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Biomedical subjects

G J Reul

Publications and source records attributed to G J Reul.

At least 19 recordsLinked to original sources
PubMed2001

Concomitant subclavian and coronary artery disease.

BACKGROUND: Proximal subclavian artery occlusive disease in the presence of a patent internal mammary artery used as a conduit for a coronary artery bypass graft procedure may cause reversal of internal mammary artery flow (coronary-subclavian steal) and produce myocardial ischemia. METHODS: We reviewed outcome to determine whether subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal. Between 1985 and 1997, 20 patients had either concomitant subclavian and coronary artery disease diagnosed before operation (group 1, 5 patients) or symptomatic coronary-subclavian steal occurring after a previous coronary artery bypass graft procedure (group 2, 15 patients). Patients in group 1 received direct subclavian artery bypass and a simultaneous coronary artery bypass graft procedure in which the ipsilateral internal mammary artery was used for at least one of the bypass conduits. Patients in group 2 received either extrathoracic subclavian-carotid bypass (5 patients, 33.3%) or percutaneous transluminal angioplasty and stenting (10 patients, 66.7%) as treatment for symptomatic coronary-subclavian steal. RESULTS: All patients were symptom-free after intervention. One patient treated with percutaneous transluminal angioplasty and stenting died of progressive renal failure. Follow-up totaled 58.5 patient-years (mean, 3.1 years/patient). In group 1, primary patency was 100% (mean follow-up, 3.7 years). In group 2, one late recurrence was treated by operative revision, yielding a secondary patency rate of 100% (mean follow-up, 2.9 years). CONCLUSIONS: Subclavian artery revascularization can provide effective protection from and treatment for coronary-subclavian steal with acceptably low operative risk. Midterm follow-up demonstrates good patency.

Coronary Circulation↗
PubMed2001

The effect of short-term prophylactic methylprednisolone on the incidence and severity of postpericardiotomy syndrome in children undergoing cardiac surgery with cardiopulmonary bypass.

OBJECTIVE: The aim of this study was to determine the effect of prophylactic immune suppression on the incidence and severity ofpostpericardiotomy syndrome (PPS) in children after cardiac surgery with cardiopulmonary bypass (CPB). BACKGROUND: Prophylactic suppression of the inflammatory response has an unknown effect on the incidence and severity of PPS in children undergoing surgery with CPB. METHODS: This randomized double-blind placebo controlled trial included two study groups. Group A received pre-CPB intravenous methylprednisolone (1 mg/kg) plus four additional intravenous doses over 24 h, and Group B received intravenous saline placebo at identical intervals. Data included patient demographics, cardiac diagnosis/operation, CPB time, incidence and severity of PPS. Noncomplicated PPS--temperature >100.5 degrees F, pericardial friction rub, patient irritability, small pericardial +/- pleural effusion. Complicated PPS--noncomplicated PPS plus hospital readmission +/- pericardiocentesis or thoracentesis. RESULTS: We randomized 266 children: 20 exclusions (6 perioperative deaths, 14 reasons unrelated to treatment) leaving Group A (n = 126) and Group B (n = 120). There were no significant group differences in gender, cardiac diagnosis or CPB time. Group mean age differed (p = 0.05) and was treated as a covariate with no substantive outcome effect. In total, 39/246 children (16%) developed PPS (noncomplicated: n = 30, complicated: n = 9). There was no inter-group difference in overall PPS incidence (p = 0.73). However, Group A had a marginally significant increase in complicated PPS (p = 0.05). CONCLUSIONS: Intravenous methylprednisolone at a standard anti-inflammatory dose administered pre-CPB and early post-CPB neither prevents nor attenuates PPS in children. Short-term pre-CPB and post-CPB methylprednisolone treatment may complicate PPS.

Analysis of Variance↗
PubMed2001

Suprarenal or supraceliac aortic clamping during repair of infrarenal abdominal aortic aneurysms.

Suprarenal or supraceliac aortic clamping during repair of infrarenal abdominal aortic aneurysms can be complicated by renal, hepatic, and intestinal ischemia. To determine whether suprarenal or supraceliac clamping increases morbidity and mortality we retrospectively reviewed our recent nonrandomized experience. Between January 1993 and December 1998, 716 patients underwent elective (n=682) or urgent (n=34) infrarenal abdominal aortic aneurysm repair. Infrarenal clamping was used in 516 (72. 1 %) and suprarenal or supraceliac clamping in 200 (279%). The suprarenal/supraceliac group had significantly more older patients (> or = 70 years of age) (65.5% vs 477%) and a higher incidence of preoperative renal insufficiency (75% vs 5.5%). Suprarenal or supraceliac clamping was used during repair of ruptured (n=25), juxtarenal (n=7), or inflammatory abdominal aortic aneurysms (n=4); during concomitant renal or visceral revascularization (n=43); in other difficult settings (n=13); or at the surgeon's discretion (n=108). The decision for such clamping was always made during surgery In treating ruptured aneurysms, suprarenal/supraceliac clamping (25/200) was used more often than infrarenal clamping (9/516) (12.5% vs 1.74%). Operative times were similar in both groups, but transfusion requirements and length of hospital stay were slightly greater in the suprarenal/supraceliac group. Perioperative mortality was 3.1% overall, but higher in the suprarenal/ supraceliac group than in the infrarenal (75% vs 1.4%). Postoperative complications developed in 26 (13%) of patients who underwent suprarenal/supraceliac clamping. Abdominal re-exploration was required in 9 other patients. We conclude that, despite associated comorbidities, elective suprarenal/supraceliac clamping during infrarenal abdominal aortic aneurysm repair is safe, facilitates repair, and does not significantly increase mortality.

Aged↗
PubMed2000

Reconstruction of the superior vena cava with the aid of an extraluminal venovenous jugulo-atrial shunt.

A 57-year-old woman had chronic benign superior vena cava syndrome related to the long-term use of multiple central venous catheters for chemotherapy. Treatment included resection of the obstructed segment and repair of the superior vena cava with an autologous pericardial patch. Intraoperatively, return venous flow was maintained with an extraluminal venovenous jugulo-atrial shunt. The shunt relieved upper-body hypertension and congestion, resulting in early extubation and a short, smooth postoperative course.

Catheterization, Central Venous↗
PubMed1999

Sinus of Valsalva aneurysm or fistula: management and outcome.

BACKGROUND: Few large or long-term series exist regarding the management of patients with sinus of Valsalva aneurysms or fistulas (SVAFs). METHODS: Between 1956 and 1997, 129 patients presented with a ruptured (64 cases; 49.6%) or nonruptured (65 cases; 50.4%) SVAF. The patients included 88 men and 41 women, with a mean age of 39.1 years. Associated findings included a history of endocarditis (42 cases; 32.6%), a bicuspid aortic valve (21 cases; 16.3%), a ventricular septal defect (15 cases; 11.6%), and Marfan's syndrome (12 cases; 9.3%). Operative procedures included simple plication (61 cases; 47.3%), patch repair (52 cases; 40.3%), aortic root replacement (16 cases; 12.4%), and aortic valve replacement/repair (75 cases; 58.1%). RESULTS: There were five in-hospital deaths (3.9%): four due to preexisting sepsis and endocarditis and one that followed dehiscence of the repair in a patient with Marfan's syndrome. Two patients (1.6%) had strokes during the early postoperative period. The survivors were followed up for 661.1 patient-years (5.3 years/patient). The following late complications occurred: prosthetic valve malfunction (5 cases; 3.9%), prosthetic valve endocarditis (3 cases; 2.3%), SVAF recurrence (2 cases; 1.6%), thrombosis (1 case; 0.8%), and anticoagulation-related bleeding (1 case; 0.8%). CONCLUSIONS: Resection and repair of SVAF entails an acceptably low operative risk and yields long-term freedom from symptoms. Early, aggressive treatment is recommended to prevent endocarditis or lesional enlargement, which causes worse symptoms and necessitates more extensive repair.

Adolescent↗
PubMed1998

Concomitant occlusive disease of the coronary arteries and great vessels.

BACKGROUND: Although an increasing number of elderly and high-risk patients, including those with generalized atherosclerosis, are undergoing coronary revascularization, few reports exist regarding the management of patients who have both occlusive disease of the great vessels and coronary artery disease. METHODS: Between 1972 and 1996, 31 consecutive patients (mean age, 56.5 years; 74% men) with multivessel coronary artery disease and symptomatic occlusive disease of the great vessels (25 single-vessel, 80.6%; 6 multiple-vessel, 19.4%) had 40 great vessels reconstructed by transthoracic bypass (n = 17, 42.5%), transthoracic endarterectomy (n = 8, 20%), or extrathoracic bypass (n = 15, 37.5%). All patients had simultaneous coronary artery bypass grafting (mean, 2.6 grafts per patient), and 8 patients had 10 distal carotid bifurcation endarterectomies (6 staged, 4 simultaneous). RESULTS: The early primary patency rate was 100%, and symptoms resolved completely in all 31 patients. There was 1 in-hospital death (3.2%) in a patient who had a respiratory arrest 11 days after operation. Perioperative morbidity included two myocardial infarctions (6.5%) and one opposite-hemisphere, embolic stroke (3.2%). Long-term follow-up of the 30 survivors (167.4 patient-years; mean, 5.6 years per patient) documented 5- and 10-year actuarial survival rates of 88.6% and 60.4%, respectively, with a 100% late brachiocephalic primary patency rate. Ten-year actuarial rates of freedom from the following events were as follows: death, 60.4%; myocardial infarction, 82.5%; stroke, 90.9%; percutaneous transluminal coronary angioplasty or redo coronary artery bypass grafting, 95.2%; and vascular operation or amputation, 78.4%. CONCLUSIONS: Depending on the anatomic distribution of the disease, an integrated approach to great vessel reconstruction that incorporated transthoracic and extrathoracic approaches and techniques of endarterectomy and bypass resulted in few adverse outcomes and excellent long-term patency. Simultaneous revascularization of the great vessels and coronary arteries can produce immediate and long-term, symptom-free outcome with acceptably low operative risk.

Aged↗
PubMed1997

Concomitant cerebral and coronary subclavian steal.

We report the unusual presentation of simultaneous coronary and cerebrovascular insufficiency secondary to subclavian steal in a patient previously treated with coronary artery bypass grafting. Movement of the arm produced reversal of flow ("steal") in both the left vertebral and left internal thoracic arteries and resulted in the onset of angina and neurologic symptoms.

Arm↗
PubMed1997

Is an integrated approach warranted for concomitant carotid and coronary artery disease?

BACKGROUND: The management of patients with severe, concomitant coronary and carotid artery occlusive disease is controversial. METHODS: Between 1975 and 1996, 512 patients (mean age, 64.9 years; 70% male) were admitted for coronary revascularization; 316 (61.7%) had asymptomatic, severe carotid disease (stenosis > 70%) and 196 (38.3%) had symptomatic carotid disease (159 [31.1%] with transient ischemia and 37 [7.2%] with completed stroke). In group 1, coronary revascularization and carotid endarterectomy were simultaneously performed in 255 patients (49.8%) with unstable angina. In group 2 (staged approach), carotid endarterectomy was performed before coronary revascularization in 257 patients (50.2%) without unstable angina. RESULTS: Before 1986, the incidence of stroke and death was greater in group 1 (n = 149) than in group 2 (n = 156) (14 [9.4%] versus 4 [2.6%]; p < 0.01). Since 1986, outcomes in group 1 (n = 106) and group 2 (n = 101) have been similar for stroke (2 [1.9%] versus 2 [2.0%]), death (4 [3.8%] versus 3 [3.0%]), and myocardial infarction (4 [3.8%] versus 5 [5.0%]). Significant univariate and multivariate predictors of adverse outcome were primarily heart-related (reoperation, intraaortic balloon use, ejection fraction < 0.50, and angina grade 4 for death; age > 70 years and congestive heart failure for stroke). CONCLUSIONS: Despite highly selected populations, contemporary surgical results do not indicate that staged treatment of severe, concomitant coronary and carotid artery occlusive disease has an advantage over simultaneous treatment. Advances in myocardial protection and perioperative hemodynamic management may account for the low incidences of stroke and death in these operations.

Adult↗
PubMed1997

Vessel wall and flow characteristics after carotid endarterectomy: eversion endarterectomy compared with Dacron patch plasty.

OBJECTIVES: Experimental studies have demonstrated that decreases in vessel wall compliance and increases in turbulence may contribute to (re)stenosis. We studied vessel wall and flow characteristics after endarterectomy with Dacron patch plasty and after eversion endarterectomy, and compared those findings with the characteristics of non-stenotic, unoperated carotid arteries (controls). METHODS: Seventy-four patients who underwent 84 carotid endarterectomies were studied postoperatively by ultrasonography (2-24 months) Recorded variables included the diameter of the bulb, strain, elastic modulus (stiffness), and presence of turbulent flow. RESULTS: The vessel wall and flow characteristics of the two groups differed significantly. The diameter was higher and the strain lower in Dacron patch plasty than in controls; eversion endarterectomy did not differ from controls. The elastic modulus was higher (stiffer) in Dacron patch plasty than in eversion endarterectomy; neither Dacron patch plasty nor eversion endarterectomy differed significantly from controls. The stiffness index was not significantly different between the groups. Turbulence was present in Dacron patch plasty and eversion endarterectomy when compared with controls. CONCLUSION: In diameter, strain and stiffness, the operated carotid artery resembles the non-stenotic, unoperated artery more closely after eversion endarterectomy than after Dacron patch plasty.

Aged↗
PubMed1997

Risk factor analysis among Egyptian patients who underwent coronary artery bypass surgery.

We conducted a retrospective review of Egyptian patients who underwent coronary artery bypass graft surgery at our institution between 1980 and 1995. We examined the prevalence of coronary artery disease risk factors and evaluated the early postoperative results. We then compared these results with the corresponding data in a subset of American patients who underwent coronary artery bypass grafting at our institution in 1993. There were 290 Egyptian patients: 275 men and 15 women. The mean age was 54.5 years (range, 30 to 70 years). Angina was present in 258 (89%) of the Egyptian patients; of these, 186 (72.1%) were in Canadian Cardiovascular Society class 3 or 4. Risk factor analysis revealed a high prevalence of hyperlipidemia (69.7%), cigarette-smoking (66.6%), family history of coronary artery disease (53.1%), hypertension (46.9%), obesity (46.2%), and diabetes mellitus (32.4%). Comparisons between the 2 groups showed that the risk factors, except for hypertension, were significantly higher in the Egyptian patients, despite the older age of the Americans (mean, 65.5 years; range, 22 to 88 years). The prevalence of triple-vessel disease was 86.6% in the Egyptian patients and 51.0% in the American patients (p < 0.001). The operative morbidity rates in the Egyptian patients were low: these included arrhythmias (13.8%), bleeding (13.4%), infection (7.6%), low cardiac output (3.4%), myocardial infarction (3.4%), and cerebrovascular accident (1.4%). The hospital mortality rate was 1.4% for the Egyptians and 1.7% for the Americans (NS). These results show that, despite the high prevalence of risk factors among Egyptian patients with coronary artery disease, coronary artery bypass grafting can be performed with low operative morbidity and mortality rates.

Adult↗
PubMed1997

Coronary artery ectasia in Egyptian patients with coronary artery disease.

We conducted a retrospective study of 45 Egyptian patients with coronary artery ectasia who underwent coronary bypass grafting at our institution between 1980 and 1995. We examined the anatomic distribution and type of coronary ectasia and its association with coronary risk factors in these patients, and evaluated the severity of their coronary artery disease. We compared these findings with those from a group of 230 Egyptian patients who did not have coronary ectasia. These patients also underwent coronary artery bypass grafting between 1980 and 1995 at our institution. Obesity was present in 60% of the patients who had coronary artery ectasia, compared with 42% of patients who did not have ectasia (P < 0.01). Coronary artery ectasia was not related to any coronary risk factors other than obesity. However, patients who had ectasia did have a higher rate of triple-vessel coronary artery disease than did patients without ectasia (82% vs 67%, P < 0.05). Of the coronary vessels affected by ectasia, 43% were left anterior descending arteries. Diffuse disease was noted in 84% of all ectatic segments. We conclude that in this patient population, 2 conditions had a positive correlation with coronary ectasia: obesity and the severity of coronary artery disease.

Adult↗
PubMed1996

Influence of age on the effect of bidirectional cavopulmonary anastomosis on left ventricular volume, mass and ejection fraction.

OBJECTIVES: We sought to identify age-related differences in the ventricular response of patients after bidirectional cavopulmonary anastomosis (CPA) and to compare changes in the ventricular response among children < 3 years of age who underwent CPA with that of age-matched control subjects who had a systemic to pulmonary artery shunt alone. BACKGROUND: Pre-Fontan CPA has been advocated over a systemic to pulmonary artery shunt alone in patients with a single ventricle to facilitate ventricular volume unloading and minimize risk of the Fontan operation. METHODS: Our study evaluated 23 patients who initially received a systemic to pulmonary artery shunt as an initial procedure before subsequent Fontan palliation. In eight of these patients (group I), bidirectional CPA was performed before age 3 years, and in four (group II), it was performed after age 10 years. The remaining 11 patients (group III, age and weight control group for group I) were maintained with their initial shunt until they underwent Fontan palliation. Serial echocardiographic analysis was used retrospectively to evaluate left ventricular volume and mass and systolic pump function (ejection fraction) before and after bidirectional CPA. RESULTS: Through 10 months of follow-up, group I patients showed significant decreases in indexed end-diastolic volume both after CPA (120 ml/m1.5 body surface area vs. 78 ml/m1.5, p = 0.001) and in comparison with values in patients in group II and III, who showed no changes in end-diastolic volume (p < 0.001). Indexed ventricular mass decreased moderately after bidirectional CPA in group I (from 228 g/m1.5 body surface area to 148 g/m1.5) but remained unchanged in groups II and III. The differences in trends between groups I and III were significant (p = 0.03). Ejection fraction decreased significantly in group II versus group I patients (0.48 to 0.27 vs. 0.51 to 0.52, p < 0.05) after CPA. Oxygen saturation measurements before and after bidirectional CPA revealed a significant increase in group I (73% to 86%, p < 0.001) and a decrease in group II (82% to 73%, p < 0.01). CONCLUSIONS: Bidirectional CPA facilitates ventricular volume unloading and promotes regression of left ventricular mass in younger children (< 3 years) in preparation for a Fontan operation. In contrast, bidirectional CPA is of questionable value in older children as a staging procedure for Fontan palliation.

Aging↗
PubMed1996

Carotid endarterectomy. Results in asymptomatic and symptomatic patients.

Objective evidence of the benefit of carotid endarterectomy in preventing stroke and its significant sequelae has recently been demonstrated by prospective trials. The salutary results depend on meeting strict operative outcome criteria as established by the American Heart Association. We retrospectively analyzed 265 consecutive carotid endarterectomies performed in 248 patients during 1 year at our institution. The perioperative mortality rate was 0; late mortality occurred 6 months postoperatively in 1 of 2 patients who experienced a perioperative stroke. The combined perioperative mortality and stroke rate was 0.8%. The combined mortality and stroke rate in patient subgroups was 0.7% (1/151) for asymptomatic patients, 1.6% (1/64) for symptomatic patients who had presented with a transient ischemic attack, and 0% (0/50) for symptomatic patients who had presented with a completed stroke. We conclude that the objective postoperative benefits of carotid endarterectomy in treating extracranial cerebrovascular disease can be achieved with low perioperative patient morbidity.

Carotid Stenosis↗
PubMed1996

Critical decision analysis for extracranial cerebrovascular disease.

Results from 6 major prospective studies that have recently been either completed, or terminated prematurely, provide compelling evidence of the benefit of carotid endarterectomy in treating certain groups of patients who have carotid stenosis. Results of these studies show that symptomatic patients (those experiencing transient ischemic attack, amaurosis, or completed mild stroke) with a 70% ipsilateral carotid stenosis have an absolute risk reduction of 39% to 65% for stroke or death when treated with carotid endarterectomy as opposed to medical therapy alone. Asymptomatic patients with a 60% ipsilateral carotid stenosis have 53% absolute risk reduction for stroke or death when treated with carotid endarterectomy, rather than medical therapy alone. Combined neurologic morbidity and perioperative mortality rates for treating carotid stenosis should not exceed 3% in the asymptomatic patient or 5% to 7% in the symptomatic patient, on the basis of criteria established by the American Heart Association. These studies show that prophylactic carotid endarterectomy can effectively reduce the risk of stroke in both asymptomatic and symptomatic patients. Centers specializing in vascular surgery can benefit patients by minimizing the operative risk to levels well below those established by the American Heart Association.

Carotid Stenosis↗
PubMed1996

Primary cardiac tumors in infants and children: immediate and long-term operative results.

BACKGROUND: The literature contains few large or long-term series involving infants and children with primary cardiac tumors. This article summarizes our 35-year experience with such lesions. METHODS: Between January 1961 and January 1996, 40 infants and children (mean age, 3.3 years; range, 2 days to 17 years; 65% female) were diagnosed at our institution with primary cardiac tumors. Of these tumors, 37 (92%) were benign and 3 (8%) were malignant. Tumors were resected in 38 patients (95%). In 2 patients (5%), biopsy confirmed rhabdomyoma; however, presenting symptoms spontaneously resolved, so these patients did not undergo tumor resection. Follow-up echocardiographic studies showed a diminishing tumor mass in each of these patients. RESULTS: Immediate, symptom-free status was achieved in all patients. There were two early deaths, for an operative mortality of 5%. Three late postoperative deaths (7.5%) occurred as follows: 1 patient with a myocardial hamartoma died at 3 months of congestive heart failure. Another patient with a recurrent rhabdomyosarcoma died at 6 months, and a third patient with a recurrent fibrosarcoma died at 28 months. Long-term follow-up was available for 34 survivors (97% complete) and totaled 240.2 patient-years (mean, 7.1 years/patient). All remaining survivors were without evidence of presenting symptoms and tumor recurrence or progression. CONCLUSIONS: The data suggest that an aggressive operative approach is warranted for benign symptomatic and malignant tumors. This aggressive approach has resulted in extended symptom-free status in patients with benign lesions, and significant palliation and longer survival in patients with malignant lesions, with acceptably low operative risk.

Adolescent↗
PubMed1996

Total aortic arch reconstruction for multiple great vessel occlusive disease.

There were no differences in mortality or morbidity rates in the intrathoracic and extrathoracic groups treated at the Texas Heart Institute. Extrathoracic bypass did not seem to decrease morbidity. Early occlusion rates were similar for both groups. In cases of extrathoracic bypass, early and long-term patency depend on the diffuse nature of the disease, especially in the inflow artery. Surgical risk is not increased by intrathoracic direct revascularization, and the use of the aorta for proximal inflow may prolong patency. Results of revascularization of diffuse lesions of the great vessels produce results similar to those for revascularization of simple lesions of the internal carotid artery with regard to both intraoperative cerebral protection and excellent long-term patency. We have recently developed and refined minimally invasive techniques for exposure of the aorta and great vessels. These methods have allowed successful, simultaneous direct revascularization of multiple great vessels in cadaver and animal models. In selected patients with anatomically suited lesions, we plan to use these methods with goals of decreasing hospital stay and surgical risk while maintaining excellent long-term graft patency.

Aorta, Thoracic↗
PubMed1996

Celiac compression syndrome: tailored therapy based on intraoperative findings.

BACKGROUND: The role of surgical treatment for the relatively rare celiac artery compression syndrome remains controversial. We used a tailored operative approach based on intraoperative findings. STUDY DESIGN: We retrospectively reviewed operative and follow-up data from the seven patients at our institution who underwent tailored operative intervention for celiac artery compression syndrome during a 15-year period. RESULTS: In all patients, decompression of the celiac axis was accomplished by division of the sympathetic neural fibers and the median arcuate ligament. In five cases in which intraoperative evaluation demonstrated compromised celiac artery flow after decompression, revascularization was also performed: three patients underwent an aortoceliac bypass, which was performed with a polytetrafluoroethylene graft in two cases and a vein graft in one case; the fourth patient had an angioplasty using a knitted polyester fiber patch, and the fifth patient underwent aortic reimplantation of the celiac artery. The tailored operative approach (decompression alone or with revascularization) for celiac artery compression syndrome, determined on the basis of intraoperative findings, provided complete (immediate and long-term) relief of preoperative symptoms in all seven patients. CONCLUSIONS: The tailored approach to operative intervention for celiac artery compression syndrome, which is based on individual operative findings, offers patients an excellent chance for immediate and long-term freedom from symptoms.

Adult↗