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Biomedical subjects

E R Giuliani

Publications and source records attributed to E R Giuliani.

At least 19 recordsLinked to original sources
PubMed1992

Prognosis in rupture of the ventricular septum after acute myocardial infarction and role of early surgical intervention.

Since 1944, 91 patients (50 men and 41 women, mean age 68 years [range 39 to 86]) with ventricular septal rupture after acute myocardial infarction were seen at the Mayo Clinic. Patients were divided into 4 groups according to therapy and timing of surgical intervention. Fourteen patients seen before 1965, when surgery was not performed for such a complication or not readily available, were excluded from the analysis. Group 1 (n = 22) had surgery within 48 hours of septal rupture, group 2 (n = 6) underwent operation between 2 and 14 days, group 3 (n = 24) had surgery after 14 days, and group 4 (n = 25) only received medical treatment. Short-term (30 days) survivors (45%, 35 of 77 patients) were compared with nonsurvivors. Using logistic regression, by univariate analysis, 3 variables were significantly associated with outcome: age (p less than 0.01), cardiogenic shock (p less than 0.00001), and long delay between ventricular septal rupture and surgical intervention (p less than 0.004). By multivariate analysis, however, only cardiogenic shock (p less than 0.00001) and age (p less than 0.007) correlated with an adverse outcome. In patients with cardiogenic shock after septal rupture, the prognosis was uniformly fatal unless patients undergo early surgery. None of the 23 patients in groups 2, 3 or 4 survived, whereas 5 of 13 patients (38%) who had surgery within 48 hours of septal rupture survived.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗
PubMed1991

Emboli in infective endocarditis: the prognostic value of echocardiography.

OBJECTIVE: To determine whether vegetations visualized on two-dimensional echocardiography are an independent risk factor for the development of subsequent emboli in patients with infective endocarditis and to assess the timing of emboli relative to the initiation of antimicrobial therapy. DESIGN: Investigator-blinded, retrospective incidence cohort study. SETTING: Tertiary referral center. PATIENTS: Patients with left-sided native valve infective endocarditis who had two-dimensional echocardiography within 72 hours of beginning antimicrobial therapy. MEASUREMENTS AND MAIN RESULTS: The crude incidence rate of first embolic events in patients receiving antimicrobial therapy was 6.2 per 1000 patient-days (95% CI, 4.2 to 9.2). The rates in patients with and without vegetations were 7.1 and 4.9 per 1000 patient-days, respectively (incidence rate ratio, 1.4; 95% CI, 0.6 to 3.3). The relation between vegetations and risk for emboli was microorganism-dependent: Stratified incidence rate ratios were 6.9 (95% CI, 1.1 to 42.5; P less than 0.05) and 1.0 (95% CI, 0.2 to 3.9) for viridans streptococcal and Staphylococcus aureus endocarditis, respectively. The rate of first embolic events diminished over time (P less than 0.001), falling from 13 per 1000 patient-days during the first week of therapy to less than 1.2 per 1000 patient-days after completion of the second week of therapy. CONCLUSIONS: Overall, the presence of vegetations on echocardiography was not associated with a significantly higher risk for embolus in patients with left-sided native valve infective endocarditis. The relative risk for embolic events associated with echocardiographically visualized vegetations may be microorganism-dependent, with a significantly increased risk seen only in patients with viridans streptococcal infection. The rate of embolic events declines with time after initiation of antimicrobial treatment.

Adolescent↗
PubMed1988

Chronic aortic regurgitation: indications for operation--1988.

Timing of operation in a patient with severe aortic regurgitation is a difficult and controversial decision, especially when the patient is asymptomatic or minimally symptomatic. A rational decision can be made when the pathophysiologic features of aortic regurgitation and the natural history of medically treated patients are understood and the benefits and risks associated with aortic valve replacement are known. Proper interpretation of the literature involving echocardiography and nuclear cardiology is essential, as is consideration of the constantly changing surgical techniques and results. Aortic valve replacement should be recommended for those patients with chronic aortic regurgitation who are severely symptomatic (New York Heart Association Functional Class III or IV), in order to ameliorate symptoms and increase longevity. In asymptomatic or minimally symptomatic patients, close continued serial follow-up is necessary in order to detect the onset of resting left ventricular dysfunction and to recommend the optimal timing for surgical intervention.

Aortic Valve Insufficiency↗
PubMed1988

Significance of T-wave pseudonormalization during exercise. A radionuclide angiographic study.

In 84 consecutive patients with resting T-wave inversion, radionuclide angiography revealed significant new wall motion abnormalities in 13 (28 percent) of the 47 patients with persistent T-wave inversion and in 23 (62 percent) of the 37 patients with T-wave pseudonormalization during exercise (p less than 0.01). The response of the ejection fraction to exercise was better in patients with persistent T-wave inversion than in those with pseudonormalization (p less than 0.04). Mechanical evidence of ischemia was seen in 14 (61 percent) of the 23 patients with T-wave pseudonormalization but without ST-segment depression. In patients with resting T-wave inversion, pseudonormalization was slightly more sensitive but less specific than a positive exercise test for predicting significant new wall motion abnormalities or decreases in the ejection fraction with exercise. Although pseudonormalization is not extremely useful alone, the presence or absence of this finding can increase the diagnostic accuracy of exercise electrocardiography in patients with resting T-wave inversion and suspected ischemic heart disease.

Coronary Disease↗
PubMed1987

Pericardial effusion in women with breast cancer.

Ninety patients with a history of breast cancer and pericardial effusion detected on echocardiography were identified and divided on a clinical basis into three groups. Group 1 consisted of 20 patients who had progressive metastatic breast cancer and echocardiography performed on a routine basis as a part of a clinical trial involving 38 patients. All 20 had small unexpected effusions, and only one patient developed symptomatic malignant pericardial disease late in her clinical course. Group 2 consisted of 32 patients who were without evidence of metastatic disease at the time of positive echocardiography and the etiology was considered benign in all patients. Six patients required pericardiectomy, five for severe radiation induced pericarditis and one for amyloid. No patient developed proven or suspected malignant pericardial disease. Group 3 comprised 38 patients who had known metastatic disease outside the pericardium at the time of positive echocardiography. Nineteen patients in Group 3 had histologically proven malignant involvement during life or at autopsy, and five more had suspected malignant pericardial disease. Ten patients initially were treated with pericardiectomy and 28 patients were managed with systemic therapy alone (24 patients) or with pericardiocentesis (four patients). Among the 12 patients with malignant effusion treated without surgery, proven local progression of pericardial disease occurred in six, with sudden death in two of those patients. No patient treated initially with surgery suffered progression of her pericardial disease. It was concluded that: small, clinically unsuspected pericardial effusions appear to be relatively common in women with metastatic breast cancer; no patient with clinical pericardial disease confirmed on echocardiography and no evidence of metastatic breast cancer developed malignant pericardial involvement; 50% of patients with known metastatic disease and a clinically apparent pericardial effusion had malignant pericardial disease; and nonsurgical therapy in patients with histologically proven or clinically suspected malignant pericardial effusion was associated with a high incidence of progressive pericardial disease.

Adult↗
PubMed1987

The association of unexplained gastrointestinal bleeding with calcific aortic stenosis.

The association of chronic gastrointestinal bleeding and aortic stenosis remains problematical. The cases of 91 patients (age 38 to 80 years) with these disorders who were examined between 1955 and 1975 were reviewed to address this controversy. All patients underwent upper and lower gastrointestinal radiography, small bowel series, and proctoscopy. Other studies were endoscopy in 84 patients, colonoscopy in 61, and visceral angiography in 16. Of the 37 patients who underwent abdominal exploration, 35 (95%) continued to bleed postoperatively, including 8 of 10 patients who had bowel resection for angiodysplasia. Forty patients did not have an abdominal operation, and all have continued to bleed. Sixteen patients (2 of whom had had an abdominal procedure) underwent aortic valve replacement for aortic stenosis. There were 2 intraoperative deaths among these 16 patients. At follow-up, which ranged from 8 to 12 years, only 1 patient who underwent aortic valve replacement had recurrent bleeding secondary to excessive anticoagulation. Thus, overall, gastrointestinal operation was successful in only 5% of patients, but aortic valve replacement was effective in 93%. For unexplained gastrointestinal bleeding associated with aortic stenosis, aortic valve replacement should be considered because of the likelihood of cure.

Adult↗
PubMed1986

Spontaneous closure of congenital ventricular septal defect in an adult.

Spontaneous closure of congenital ventricular septal defect occurs commonly in infants and young adults. Occurrence in adults--patients older than 21 years--however, is rare. For this reason, we report on spontaneous closure of a congenital ventricular septal defect in a patient older than 26 years. This case was documented by catheterization before and after spontaneous closure. They proposed mechanisms of spontaneous closure are briefly reviewed.

Adult↗
PubMed1986

Mechanical decalcification of the aortic valve.

Thromboembolism and anticoagulant-related complications secondary to prosthetic aortic valve replacement constitute a significant risk (28% at 5 years). From 1978 through 1984, decalcification of the aortic valve was performed in 8 patients who were undergoing coronary artery revascularization. Preoperative gradients of between 30 and 80 mm Hg (mean, 50 mm Hg) were abolished after operation. To determine the viability of decalcification, the records of 84 additional patients who had undergone this procedure between 1959 and 1978 were reviewed (86% before 1965). There were 60 male and 32 female patients ranging from 14 to 74 years old (mean, 49 years). The cause of the calcification was a bicuspid valve in 32 patients (35%), senile calcification in 9 (10%), and rheumatic fever in 50 (54%); the cause in 1 patient was unknown. Thirty-day mortality was 13%. Follow-up was 98% complete and ranged from 6 months to 22 years (mean, 7 years). Aortic valve replacement was subsequently required in 25 patients. Freedom from reoperation at 1, 5, 10, and 15 years was 98%, 75%, 43%, and 26%, respectively, for patients with rheumatic valves compared with 97%, 76%, 57%, and 51%, respectively, for those with bicuspid valves. Survival for patients with rheumatic valves at 1, 5, 10, 15, and 20 years was 93%, 70%, 48%, 40%, and 35%, respectively, compared with 100%, 66%, 57%, 46%, and 46% for patients with bicuspid valves. At follow-up, 61% of the patients were in New York Heart Association Functional Class I or II. Causes of late death were valve related (30%), congestive heart failure (27%), and myocardial infarction (24%).(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1984

High-energy versus low-energy defibrillation: experience in patients (excluding those in the intensive care unit) at Mayo Clinic-affiliated hospitals.

/he purpose of this study was to determine whether electric shocks of low (200 to 240 J), intermediate (300 to 320 J), or high (400 to 440 J) delivered energy were most successful in defibrillating hospitalized patients (excluding those in intensive care units) in whom resuscitation was attempted by a code emergency team. From January 1980 through December 1982, 101 cases of ventricular fibrillation in 100 patients were treated by Mayo Clinic code emergency teams. Many of the patients in this trial had secondary or agonal ventricular Defibrillation. Most patients (64%) were defibrillated by one to eight shocks. For the first shock, intermediate and high energy seemed to be more effective than low energy. Patient weight, time of delivery of shock 1 after onset of the code emergency, blood pH, acute and chronic medical diagnoses, and pharmacotherapy before the onset of ventricular fibrillation were not clearly related to the response to shock 1. Nine of 16 patients who did not initially respond to shocks of low or intermediate energy were defibrillated when higher energy was subsequently used. Only 14 patients ultimately survived and were dismissed from the hospital. These results suggest that in this patient population, high levels of delivered energy are preferable to low energy for the first shocks administered; we recommend that 400 J of delivered energy be used initially. The 360-J maximal energy dose available in most currently manufactured defibrillators should be sufficiently close to this recommendation to justify use of that dose with the initial shock.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1983

Serum and hepatic enzyme activity in rats treated with diethylnitrosamine.

Comparative studies of enzyme activities during the dedifferentiation of hepatic cells and through their development into overt hepatomas are few and contradictory. This study was designed to investigate the histochemical, biochemical and morphologic features of the altered liver cells with particular emphasis on the importance and validity of the histoenzymatic behavior of glucose-6-phosphatase (G6Pase) as a marker for the detection of precancerous hepatic cells. Serum and hepatic levels of G6Pase were analyzed and compared with the histoenzymatic behavior of this enzyme. The use of other enzymes, such as adenosine triphosphatase (ATPase) and gamma glutamyl-transpeptidase (GGT) as histochemical markers for malignancy was also tested. The activities of a variety of enzymes commonly used as diagnostic tools were also evaluated in both the liver homogenates and sera of rats treated with 2 mg diethylnitrosamine (DENA)/kg body weight for 2-28 weeks. Using G6Pase as a histoenzymatic marker, precancerous cells appeared after 4 weeks of exposure to DENA in the form of small islets devoid of G6Pase activity. These G6Pase free cells increased in number forming larger islands and finally appeared as tumor nodules after 28 weeks of treatment. The histoenzymatic behavior of ATPase was identical to that of G6Pase. The precancerous cells, as well as the tumor cells appeared devoid of ATPase activity. The application of GGT as a marker, showed significantly increased activity in the altered liver and tumor cells. Increased serum levels of G6Pase were noted after 10 weeks and were greatly elevated in the late stages of the evolution of the precancerous cells.(ABSTRACT TRUNCATED AT 250 WORDS)

Animals↗
PubMed1980

Evaluation of cardiac murmurs.

We have attempted to review the evaluation of cardiac murmurs as we approach the patient in the office setting. It is obvious that although the character and location of the murmurs themselves are a clue to the genesis of the murmur, it is only by combining the history with a complete cardiovascular examination that we can truly establish the origin of the murmur in virtually every patient. If we combine these findings with selective noninvasive tests, then we will need to resort to the more expensive and invasive studies only on a selective basis.

Adolescent↗
PubMed1979

Assessment of left ventricular function in secundum atrial septal defect by computer analysis of the M-mode echocardiogram.

Left ventricular function in 53 patients with secundum atrial septal defect was assessed by computer-assisted analysis of the left ventricular echocardiogram and by cardiac catheterization. The patients were divided into two groups, those younger and those older than 60 years, to investigate the effect of aging on left ventricular function. Cavity size was significantly smaller than normal (p less than 0.01) and septal motion was abnormal in 86%, but values for cardiac index, left ventricular end-diastolic pressure, velocity of circumferential fiber shortening, left ventricular filling rate, and duration of rapid filling were normal in both groups. Regional dynamics assessed in terms of peak rates of systolic thickening and diastolic thinning of the septum and posterior wall were also normal in both groups. We concluded that, although left ventricular minor dimensions are small, and septal motion is reversed in the majority of patients with atrial septal defect, left ventricular function is normal, and it does not appear to deteriorate with increased age, pulmonary hypertension, or the presence of right ventricular failure. The abnormal septal motion appears to be compensated for by enhanced septal and posterior wall percentage thickening.

Adolescent↗
PubMed1979

Cardiac valve replacement in congestive heart failure due to infective endocarditis.

From January 1961 to July 1974, 138 patients underwent cardiac valve replacement because of complications of infective endocarditis. The overall operative mortality was higher in patients with Class IV cardiac functional disability (17%) than in patients with Class III (7%) or II (8%). The mortality for patients who had undergone aortic valve replacement with Class IV disability was higher (22%) than that for patients with Class III (0) or II (6%). When compared with patients without infective endocarditis who had undergone cardiac valve replacement, the operative mortality per valve replacement was approximately the same when the degree of cardiac disability was the same at the time of surgery for both groups of patients. Patients with aortic regurgitant murmurs caused by infective endocarditis should be observed closely for the onset of heart failure, especially during the first month of disease. In patients with aortic or mitral incompetence, if heart failure develops or progresses during the first month, we believe that prompt cardiac valve replacement should be considered, because even heart failure that may initially appear mild often progresses to severe heart failure during this period.

Aortic Valve Insufficiency↗
PubMed1979

Ebstein's anomaly: the clinical features and natural history of Ebstein's anomaly of the tricuspid valve.

The clinical features and natural history of Ebstein's anomaly are analyzed on the basis of experience with 67 consecutive patients who have had a mean follow-up of 12 years. Of the total group, 26 (39%) of the patients remained in functional Class I or II and 41 (61%) progressed at some time into Class III or IV. Death occurred in 14 (21%) of the patients, and these were characterized by one or more of the following features: (1) they were in functional Class III or IV, (2) they had moderate to severe cardiomegaly with a cardiothoracic ratio greater than 0.65, (3) they had cyanosis or an arterial oxygen saturation of less than 90%, and (4) they were infants when the diagnosis was made (10 patients, of whom 5 died). In patients in Class III or IV, a comparison was made between patients treated medically (10) and those treated surgically--either with tricuspid valve replacement (15) or with a modified tricuspid annuloplasty (16). It appears that modified tricuspid annuloplasty is the procedure of choice, because despite an operative mortality of 25% (4 patients), 12 of the 16 patients so treated improved clinically or had a reduction in heart size.

Adolescent↗
PubMed1978

Hyperuricemia in congenital heart disease.

Gout is rarely noted as a clinical problem in secondary polycythemia-- even if profound polycythemia exists, as in cyanotic congenital heart disease. A retrospective study of 81 patients with congenital heart disease was done to assess the incidence of hyperuricemia. Twenty of 46 patients with cyanotic congenital heart disease had serum levels of uric acid greater than 8 mg/dl. Thirteen of 16 (81%) cyanotic male patients more than 15 years old had serum levels greater than 8 mg/dl. For cyanotic patients, serum levels of uric acid were related directly to the degree of polycythemia (r = .44; P less than .02). Impaired renal function or drug therapy did not seem to account for the hyperuricemia. Because levels of uric acid greater than 10 mg/dl probably are nephropathic, many of these patients may be incurring subclinical uric acid nephropathy.

Adolescent↗
PubMed1978

Idiopathic hypertrophic subaortic stenosis in the young.

Thirty-six young patients with idiopathic hypertrophic subaortic stenosis were studied. Twenty-seven patients were male and 9 female, and their mean age was 11.3 years (range 5 months to 20 years). Twenty-three patients (64 percent) had symptoms, the most common being dyspnea, angina and syncope. Diagnostic difficulties were encountered frequently in younger patients, especially those with right heart involvement, and in asymptomatic patients with murmurs suggestive of other cardiac defects. Patients were classified retrospectively into three groups on the basis of management. The first group consisted of 16 patients who were operated on; 4 of these patients died, 1 operatively and 3 suddenly late postoperatively (at 1.6, 2 and 10 years). The 12 long-term survivors (average follow-up period 6.2 years) have had good relief of symptoms. The second group comprised seven patients treated with propranolol; none of these died. The 13 patients in the third group received no therapy; 7 of these patients died, 6 suddenly and 1 from congestive cardiac failure. Idiopathic hypertrophic subaortic stenosis is a serious disorder that may present at any age and that may be difficult to diagnose. All patients with this disorder should be treated with propranolol; surgical intervention, although it does not totally abolish the risk of sudden death, appears to offer symptomatic improvement in most cases over a long-term follow-up period.

Adolescent↗