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Delos M Cosgrove

Publications and source records attributed to Delos M Cosgrove.

At least 37 records · Page 2Linked to original sources
PubMed2004

Biomechanical and echocardiographic characterization of flail mitral leaflet due to myxomatous disease: further evidence for early surgical intervention.

BACKGROUND: Flail mitral leaflet (FML) is a common complication of mitral valve prolapse, often leading to severe mitral regurgitation (MR) and left ventricular dysfunction. In the absence of timely surgical correction, survival is significantly impaired. Early recognition of FML and identification of risk factors is important because early intervention increases the chances of survival. METHODS: We studied 123 patients undergoing mitral valve surgery for severe MR caused by myxomatous disease. Chart review, echocardiography, and tensile testing were performed. RESULTS: Thirty-eight patients had FML, and 85 patients had non-flail mitral leaflet (non-FML). Patients with FML were younger (53.7 +/- 1.8 vs 59.3 +/- 1.4 years, P =.02), had more severe MR (3.89 +/- 0.04 vs 3.76 +/- 0.04, P =.02), were less likely to be in New York Heart Association class III or IV heart failure (5% vs 20%, P =.037), and were less likely to have bileaflet mitral valve prolapse (5% vs 38%, P <.001) than non-FML patients. Valve tissue from patients with FML had less stiff chordae (23.5 +/- 3.6 vs 59.1 +/- 11.7 Mpa, P =.006) that tended to have a lower failure stress (3.8 +/- 0.9 vs 9.6 +/- 2.2 Mpa, P =.07) and had more extensible leaflets (56.4% +/- 7.9% vs 42.9% +/- 2.7% strain, P =.04) compared with that of non-FML patients. CONCLUSIONS: The development of FML may result from intrinsic tissue abnormalities and is associated with a distinct subset of the myxomatous population. Identification of such clinical characteristics in this population and knowledge of an implicit mechanical abnormality of valve tissue may further the argument for early surgical correction.

Chordae Tendineae↗
PubMed2004

Cannulation of the axillary artery with a side graft reduces morbidity.

BACKGROUND: The axillary artery is our preferred arterial cannulation site when the ascending aorta cannot be cannulated. Previously, we cannulated the artery directly; now we use a side graft. The purposes of this study were to (1) investigate cannulation-related morbidity and (2) determine whether use of a side graft reduces it. METHODS: From January 1993 to January 2001, 392 patients underwent 399 axillary artery cannulations. Indications included calcified ascending aorta (129, 32%), ascending aortic aneurysm (115, 29%), type I aortic dissection (85, 21%), cardiac reoperation (70, 18%), and calcified femoral artery (26, 6%). The axillary artery was cannulated directly in 212 (53%) and with a side graft in 187 (47%). Comparisons of cannulation-related morbidity between the direct cannulation and side graft groups were made overall and after both adjusting and matching for propensity score. RESULTS: Cannulation-related morbidity was infrequent, with brachial plexus injury in 7 (1.8%), axillary artery damage in 7 (1.8%), aortic dissection in 3 (0.8%), and arm ischemia in 3 (0.8%). Only 4 of 187 (2.1%) occurred in the side graft group, versus 16 of 212 (7.0%) with direct cannulation (p = 0.03). After propensity adjustment, the odds ratio for reduction of risk of cannulation-related morbidity with use of a side graft was 0.15 (p = 0.002). CONCLUSIONS: Use of the axillary artery as inflow for cardiopulmonary bypass is associated with low morbidity. However, cannulation with a side graft was associated with less cannulation-related morbidity than direct cannulation. Routine use of a side graft is recommended whenever axillary artery cannulation is indicated.

Adolescent↗
PubMed2004

Does preoperative atrial fibrillation reduce survival after coronary artery bypass grafting?

BACKGROUND: Preoperative atrial fibrillation has been identified as a risk factor for reduced long-term survival after coronary artery bypass grafting. This study sought to determine whether atrial fibrillation is merely a marker for high-risk patients or an independent risk factor for time-related mortality. METHODS: From 1972 to 2000, 46,984 patients underwent primary isolated coronary artery bypass grafting; 451 (0.96% prevalence) had electrocardiogram-documented preoperative atrial fibrillation (n = 411) or flutter (n = 40). Characteristics of patients with and without atrial fibrillation were contrasted by multivariable logistic regression to form a propensity score. With this, comparable groups with and without atrial fibrillation were formed by pairwise propensity-matching to assess survival. RESULTS: Patients with preoperative atrial fibrillation were older (67 +/- 9.0 versus 59 +/- 9.8 years, p < 0.0001), had more left ventricular dysfunction (66% versus 52%, p < 0.0001) and hypertension (73% versus 59%, p < 0.0001), but less severe angina (39% moderate or severe versus 49%, p < 0.0001). Many of these factors are themselves predictors of increased time-related mortality. In propensity-matched patients, survival at 30 days and at 5 and 10 years for patients with versus without atrial fibrillation was 97% versus 99%, 68% versus 85%, and 42% versus 66%, respectively, a survival difference at 10 years of 24%. Median survival in patients with atrial fibrillation was 8.7 years versus 14 years for those without it. CONCLUSIONS: Atrial fibrillation in patients undergoing coronary artery bypass grafting is a marker for high-risk patients; in addition, atrial fibrillation itself substantially reduces long-term survival. Thus, if patients in atrial fibrillation require surgical revascularization, it is appropriate to consider performing a concomitant surgical ablation procedure.

Aged↗
PubMed2004

Elephant trunk procedure: newer indications and uses.

BACKGROUND: The elephant trunk procedure is used for extensive aortic aneurysms. We evaluated its safety, newer indications, and influence of second-stage completion on survival. METHODS: Records were reviewed for 94 consecutive patients (age 67 +/- 11 years, 47% men) who underwent the procedure between November 1990 and February 2003. The trunk was implanted as an extension of the ascending aorta and arch graft in 83 of 94 (88.3%) patients, distal arch graft in 8 of 94 (8.5%) patients, and in 3 distal to the left subclavian artery (3 of 94 patients [3.2%]). Aortic dissection was present in 37 (39.4%) patients and Marfan syndrome was present in 7 (7.4%). Twenty-three were reoperations (24.5%). In 9 patients, the trunk procedure was adjunctive in preparation for the second operation. In 15 patients, the anastomosis was completed between the left subclavian and common carotid arteries. Coronary artery bypass was performed in 36 (38.4%) and aortic valve operation in 55 (58.5%; 20 root sparing repairs, 16 composite grafts and 19 replacements) patients. RESULTS: There were two early 30-day in-hospital deaths (2.1%) and 5 permanent strokes (5.3%). Eleven died before the second-stage procedure. Forty-seven (57%) underwent second-stage procedures; 40 by thoracotomy and 7 by stent graft insertion, including 2 thoracoabdominal aneurysm repairs with visceral bypasses before stent grafting with 4 early deaths (8.5%). Five-year survival was 34% without a second-stage procedure versus 75% 3-year survival with it. CONCLUSIONS: With a current total of 142 elephant trunk procedures, we found it is safe and should be used more with initial cardiac surgery before descending or thoracoabdominal aorta repair.

Aged↗
PubMed2004

Does the arterial cannulation site for circulatory arrest influence stroke risk?

BACKGROUND: We investigated whether axillary/subclavian artery inflow with a side graft decreases the risk of stroke versus cannulation at other sites during hypothermic circulatory arrest. METHODS: Between January 1993 and May 2003, 1,352 operations with circulatory arrest were performed for complex adult cardiac problems. A single arterial inflow cannulation site was used in 1,336 operations, and these formed the basis for comparative analyses. Cannulation sites were axillary plus graft in 299 operations, direct cannulation of the aorta in 471, femoral in 375, innominate in 24, and axillary or subclavian without a side graft in 167. Retrograde brain perfusion was used in 933 (69%). A total of 272 (20%) were for emergencies, 432 (32%) were reoperations, and 439 (32%) were for dissections. A total of 617 (46%) had aortic valve replacement and 1,160 (87%) ascending, 415 arch (31%), and 248 descending (18%) aortic replacements. Indications also included arteriosclerosis (n = 301) and calcified aorta (n = 278). Primary comparisons were made by using propensity matching, and, secondarily, risk factors for stroke or hospital mortality were identified by multivariable logistic regression. RESULTS: Stroke occurred in 6.1% of patients (81/1,336): 4.0% (12/299) of those had axillary plus graft and 6.7% who had direct cannulation (69/1,037; p = 0.09; p = 0.05 among propensity-matched pairs). Operative variables associated with stroke included direct aortic cannulation, aortic arteriosclerosis, descending aorta repair, and mitral valve replacement. The risk of hospital mortality was higher (11%; 42/375) for patients who had femoral cannulation than axillary plus graft (7.0%; 21/299; p = 0.06; p = 0.02 among propensity-matched pairs). CONCLUSIONS: Axillary inflow plus graft reduces stroke and is our method of choice for complex cardiac and cardioaortic operations that necessitate circulatory arrest. Retrograde or antegrade perfusion is used selectively.

Aged↗
PubMed2004

The effect of bilateral internal thoracic artery grafting on survival during 20 postoperative years.

BACKGROUND: To compare survival of patients receiving bilateral internal thoracic artery grafts and single internal thoracic artery grafts more than 20 postoperative years, assess magnitude of benefit, and identify predictors of benefit. METHODS: From cohorts of 8123 patients receiving single internal thoracic artery grafts and 2001 receiving bilateral internal thoracic artery grafts during primary isolated bypass operations for multivessel coronary disease between 1971 and 1989, we identified 1152 propensity-matched pairs. Mean follow-up of survivors was 16.5 years, with 51 patients followed for 20 years or more. Hazard function methodology was used to identify risk factors for mortality, compare survival, and assess magnitude of benefit. RESULTS: Comparison of the matched pairs showed survival of the bilateral internal thoracic artery and single internal thoracic artery groups at 7, 10, 15, and 20 years was 89% versus 87%, 81% versus 78%, 67% versus 58%, and 50% versus 37%, respectively (p < 0.0001). Divergence of bilateral internal thoracic artery and single internal thoracic artery hazard function curves continued to widen through 20 postoperative years. At 20 years, bilateral internal thoracic artery grafting was predicted to produce worse survival in 2.8% of patients, a survival advantage of less than 5% in 12.9%, greater than 10% in 52%, and greater than 15% in 7.6%. Combinations of cardiac and noncardiac descriptors were used to define higher and lower risk patient subsets. Advanced age, abnormal left ventricular function and noncardiac risk factors decreased overall survival but the incremental benefit of bilateral internal thoracic artery grafting persisted. CONCLUSIONS: Bilateral internal thoracic artery grafting produces improved survival compared with single internal thoracic artery grafting during the second postoperative decade, and the magnitude of that benefit increases through 20 postoperative years.

Coronary Disease↗
PubMed2004

Aortic dissection after previous cardiovascular surgery.

BACKGROUND: Risk of repairing aortic dissection after previous cardiovascular surgery has not been described clearly. This study assesses early and late outcomes of such reoperations. METHODS: From January 1, 1990, to January 1, 2002, 108 patients with prior cardiovascular surgery (isolated coronary artery bypass grafting, 51%; isolated valve surgery, 21%; aortic aneurysm repair, 24%; and combinations of these in the remainder) underwent reoperation for aortic dissection (emergency operation for acute dissection in 24%). Mean age was 63 +/- 13 years, and 85% were men. The interval since prior surgery ranged from 10 days to 22 years (median, 3.8 years). This was the third operation for 8%. Ascending aortic repair with or without aortic arch or descending aortic repair was performed in 40%, aortic valve replacement (n = 15) or repair (n = 17) with ascending aortic repair in 30%, aortic root replacement with or without aortic arch or descending aortic repair in 30%, and aortic arch with or without descending aortic repair in 1%. Circulatory arrest was used in 78%, with retrograde brain perfusion in 58%. RESULTS: Hospital mortality was 6%, stroke 4%, renal failure 2%, and respiratory failure 7%. Survival at 30 days and 1, 3, 5, and 7 years was 93%, 85%, 74%, 63%, and 53%, respectively. Aortic reoperation was performed in 7 patients, with freedom from this event at 30 days and 1, 3, 5, and 7 years of 98%, 95%, 93%, 91%, and 89%., respectively CONCLUSIONS: Aortic dissection after cardiovascular surgery is rare and can be managed with acceptable operative risks and good long-term survival. Need for subsequent aortic reoperation is uncommon.

Aged↗
PubMed2004

Annular geometry and motion in human ischemic mitral regurgitation: novel assessment with three-dimensional echocardiography and computer reconstruction.

BACKGROUND: Annular geometry and motion in functional ischemic mitral regurgitation are incompletely understood. Three-dimensional echocardiography demonstrates saddle-shaped annular geometry, but standard methodology does not enable quantification of annular motion. Therefore, a novel technique using three-dimensional echocardiography and computer software was used to characterize alterations in mitral annular geometry and motion in patients with ischemic mitral regurgitation. METHODS: We developed a computer program to reconstruct the mitral annulus based on spatial coordinates from three-dimensional echocardiography. Data were obtained at end-diastole and end-systole in 7 patients with ischemic mitral regurgitation and 5 normal control subjects. Mitral annular motion was quantified by calculating the displacement area of the annulus between end-diastole and end-systole. RESULTS: Comparison of ischemic mitral regurgitation and control patients revealed differences in annular geometry and motion at end-diastole. Annular perimeter was greater in ischemic mitral regurgitation patients (10.7 +/- 0.7 cm versus 8.6 +/- 0.2 cm in control group; p < 0.03), with increased intertrigonal distance in ischemic mitral regurgitation patients (2.8 +/- 0.3 cm versus 2.1 +/- 0.1 cm; p < 0.06). These changes resulted in increased annular orifice area in ischemic mitral regurgitation patients (9.1 +/- 1.2 cm2 versus 5.7 +/- 0.3 cm2; p < 0.03). Ischemic mitral regurgitation patients had altered annular motion, with reduced movement of the posterior annulus (5.4 +/- 0.7 cm2 versus 8.7 +/- 1.1 cm2; p < 0.03). CONCLUSIONS: Computer analysis of data obtained from three-dimensional echocardiography demonstrates altered annular geometry and motion in patients with ischemic mitral regurgitation. Patients with ischemic mitral regurgitation have annular dilatation, with an increase in anterior and posterior annular perimeters; this is accompanied by an increase in the intertrigonal distance and restriction of annular motion.

Aged↗
PubMed2004

Equivalent midterm outcomes after off-pump and on-pump coronary surgery.

OBJECTIVE: Multiple reports demonstrate that off-pump surgery reduces the early morbidity associated with coronary artery bypass grafting. To determine if there are any differences in later outcomes, we compared midterm results of propensity-matched patients who underwent off- and on-pump coronary artery bypass grafting. METHODS: From January 1997 to July 2000, 481 patients underwent off-pump coronary artery bypass grafting and 3231 underwent on-pump coronary artery bypass grafting. Propensity matching was used to match 406 patients from each group. Previously, the propensity-matched off-pump patients were found to have had significantly fewer bypass grafts. These 812 patients were followed for time-related events, including death, myocardial infarction, percutaneous coronary intervention, coronary reoperation, and the combined end point of all-cause mortality, myocardial infarction, and all coronary reintervention. Follow-up was 95% complete. RESULTS: At 4 years, survival was 87.5% after off-pump and 91.2% after on-pump coronary artery bypass grafting (P =.2); freedom from myocardial infarction was 92.6% and 95.7% (P =.7), respectively; freedom from percutaneous coronary intervention was 94.3% and 95.5% (P =.9), respectively; freedom from coronary reoperation was 98.1% and 99.0% (P =.4), respectively; and freedom from the combined end point of all-cause mortality, myocardial infarction, and coronary reintervention was 75.2% and 82.9% (P =.14), respectively. CONCLUSIONS: Off-pump and on-pump coronary artery bypass grafting results in equivalent midterm outcomes. Fewer bypass grafts in the off-pump patients did not decrease survival or increase ischemic events at 4 years.

Aged↗
PubMed2004

Tricuspid valve repair: durability and risk factors for failure.

OBJECTIVES: To compare durability of tricuspid valve annuloplasty techniques, identify risk factors for repair failure, and characterize survival, reoperation, and functional class of surviving patients. METHODS: From 1990 to 1999, 790 patients (mean age 65 +/- 12 years, 51% New York Heart Association functional class III or IV, and mean right ventricular systolic pressure 56 +/- 18 mm Hg) underwent tricuspid valve annuloplasty for functional regurgitation using 4 techniques: Carpentier-Edwards semi-rigid ring, Cosgrove-Edwards flexible band, De Vega procedure, and customized semicircular Peri-Guard annuloplasty. Of these patients, 89% had concomitant mitral valve surgery. A total of 2245 follow-up transthoracic echocardiograms were retrieved. Tricuspid regurgitation was analyzed, and risk factors for worsening regurgitation were identified, by multivariable ordinal longitudinal methods. RESULTS: Tricuspid regurgitation 1 week after annuloplasty was 3+ or 4+ in 14% of patients. Regurgitation severity was stable across time with the Carpentier-Edwards ring (P =.7), increased slowly with the Cosgrove-Edwards band (P =.05), and rose more rapidly with the De Vega (P =.002) and Peri-Guard (P =.0009) procedures. Risk factors for worsening regurgitation included higher preoperative regurgitation grade, poor left ventricular function, permanent pacemaker, and repair type other than ring annuloplasty. Right ventricular systolic pressure, ring size, preoperative New York Heart Association functional class, and concomitant surgery were not risk factors. Tricuspid reoperation was rare (3% at 8 years), and hospital mortality after reoperation was 37%. CONCLUSIONS: Tricuspid valve annuloplasty did not consistently eliminate functional regurgitation, and across time regurgitation increased importantly after Peri-Guard and De Vega annuloplasties. Therefore, these repair techniques should be abandoned, and transtricuspid pacing leads should be replaced with epicardial leads.

Aged↗
PubMed2004

Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation.

OBJECTIVES: We sought to characterize the temporal return of mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation; to identify its predictors, particularly with respect to annuloplasty type; and to determine whether annuloplasty type influences survival. METHODS: From April 1985 through November 2002, 585 patients underwent annuloplasty alone for repair of functional ischemic mitral regurgitation, generally with concomitant coronary revascularization (95%). A flexible band (Cosgrove) was used in 68%, a rigid ring (Carpentier) in 21%, and bovine pericardial annuloplasty (Peri-Guard) in 11%. Six hundred seventy-eight postoperative echocardiograms were available in 422 patients to assess the time course of postoperative mitral regurgitation and its correlates. Most echocardiograms were performed early after the operation (median, 8 days); 17% were performed at 1 year or beyond. RESULTS: During the first 6 months after repair, the proportion of patients with 0 or 1+ mitral regurgitation decreased from 71% to 41%, whereas the proportion with 3+ or 4+ regurgitation increased from 13% to 28% ( P < .0001); the regurgitation grade was stable thereafter. The temporal pattern of development of 3+ or 4+ regurgitation was similar for Cosgrove bands and Carpentier rings (25%) but substantially worse for Peri-Guard annuloplasties (66%). Small annuloplasty size did not influence postoperative regurgitation grade ( P = .2), although Cosgrove bands were used in most patients receiving 26- and 28-mm annuloplasties. Freedom from reoperation was 97% at 5 years. Annuloplasty type was not associated with survival. CONCLUSIONS: Although initial mitral valve replacement would eliminate the risk of postoperative mitral regurgitation, this strategy has been associated with reduced survival. Therefore the development of additional techniques is necessary to achieve more secure repair of functional ischemic mitral regurgitation.

Aged↗
PubMed2004

Hemolysis after mitral valve repair: mechanisms and treatment.

BACKGROUND: The objectives of this study were to determine the mechanisms of hemolysis after mitral valve repair and to determine outcomes after surgical treatment (mitral replacement or re-repair). METHODS: Between 1981 and 2002, 32 patients (mean age, 58 years) presented with hemolytic anemia after mitral valve repair for degenerative, rheumatic, or ischemic mitral regurgitation (MR). Three types of annuloplasty were used at the initial mitral valve repair: Cosgrove-Edwards, Carpentier-Edwards, and bovine pericardial (Perigard). The diagnosis and the mechanisms of hemolysis were investigated with laboratory testing and echocardiography. RESULTS: Median interval from initial mitral valve surgery to diagnosis of hemolysis was 3 months (range, 1 week to 4 years). At presentation, mean hematocrit was 27.5% +/- 4.9% and 22 patients (69%) required transfusion. Echocardiographic findings varied. Twenty-four patients (77%) had grade 3 or 4 MR. Mitral regurgitant jet types included fragmentation (11 patients, 34%), acceleration (10, 31%), slow deceleration (5, 16%), collision (4, 13%), and free jet (2, 6%). Mitral valve replacement was performed in 28 patients, mitral valve re-repair in 3, and 1 patient did not undergo reoperation. At reoperation the mitral valve repair was physically intact in 25 of 31 patients (81%). There were 2 hospital deaths in patients having reoperation (6%). Actuarial survival was 95% at 1 year and 85% at 5 years. In 1 patient recurrent mechanical hemolysis developed caused by a perivalvular leak after mitral valve replacement. CONCLUSIONS: Hemolysis is a mode of failure of mitral valve repair. Patients with hemolysis generally present within 3 months of mitral valve repair. Although echocardiographic features varied, most patients had high-grade MR and regurgitant jets that fragmented or accelerated. Mitral valve replacement yields favorable outcomes for patients with hemolysis after mitral valve repair.

Anemia, Hemolytic↗
PubMed2004

Chordal transfer for repair of anterior leaflet prolapse.

A variety of techniques have been developed for repair of prolapse of the anterior leaflet of the mitral valve. At The Cleveland Clinic Foundation, we favor chordal transfer for this entity. In most instances, normal chordae with a strip of leaflet tissue are transferred from the posterior leaflet to the free edge of the unsupported anterior leaflet; the posterior leaflet is repaired in standard fashion employed for quadrangular resection. In selected cases, chordal transfer is accomplished by transfer of secondary anterior leaflet chordae to the unsupported free edge. Because normal chordae are used in both instances, there is no need for measurement of chordae or judgment of their length. With this technique for correction of anterior leaflet prolapse, 5-year freedom from reoperation after mitral valve repair is 96%.

Calcinosis↗
PubMed2003

Glycosaminoglycan profiles of myxomatous mitral leaflets and chordae parallel the severity of mechanical alterations.

OBJECTIVES: This biochemical study compared the extracellular matrix of normal mitral valves and myxomatous mitral valves with either unileaflet prolapse (ULP) or bileaflet prolapse (BLP). BACKGROUND: Myxomatous mitral valves are weaker and more extensible than normal valves, and myxomatous chordae are more mechanically compromised than leaflets. Despite histological evidence that glycosaminoglycans (GAGs) accumulate in myxomatous valves, previous biochemical analyses have not adequately examined the different GAG classes. METHODS: Leaflets and chordae from myxomatous valves (n = 41 ULP, 31 BLP) and normal valves (n = 27) were dried, dissolved, and assayed for deoxyribonucleic acid, collagen, and total GAGs. Specific GAG classes were analyzed with selective enzyme digestions and fluorophore-assisted carbohydrate electrophoresis. RESULTS: Biochemical changes were more pronounced in chordae than in leaflets. Myxomatous leaflets and chordae had 3% to 9% more water content and 30% to 150% higher GAG concentrations than normal. Collagen concentration was slightly elevated in the myxomatous valves. Chordae from ULP had 62% more GAGs than those from BLP, primarily from elevated levels of hyaluronan and chondroitin-6-sulfate. CONCLUSIONS: The GAG classes elevated in the myxomatous chordae are associated with matrix microstructure and elastic fiber deficiencies and may influence the hydration-related "floppy" nature of these tissues. These abnormalities may be related to the reported mechanical weakness of myxomatous chordae. The biochemical differences between ULP and BLP confirm previous mechanical and echocardiographic distinctions.

Adult↗
PubMed2003

Geometric differences of the mitral apparatus between ischemic and dilated cardiomyopathy with significant mitral regurgitation: real-time three-dimensional echocardiography study.

BACKGROUND: This study was conducted to elucidate the geometric differences of the mitral apparatus in patients with significant mitral regurgitation caused by ischemic cardiomyopathy (ICM-MR) and by idiopathic dilated cardiomyopathy (DCM-MR) by use of real-time 3D echocardiography (RT3DE). METHODS AND RESULTS: Twenty-six patients with ICM-MR caused by posterior infarction, 18 patients with DCM-MR, and 8 control subjects were studied. With the 3D software, commissure-commissure plane and 3 perpendicular anteroposterior (AP) planes were generated for imaging the medial, central, and lateral sides of the mitral valve (MV) during mid systole. In 3 AP planes, the angles between the annular plane and each leaflet (anterior, Aalpha; posterior, Palpha) were measured. In ICM-MR, Aalpha measured in the medial and central planes was significantly larger than that in the lateral plane (39+/-5 degrees, 34+/-6 degrees, and 27+/-5 degrees, respectively; P<0.01), whereas Palpha showed no significant difference in any of the 3 AP planes (61+/-7 degrees, 57+/-7 degrees, and 56+/-7 degrees, P>0.05). In DCM-MR, both Aalpha (38+/-8 degrees, 37+/-9 degrees, and 36+/-7 degrees, P>0.05) and Palpha (59+/-6 degrees, 58+/-5 degrees, and 57+/-6 degrees, P>0.05) revealed no significant differences in the 3 planes. CONCLUSIONS: The pattern of MV deformation from the medial to the lateral side was asymmetrical in ICM-MR, whereas it was symmetrical in DCM-MR. RT3DE is a helpful tool for differentiating the geometry of the mitral apparatus between these 2 different types of functional mitral regurgitation.

Cardiomyopathies↗
PubMed2003

Failed mitral valve repair caused by polypropylene suture.

A 65-year-old man with degenerative mitral valve disease had mitral valve repair consisting of posterior leaflet resection and leaflet repair with polypropylene suture and annuloplasty. Six years later, he presented with recurrent mitral regurgitation. The cut tail of a polypropylene suture used at the initial repair had eroded the free edge of the anterior leaflet and its chordae. Chordal transfer was used to re-repair the valve. Soft, braided suture is preferred for leaflet approximation at mitral valve repair; if polypropylene suture is used, suture tails and knots should be positioned such that they do not come into contact with leaflet tissue.

Aged↗
PubMed2003

Does competitive flow reduce internal thoracic artery graft patency?

BACKGROUND: In coronary arteries with moderate stenosis, competitive flow may lead to internal thoracic artery (ITA) graft occlusion. The goals of this study were to determine if competitive flow reduces ITA patency, and if there is a degree of coronary stenosis below which ITAs should not be used. METHODS: From 1972 to 1999, 50,278 patients underwent primary coronary artery bypass grafting (CABG). Of these, 2,002 had at least one ITA graft and postoperative angiography before coronary reintervention; 2,999 angiograms of 2,121 ITAs were made. Time-related ITA occlusion was modeled using longitudinal analysis to identify its risk factors while accounting for lack of independence introduced by repeated angiography and multiple ITA anastomoses per patient. Proximal coronary stenosis (maximum preoperative stenosis between ITA anastomosis and aorta) was the surrogate for competitive flow. RESULTS: Unadjusted ITA patency was 93%, 89%, 90%, and 92% at 1, 5, 10, and 15 years after CABG. Risk factors associated with ITA occlusion were lesser degree of proximal coronary stenosis (p < 0.0001); longer time from CABG in grafts to non-left anterior descending coronary arteries (p < 0.0001); female sex (p = 0.0003); later date of CABG (p = 0.01); right ITA (p < 0.0001); and smoking (p < 0.0001). In all arteries, as preoperative proximal coronary stenosis decreased, ITA patency declined; however, at no degree of stenosis was there a sharp decline. CONCLUSIONS: Internal thoracic artery patency decreases as coronary competitive flow increases. However, the nature of this relationship indicates ITAs should not be abandoned at moderate grades of stenosis.

Aged↗