annuloplasty for posterior leaflet prolapse and was enhanced by the use of intraoperative echocardiography. Death before reoperation was increased in patients having isolated anterior leaflet prolapse or valvular calcification and by use of chordal shortening or annuloplasty alone. CONCLUSIONS: Repair durability is greatest in patients with isolated posterior leaflet prolapse who have posterior leaflet resection and annuloplasty. Chordal shortening, annuloplasty alone, and leaflet resection without annuloplasty jeopardize late results.

Calcinosis↗
PubMed1998

Three-dimensional echocardiographic planimetry of maximal regurgitant orifice area in myxomatous mitral regurgitation: intraoperative comparison with proximal flow convergence.

OBJECTIVES: We sought to validate direct planimetry of mitral regurgitant orifice area from three-dimensional echocardiographic reconstructions. BACKGROUND: Regurgitant orifice area (ROA) is an important measure of the severity of mitral regurgitation (MR) that up to now has been calculated from hemodynamic data rather than measured directly. We hypothesized that improved spatial resolution of the mitral valve (MV) with three-dimensional (3D) echo might allow accurate planimetry of ROA. METHODS: We reconstructed the MV using 3D echo with 3 degrees rotational acquisitions (TomTec) using a transesophageal (TEE) multiplane probe in 15 patients undergoing MV repair (age 59 +/- 11 years). One observer reconstructed the prolapsing mitral leaflet in a left atrial plane parallel to the ROA and planimetered the two-dimensional (2D) projection of the maximal ROA. A second observer, blinded to the results of the first, calculated maximal ROA using the proximal convergence method defined as maximal flow rate (2pi(r2)va, where r is the radius of a color alias contour with velocity va) divided by regurgitant peak velocity (obtained by continuous wave [CW] Doppler) and corrected as necessary for proximal flow constraint. RESULTS: Maximal ROA was 0.79 +/- 0.39 (mean +/- SD) cm2 by 3D and 0.86 +/- 0.42 cm2 by proximal convergence (p = NS). Maximal ROA by 3D echo (y) was highly correlated with the corresponding flow measurement (x) (y = 0.87x + 0.03, r = 0.95, p < 0.001) with close agreement seen (AROA (y - x) = 0.07 +/- 0.12 cm2). CONCLUSIONS: 3D echo imaging of the MV allows direct visualization and planimetry of the ROA in patients with severe MR with good agreement to flow-based proximal convergence measurements.

Adult↗
PubMed1998

Tricuspid valve surgery and intraoperative echocardiography: factors affecting survival, clinical outcome, and echocardiographic success.

BACKGROUND: The impact of echocardiographic-guided treatment on outcome after tricuspid valve (TV) surgery is not well defined. OBJECTIVES: The purpose of this study was to determine clinical and echocardiographic factors associated with adverse outcomes after TV surgery and determine the role of intraoperative echo (IOE) in facilitating successful outcomes after TV surgery. METHODS: Four hundred and one patients (279 females, mean age 60 years) underwent TV surgery and other concomitant cardiac surgery at a single institution and were followed clinically and by echocardiography during a 10-year period. RESULTS: Decreased survival after TV surgery was associated with: preoperative increased New York Heart Association (NYHA) functional classification (relative risk [RR]=2.02), increased left ventricular dysfunction by echocardiography (RR=1.28), and use of a TV replacement strategy (RR=2.92). Decreased event-free survival after TV surgery was associated with concomitant coronary artery bypass grafting (RR=2.97). Late echocardiographic failure (3 to 4+ tricuspid valve regurgitation [TR]) after TV surgery was associated with increased severity of TR on preoperative echocardiogram (odds ratio [OR]=1.91). Decreased late echocardiographic failure after TV surgery was associated with the use of a TV annuloplasty ring with a repair strategy (OR=0.40). The surgical plan was altered at the time of surgery to insure a successful outcome in 32 (10%) of 335 patients based on IOE findings. CONCLUSIONS: Adverse outcomes after TV surgery can be predicted by several preoperative clinical and echocardiographic variables. IOE is useful in improving immediate, but not late, outcomes after TV surgery.

Adult↗
PubMed1998

Dexamethasone decreases the incidence of shivering after cardiac surgery: a randomized, double-blind, placebo-controlled study.

UNLABELLED: Shivering after cardiac surgery is common, and may be a result of intraoperative hypothermia. Another possible etiology is fever and chills secondary to activation of the inflammatory response and release of cytokines by cardiopulmonary bypass. Dexamethasone decreases the gradient between core and skin temperature and modifies the inflammatory response. The goal of this study was to determine whether dexamethasone can reduce the incidence of shivering. Two hundred thirty-six patients scheduled for elective coronary and/or valvular surgery were randomly assigned to receive either dexamethasone 0.6 mg/kg or placebo after the induction of anesthesia. All patients received standard monitoring and anesthetic management. After arrival in the intensive care unit (ICU), nurses unaware of the treatment groups recorded visible shivering, as well as skin and pulmonary artery temperatures. Analysis of shivering rates was performed by using chi2 tests and logistic regression analysis. Compared with placebo, dexamethasone decreased the incidence of shivering (33.0% vs 13.1%; P = 0.001). It was an independent predictor of reduced incidence of shivering and was also associated with a higher skin temperature on ICU admission and a lower central temperature in the early postoperative period. IMPLICATIONS: Dexamethasone is effective in decreasing the incidence of shivering. The effectiveness of dexamethasone is independent of temperature and duration of cardiopulmonary bypass. Shivering after cardiac surgery may be part of the febrile response that occurs after release of cytokines during cardiopulmonary bypass.

Anti-Inflammatory Agents↗
PubMed1998

Long-term durability and patient functional status of the Carpentier-Edwards Perimount pericardial bioprosthesis in the aortic position.

BACKGROUND AND AIMS OF THE STUDY: The study aim was to examine the long-term durability of the aortic Carpentier-Edwards Perimount pericardial bioprosthesis using actuarial and actual analyses. METHODS: A total of 267 patients were implanted at four centers between September 1981 and December 1983. Of these patients, 171 (64%) were males and 96 (36%) females; mean age at implant was 64.9+/-11.8 years (range: 21 to 86 years). Patients have been followed for 9.1+/-4.2 years (total 2335.7 patient-years). Long-term echocardiography data are presented. RESULTS: The total operative (<30 days postoperative) mortality rate was 4.9%; of this, 0.4% was valve-related. The total late (> or = 30 days postoperative) mortality rate was 6.2%/pt-yr and included a valve-related mortality rate of 1.6%/pt-yr. Complications of thromboembolism, thrombosis and bleeding showed linearized rates of 1.6%/pt-yr and 0.4%/pt-yr, respectively. Valve dysfunction resulted in an explant rate of 0.9%/pt-yr and an associated mortality rate of 0.1%/pt-yr. At 14 years post implant, actuarial freedom from overall and valve-related death was 39.3% and 78.8%, respectively. Actuarial and actual freedom from valve dysfunction was 70.4% and 81.7%. Actuarial freedom from valve explant as a result of dysfunction was 85.1% in all patients; explant in patients aged < or = 65 years at implant was less (76.1%) than in patients aged >65 years (96.3%). CONCLUSION: The high actuarial and actual freedom from explant due to structural valve dysfunction supports the long-term durability of this pericardial bioprosthesis and justifies its clinical use in patients older than 65 years at implant.

Adult↗
PubMed1997

Time-related trends in the preoperative evaluation of patients with valvular stenosis.

To investigate time-related trends in the use of preoperative invasive hemodynamics in patients with pure valvular stenosis, the preoperative evaluations and preoperative echocardiograms of consecutive patients who underwent aortic or mitral valve surgery from 1986 to 1994 at the Cleveland Clinic Foundation were reviewed. The study group consisted of 1,985 patients, 1,476 with aortic stenosis and 509 with mitral stenosis. Preoperative cardiac catheterization was performed in 1,456 patients with aortic stenosis (99%) and 488 with mitral stenosis (96%). Measurement of invasive hemodynamics (including transvalvular gradients and estimated valve areas) during catheterization decreased over time both in patients with aortic (from 64% in 1986 to 30% in 1994, test for trend p <0.0001) and mitral stenosis (from 63% in 1986 to 18% in 1994, test for trend p <0.0001). After adjusting for age, gender, and other characteristics, the only predictors of performance of invasive hemodynamics in patients with aortic stenosis were more recent surgery (inverse relation, p = 0.0001) and New York Heart Association class (p = 0.01); in patients with mitral stenosis the only predictor was also more recent surgery (inverse relation, p = 0.0001). Thus, use of preoperative invasive hemodynamics in patients with valvular stenosis has markedly decreased over the last decade. This is an example of how a noninvasive modality can supercede an invasive one, even when surrounding a procedure as fundamentally invasive as valvular heart surgery.

Aged↗
PubMed1997

Coagulase-negative staphylococcal sternal wound infections after open heart operations.

BACKGROUND: Coagulase-negative staphylococci are commonly isolated from wounds of patients after median sternotomy; however, the epidemiology of these infections is poorly described and the morbidity, mortality, and cost of care remain undefined. METHODS: Retrospectively, we studied all patients with sternal wound infections attributable to coagulase-negative staphylococci after 22,180 open heart procedures performed at the Cleveland Clinic between January 1, 1988, and December 31, 1994 (84 months). In an assessment of potential risk factors for sternal wound infections caused by coagulase-negative staphylococci, 17 patients with coagulase-negative staphylococcal sternal wound infections were compared with 29 patients who underwent open heart operations without subsequent sternal wound infections, as well as with another 22 patients in whom sternal wound infections attributable to other pathogens developed. RESULTS: A total of 436 sternal wound infections were identified (19 per 1,000 procedures), of which 100 (23%) were attributable to coagulase-negative staphylococci (4.5 per 1,000). Fifty-six percent of coagulase-negative staphylococcal sternal wound infections were superficial, 27% were deep, and 17% represented mediastinitis; 14% of patients had a concomitant secondary bloodstream infection. Ninety-two percent of coagulase-negative staphylococcal isolates were methicillin resistant. The mean interval from operation to onset of infection was 24 days (range, 4 to 388 days), and most patients had purulent discharge from the chest wound, fever, and leukocytosis. Adverse outcomes included reexploration (39%), flap operation (12%), and sternectomy (5%); 89% required parenteral antibiotics for a mean of 22 days. This resulted in 2,600 additional hospital days, with an average additional direct cost per case of $20,000. In both case-control studies, insulin-dependent diabetes mellitus was the only risk factor significantly associated with sternal wound infections attributable to coagulase-negative staphylococci (p value = 0.02 by two-tailed Fisher's exact test). CONCLUSIONS: Sternal wound infections attributable to coagulase-negative staphylococci had a substantial impact on cardiothoracic surgery-related morbidity.

Anti-Bacterial Agents↗
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

Tricuspid valve repair with the Cosgrove-Edwards Annuloplasty System.

The technique of tricuspid valve repair with the Cosgrove-Edwards Annuloplasty System is described. This system provides a measured plication of the tricuspid valve annulus with a technique that is easily reproducible and permits physiologic motion of the tricuspid annulus.

Cardiac Surgical Procedures↗