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Biomedical subjects

D M Cosgrove

Publications and source records attributed to D M Cosgrove.

At least 127 records · Page 7Linked to original sources
PubMed1994

Cardiac reoperation in patients with bilateral internal thoracic artery grafts.

The superior long-term patency of the left internal thoracic artery (ITA) graft is reflected in the enhanced survival of the patients who undergo the procedure, and its use has been shown to lead to a reduced need for reoperation. Evidence is accumulating that use of both ITAs at the primary operation further decreases the need for reoperation, and it is hoped that the use of other arterial conduits will augment this trend. Therefore, the popularity of bilateral ITAs and other arterial conduits in coronary artery operations is growing. However, many surgeons defer using both ITAs at the primary operation partly out of fear of the difficulties that may arise in conjunction with a possible future reoperation. Thirty-six patients underwent reoperation at The Cleveland Clinic Foundation 2 days to 13 years after an earlier bilateral ITA operation because of the progression of native disease, failure of the ITA or vein grafts, or the development of valve disease or end-stage ischemic heart disease. There were four early deaths (11%) and two late deaths, with an average follow-up of 4.3 years (range, 0 to 9.8 years). Forty-seven ITAs were patent preoperatively and 11 crossed the midline. Eleven were patent but stenosed and in need of revision or replacement. Two were damaged during reoperation; both were repaired, but one was ultimately replaced. Although the mortality associated with this procedure is relatively high and these operations are difficult, reoperation can be performed at an acceptable risk, and substantial surgical objectives can be achieved with good long-term results.(ABSTRACT TRUNCATED AT 250 WORDS)

Coronary Disease↗
PubMed1994

Systolic anterior motion of mitral valve after the posterior leaflet sliding advancement procedure.

The posterior leaflet sliding advancement procedure was developed to prevent the occurrence of systolic anterior motion of mitral valve and consequently outflow obstruction after mitral annuloplasty. We present a patient with extremely redundant posterior mitral leaflet in whom outflow obstruction developed despite employment of this procedure. This case underscores the utility of preoperative and intraoperative echocardiography in surgical decision making. Systolic anterior motion can develop in some patients despite this new surgical technique.

Humans↗
PubMed1994

Coronary reoperation: results of adding an internal mammary artery graft to a stenotic vein graft.

Although it is desirable at coronary reoperation to replace a stenotic vein graft to the left anterior descending coronary artery (LAD) with an internal mammary artery (IMA) graft, previous reports have shown that if the stenotic vein graft is removed, that strategy can be complicated by severe hemodynamic deterioration and increased perioperative mortality. We report the results for 90 patients in whom an IMA was used to graft a completely obstructed LAD with the stenotic vein graft left intact. For 10 patients, reoperation involved only an IMA-LAD graft, and in 80 patients, a second IMA, veins, or both were used to graft other vessels. There were no hospital deaths. One patient had a perioperative myocardial infarction. Follow-up at a mean postoperative interval of 58 months documented 11 late deaths (eight cardiac related) and actuarial 5-year survival of 88%. Twenty-two patients underwent coronary angiography at a mean postoperative interval of 48 months. The IMA-LAD graft was found to be perfectly patent in 20 and obstructed in 2. The strategy of adding an IMA graft to the LAD and leaving a stenotic vein graft intact has been associated with a low risk of perioperative myocardial infarction, the late clinical results are favorable, and repeat angiography indicates that serious competitive flow from the stenotic vein graft is uncommon.

Adult↗
PubMed1994

Repair of insufficient bicuspid aortic valves.

A technique for the repair of bicuspid aortic valves that includes resection of the flail segment of the prolapsing leaflet, annuloplasty, and resection of the raphe, when present, has been reported. To assess the efficacy of this technique in the repair of insufficient bicuspid aortic valves, the results in 72 consecutive patients were assessed. The mean age of the patients was 39 +/- 11 years; 94% were male. Fifty-six patients (78%) underwent isolated aortic valve repair, 9 (12.5%) underwent aortic and mitral valve repair, and 7 (9.7%) had other associated procedures. All patients underwent leaflet resection, including 35 (48%) at the raphe. The mean aortic occlusion time was 39 +/- 12 minutes. There were no operative deaths. The severity of aortic insufficiency, as assessed by Doppler echocardiography (graded from 0 to 4) preoperatively and intraoperatively and at late follow-up, was 3.6 +/- 0.6, 0.4 +/- 0.4, and 0.9 +/- 0.8, respectively, with a p value of < 0.0001 for the latter two values versus the preoperative one. There have been no postoperative deaths. Patients did not receive anticoagulation treatment and there were no strokes or episodes of endocarditis. Six patients have required reoperation; 3 underwent repeat repair. The Kaplan-Meier freedom from aortic valve reoperation probabilities at 12 and 24 months were 94% and 89.5%, respectively. We conclude that valvuloplasty for insufficient bicuspid aortic valves is technically safe, is associated with a low incidence of recurrent insufficiency, and has been associated with no other valve-related complications.

Actuarial Analysis↗
PubMed1994

Surgical techniques for aortic valvuloplasty.

Since 1988, reparative techniques have been used at our institution to treat valvular insufficiency in selected patients with aortic valve disease. The limitations of aortic valve replacement are well recognized; it is this knowledge that has motivated us to find out whether a subgroup of patients who have aortic insufficiency might be candidates for preservation of their native aortic valves. This subgroup includes patients who have leaflet prolapse, perforation, or calcification. We describe our methods of patient evaluation and selection, as well as our surgical techniques for both bicuspid and tricuspid aortic valve repair.

Aortic Valve↗
PubMed1994

Gastroepiploic and inferior epigastric arteries for coronary artery bypass. Early results and evolving applications.

BACKGROUND: Internal thoracic artery (ITA) conduits are known to provide long-term patency and increased patient survival with low morbidity after coronary artery bypass grafting (CABG). Excellent clinical results with the ITA have stimulated interest in additional arterial grafts. METHODS AND RESULTS: To review our experience and evaluate postoperative complications associated with these new conduits, from May 1985 to September 1993, we studied 290 patients who underwent CABG using additional arterial conduits. The right gastroepiploic artery (GEA) was used in 152 patients and the inferior epigastric artery (IEA) was used in 130 patients. Eight patients with both GEA and IEA grafts were excluded. Patient records were analyzed as to preoperative characteristics, angiographic findings, operative data, and postoperative complications. Statistical analysis was done using the Pearson chi 2 statistic and the t test. Ninety-eight percent of patients received one concomitant ITA graft, and the majority of patients in both groups had bilateral ITA grafts. The GEA group had a higher proportion of reoperations (GEA group, 54%; IEA group, 16%; P < .001), previous myocardial infarction (MI) (GEA group, 67%; IEA group, 50%; P = .004) and New York Heart Association class IV (GEA group, 28%; IEA group, 6%; P = .001). The IEA group was generally slightly older (IEA group, 56 years; GEA group, 52 years; P = .001). Hospital mortality (GEA group, 4%; IEA group, 0.8%) and postoperative morbidity (mediastinal bleeding, infection, stroke, MI, and low cardiac output) were not significantly different between the two groups or from our experience with routine CABG using the ITA. Three intraabdominal complications occurred in the GEA group: 2 episodes of bleeding and 1 of pancreatitis. One patient in the IEA group had abdominal wall bleeding. With overall short follow-up, angiographic patency in a small number of patients has been good: 80% for the GEA group and 85.7% for the IEA group. CONCLUSIONS: We conclude that the morbidity associated with these additional arterial conduits is low and is comparable with that associated with routine CABG using the ITA. Currently we use the ITA for primary targets and alternative arterial conduits for vessels of secondary importance or when the ITA and/or saphenous vein is not available.

Abdominal Muscles↗
PubMed1994

Surgical treatment of isolated left anterior descending coronary stenosis. Comparison of left internal mammary artery and venous autograft at 18 to 20 years of follow-up.

To assess the long-term results of the surgical treatment of isolated left anterior descending coronary artery stenosis and compare surgical strategies for graft selection, we reviewed 100 consecutive patients receiving left internal mammary artery-to-left anterior descending artery grafts and 100 consecutive patients who received a saphenous vein autograft to the left anterior descending artery. All patients underwent operation from 1971 through 1973. The internal mammary artery and saphenous vein graft groups were equivalent with regard to preoperative clinical and angiographic variables, except that patients receiving left internal mammary artery grafts had a higher prevalence of noncritical disease (less than 50% stenosis) in the circumflex and right coronary arteries than did the saphenous vein graft group. Mean follow-up for the internal mammary artery and saphenous vein graft groups was 18.7 years and 20.7 years, respectively. The 18-year outcome was superior for the internal mammary artery group. Cox regression analysis confirmed that patients with left internal mammary artery grafts had superior survival, intervention-free survival, and event-free survival (all p < 0.01). The presence of noncritical disease in other vessels adversely affected intervention-free survival and event-free survival for both groups (all p < 0.03) and decreased survival for the saphenous vein graft group (p = 0.01) but not for the internal mammary artery group (p = 0.24). We conclude that in long-term follow-up of surgically treated isolated left anterior descending artery stenosis (1) the left internal mammary artery consistently yields better overall and intervention-free survival than does the saphenous vein graft, (2) outcome is influenced by the presence of noncritical disease in other vessels at the initial operation, and (3) deployment of the left internal mammary artery in the treatment of isolated left anterior descending artery stenosis yielded 18 years of intervention-free survival of 60.5% and provides a standard for comparison with other forms of therapeutic intervention.

Coronary Angiography↗
PubMed1994

Influence of arterial coronary bypass grafts on the mortality in coronary reoperations.

From 1988 through 1991, 1663 patients underwent a first reoperation for isolated coronary bypass grafting with 62 (3.7%) in-hospital deaths. At the primary operation, 575 patients had received at least one internal thoracic artery graft and 489 patients had at least one patent internal thoracic artery graft present at the time of reoperation. At reoperation, 1014 patients received at least one internal thoracic artery graft, 10 received an inferior epigastric graft, and 37 received a gastroepiploic graft. Of 489 patients with patent internal thoracic artery grafts at reoperation, the internal thoracic artery was damaged in 17 (3.5%); of 428 patients with a patent internal thoracic artery graft to the left anterior descending coronary artery, 14 (3.3%) had graft damage necessitating regrafting. All patients with damaged internal thoracic arteries survived. Multivariate testing of variables for their association with in-hospital mortality identified no internal thoracic artery graft at either primary surgery or reoperation (p < 0.0001), a history of congestive heart failure (p < 0.0001), advancing age (p = 0.018), female gender (p = 0.029), and emergency operation (p = 0.01) as factors linked to increased risk. Left ventricular function, left main stenosis, extent of native coronary atherosclerosis, and the interval between operations did not influence mortality. Furthermore, the presence of an atherosclerotic vein graft to the left anterior descending coronary artery a factor shown to increase in-hospital risk in previous studies did not increase risk during these years. We attribute the observation that patent internal thoracic artery and atherosclerotic vein grafts do not appear to be factors specifically increasing the risk of reoperation to the use of retrograde cardioplegic solution and increased surgical experience. The use of internal thoracic artery grafts at a primary operation does not increase the risk of a reoperation, and the use of internal thoracic artery grafts at reoperation does not increase in-hospital morbidity or mortality.

Age Factors↗
PubMed1993

Analysis of coronary angioplasty practice in the United States with an insurance-claims data base.

BACKGROUND: Coronary angioplasty is frequently performed in the United States, with more than 300,000 procedures in 1990. Despite the high rate of use of the procedure, there have been few studies addressing practice patterns. METHODS AND RESULTS: From a private insurance claims data base of 5.4 million individuals, a total of 2,101 patients who underwent coronary angioplasty during 1988-1989 were identified. Using their 4,578 hospital admission records and 87,578 outpatient claim records, with an average follow-up of 332 +/- 182 days, we compared patients' outcomes and charges according to whether they had an exercise stress test before the procedure, by sex, by region of the country, and by whether the angioplasty was performed in an institution with a training program. Only 29% of the study cohort had exercise testing before angioplasty; patients in the West (p = 0.001), those undergoing multivessel angioplasty (p = 0.00001), and those whose procedures were performed at sites with training programs (p = 0.04) were more likely to have a screening test, whereas women (p = 0.008) and those with a recent myocardial infarction (p = 0.00001) were less likely to have a screening test. The average length of stay for patients without myocardial infarction as a primary diagnosis was 5.6 days, with a total hospital charge of $15,027. In follow-up, 15.1% had coronary artery bypass surgery and 15% had at least one additional angioplasty procedure; the average follow-up charges were $4,879. Charges varied according to sex, region of the country, and academic status of the angioplasty institution. Certain outcomes showed variation by region of the country and academic status of the angioplasty institution. CONCLUSIONS: The relative lack of an objective definition of myocardial ischemia and the marked variability of use of procedures according to geographic region suggest the need for further implementation of established guidelines.

Age Factors↗
PubMed1993

Mechanism of outflow tract obstruction causing failed mitral valve repair. Anterior displacement of leaflet coaptation.

BACKGROUND: Systolic anterior motion of the mitral valve causing left ventricular outflow tract obstruction occurs in 1% to 2% of patients having mitral valve repair, in some cases requiring further surgery to relieve the obstruction, but the mechanism and the geometry involved are not certain. METHODS AND RESULTS: We studied 14 patients who developed systolic anterior motion and left ventricular outflow tract obstruction, all after posterior leaflet resection and annuloplasty, in whom a second repair eliminated systolic anterior motion by complete (n = 6) or partial (n = 8) ring removal. Intraoperative transesophageal echocardiography was recorded before pump, after failed repair during left ventricular outflow tract obstruction, and after a corrective second pump run to relieve the systolic anterior motion. Systolic anterior motion occurred when the mitral valve coaptation to septum distance was reduced (before, 26.5 +/- 4.3; during systolic anterior motion, 17.4 +/- 4.4 versus after second pump, 23.4 +/- 6.9 mm) and the mitral valve coaptation to posterior mitral annulus distance was greater (before, 18.9 +/- 3.4; during systolic anterior motion, 22.2 +/- 4.6 versus after second pump, 17.4 +/- 3.6 mm), both P < .01. Comparing dimensions before pump, during systolic anterior motion, and after the second pump, there were no differences in left ventricular cavity diameter in systole or diastole, the septum to posterior annulus distance, or the angle between the aortic and mitral annular planes. CONCLUSIONS: After mitral repair, left ventricular outflow tract obstruction occurs when the mitral coaptation line is displaced anteriorly. When systolic anterior motion occurs, reduction of the amount of annuloplasty or use of the posterior leaflet sliding procedure may eliminate this problem. Understanding the geometry of this phenomenon may facilitate preoperative echo selection of high-risk patients (those with large redundant posterior leaflets and relatively normal ventricular size) and modification of surgical technique to avoid the problem of outflow tract obstruction after mitral valve repair.

Echocardiography, Transesophageal↗
PubMed1993

The effect of coronary reoperation on the survival of patients with stenoses in saphenous vein bypass grafts to coronary arteries.

Does coronary artery reoperation improve the survival of patients with stenoses in saphenous vein bypass grafts to coronary arteries? To examine this question, we retrospectively reviewed 1117 patients who had coronary bypass grafting and then underwent a postoperative coronary angiogram that showed a stenosis (> or = 20%) of at least one vein graft. Reoperation within 1 month of the postoperative angiogram was performed for 394 patients (REOP group) whereas 723 patients (MED group) received initial medical treatment (no reoperation or percutaneous transluminal coronary angioplasty within 1 year). Compared with the MED group, patients in the REOP group were older, more symptomatic, more likely to have left main stenosis, and had fewer patent bypass grafts (all p < 0.001). In-hospital mortality for the REOP group was 4.3%. Mean postangiogram follow-up of the entire group was 73 months. On the basis of the interval between the primary operation and the postoperative angiogram, patients were designated as having early (< 5 years) or late (> or = 5 years) saphenous vein graft stenosis. Univariate and multivariate analyses were used to identify factors influencing the survival of these subgroups. Reoperation was not identified as a variable improving the survival of patients with early vein graft stenoses. For patients with late vein graft stenoses, moderate or severe impairment of left ventricular function (p < 0.0001), advanced age (p < 0.0001), triple-vessel or left main stenosis (p = 0.0011), and stenosis in a vein graft to the left anterior descending artery (p = 0.0019) decreased survival, whereas reoperation improved survival (p = 0.0007). The improvement in survival with reoperation was particularly strong for patients with a stenotic vein graft to the left anterior descending artery. For that subset, survival was 84% and 74% for the REOP group versus 76% and 53% for the MED group at 2 and 4 years after catheterization, respectively (p = 0.004). For patients with stenotic vein grafts to the right coronary artery or circumflex coronary artery (or both), survival was 92% and 87% for the REOP group versus 89% and 78% for the MED group at 2 and 4 years after catheterization, respectively (p = 0.13). Even for patients with class I or II symptoms, reoperation prolonged survival (p = 0.002 with multivariate testing). Reoperation improves the survival of patients with late vein graft stenoses, particularly those with stenotic grafts to the left anterior descending coronary artery.

Constriction, Pathologic↗
PubMed1993

Initial experience with the maze procedure for atrial fibrillation.

From January 1991 until May 1992, a total of 14 patients (mean age 48 years) underwent the maze procedure for refractory atrial fibrillation (mean duration, 7 years; mean number of antiarrhythmic medications, six). Three patients had had embolic events, one patient had had a cardiac arrest from flecainide, one had pulmonary fibrosis from amiodarone, and six of ten who were employed were temporarily disabled. Two patients underwent successful mitral valve repair in which the maze procedure was added as a secondary goal of the operation. Postoperative fluid retention was a problem in five patients (36%). Six patients (43%) were temporarily treated with an antiarrhythmic medication. Two patients (14%) with preoperative sick sinus syndrome required pacemakers. One patient was discharged from the hospital but died suddenly less than 1 month after the operation (7% operative mortality) of hyperkalemia caused by acute renal failure. All patients beyond 3 postoperative months (100% "cure") are receiving no antiarrhythmic medications, have sinus rhythm, or have p-wave tracking with ventricular pacing. Atrial contraction has been documented by cinegraphic magnetic resonance imaging studies and by Doppler echocardiography performed when sinus rhythm had resumed. The maze procedure is an extensive operation but is indicated for selected patients who have the severe sequelae of atrial fibrillation.

Adult↗
PubMed1992

Effects of mitral regurgitation on pulmonary venous flow and left atrial pressure: an intraoperative transesophageal echocardiographic study.

OBJECTIVES AND BACKGROUND: Pulmonary venous flows recorded by pulsed wave Doppler transesophageal echocardiography examination can be used to assess the severity of mitral regurgitation. Pulmonary venous flows are also related to left atrial pressures; however, the determinants of these flows have yet to be characterized in the presence of mitral regurgitation. METHODS: We simultaneously recorded intraoperative pulmonary venous flows by transesophageal echocardiography and left atrial pressures by direct left atrial puncture in 16 patients with different grades of mitral regurgitation: 2+ (n = 5), 3+ (n = 4) and 4+ (n = 7). Pulmonary venous peak systolic and diastolic flow velocities and peak reversed systolic flow velocities were compared with left atrial pressure a and v waves, a-x and v-y descent values and left atrial volumes. RESULTS: Pulmonary venous systolic to diastolic flow ratios correlated with decreases in left atrial pressure a/v ratios and with increases in the v waves of patients with higher grades of mitral regurgitation. Univariate analysis revealed that the best determinants of the pulmonary venous systolic to diastolic flow ratio were the left atrial pressure v wave (r = -0.76), the v-y descent value (r = -0.73) and the a/v ratio (r = 0.71). Lower correlations were found for left atrial end-systolic (r = -0.48) and end-diastolic (r = -0.42) volumes. Reversed systolic flow was present in patients with 4+ mitral regurgitation, despite left atrial enlargement. CONCLUSIONS: Pulmonary venous flow can be used to assess the severity of mitral regurgitation and reflects the effects of mitral regurgitation severity on the left atrial pressure a and v waves.

Adult↗