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Biomedical subjects

H E Scully

Publications and source records attributed to H E Scully.

At least 19 recordsLinked to original sources
PubMed1992

Strut fracture with Björk-Shiley 70 degrees convexo-concave valve. An international multi-institutional follow-up study.

Between 1980 and 1983, 831 Björk-Shiley 70 degrees convexo-concave prosthetic heart valves were implanted at five institutions in Sweden, Germany. The Netherlands, and Canada. As of January 1991, there were 34 outlet strut fractures occurring from 0.2 to 10.1 years (median = 4.6 years) after implantation. In addition, there were 28 sudden, unexplained deaths. The mortality after strut fracture was 84%. The mortality after emergency valve replacement for strut fracture was 50%. The 10-year actuarial fracture rate (standard error) was 10.5 (2.4)% for large (29-33 mm) valves vs. 3.3 (1.2)% for 21-27 mm valves (P less than 0.001). Within valve size groups, fracture rates for aortic and mitral valves were similar. Cox regression analysis found only valve size to be significantly associated with strut fracture. There is a further subgrouping of the valves according to the manufacturer: group I are the earlier large 29-33 mm) valves; group II are the later large valves; group III are the small size (21-27 mm) valves. The risk of strut fracture was highest in group I (12.3% at 10 years) with an approximatively constant hazard (1.4% per year). A comparison was made with a statistical model incorporating all cases reported to the manufacturer. This model estimates fracture rates approximately 63%-73% of those found in the present study. These findings lead us to recommend that group I patients should be considered for elective reoperation on an individual basis, giving careful attention to risk factors and contraindications.

Adolescent↗
PubMed1991

Medicare: the Canadian experience.

In the 1940s Canada and the United States had similar lack of structure and reimbursement for diagnostic, hospital, and physician services. In Canada over the next 40 years there evolved a complex system mandated and partially funded by the federal government, but administered and delivered through 10 provincial and 2 territorial jurisdictions. Each must negotiate with federal government on cost sharing and deal with hospital budgets and physician compensation at the provincial or territorial level. The Medical Care Act of 1966 enshrined in law the five principles of public administration, universality, comprehensiveness, portability, and accessibility, converting all medical services in Canada from a privilege to a right. Any patient participation in hospital or physician charges came under increasing political attack. In 1984 the Canada Health Act specified financial penalties in federal transfer payments to provinces that permitted any direct patient charges. While Canada has "contained" health expenditures at 8.7% of gross national product, universal access to quality care is increasingly subject to rationing. The relationship between the profession and governments hard pressed to fund escalating costs in a deteriorating economy has been one of increasingly bitter confrontations. There have been four acrimonious doctors' strikes. More optimistically, there is now an emerging recognition of society's need to have physicians actively participating with other providers and governments to create a balance between access to quality health services and both public and private funding.

Canada↗
PubMed1991

Thoracic aortic surgery.

Between 1982 and 1989, 119 patients had repair of thoracic aortic pathology. Thirty-seven had repair of ascending aortic aneurysms, with an 11% hospital mortality. Forty-one patients had urgent repair of acute type A aortic dissections, with a 32% hospital mortality. The independent predictors of mortality were the use of crystalloid cardioplegia, aortic dissection, and the use of an intraluminal prosthesis or the inclusion surgical technique. Better grafts and the resection technique has reduced mortality since 1986. Seventeen patients had their primary pathology in the aortic arch, with a 47% hospital mortality. The urgency of the procedure and crystalloid cardioplegia predicted an unsuccessful outcome. Seventeen patients had descending aortic aneurysms repaired, with an 18% mortality. The urgency of surgery was the predictor of mortality. Seven patients had a descending thoracic aortic disruption repaired, with one death (14%). Better graft materials, surgical techniques, and methods of myocardial protection have contributed to the improved results of thoracic aortic surgery in recent years.

Aortic Dissection↗
PubMed1989

Hormonal and metabolic responses during coronary artery bypass surgery: role of infused glucose.

Anesthesia, surgery, and hypothermia are conventionally considered the major stress factors in the metabolic and hormonal responses to cardiac surgery. We compared these responses in 14 nondiabetics during and for 24 h after coronary artery bypass surgery; 8 received cardioplegic solutions (C+), and 6 did not (C-). The mean intraoperative glucose load in C+ was 106 g compared to 32 g in C-; postoperatively both groups received 50 g. Marked hyperglycemia (31.8 +/- 4.8 mmol/L) occurred during hypothermia in C+, but dropped to 18.9 mmol/L before surgery ended and to 11.2 +/- 1.1 mmol/L by 2 h postop. In contrast, C- showed constant mild hyperglycemia of 8.3-9.8 mmol/L throughout, significantly less than C+ until 1 h postop. Insulin was suppressed by 55% only during hypothermia, peaking with rewarming in C+ at 2,849 +/- 911 vs. 639 +/- 251 pmol/L in C- (P less than 0.05); as with glycemia, values were comparable after 2 h postop. The pancreatic beta-cell thus responded to hyperglycemia during restoration of normothermia, resulting in a rapid decline in glycemia. This occurred despite elevations in antiinsulin factors in both groups; GH was 14 +/- 4 micrograms/L, cortisol was 607 +/- 38.6 nmol/L, norepinephrine was 11.5 +/- 3.7 nmol/L, epinephrine was 13,863 +/- 3,875 pmol/L, and FFA were 0.36 +/- 0.05 g/L. Early postop, a secondary rise in stress hormones occurred in both groups. Maximal cortisol values were at 4 h (1,186 +/- 140 nmol/L) and peaks of norepinephrine (6.50 +/- 1.66 nmol/L), epinephrine (7,969 +/- 3,602 pmol/L), and FFA (0.27 +/- 0.03 g/L) occurred. The only significant glucagon elevation was at 24 h (C+, 464 +/- 53 ng/L; C-, 350 +/- 241 ng/L; P less than 0.02), Thus, 1) many metabolic responses during coronary artery bypass surgery are influenced by the glucose-containing cardioplegic solution; 2) hypothermia suppresses insulin secretion, but it responds thereafter despite marked elevations of catecholamines, and is associated with decreasing glycemia despite elevated antiinsulin factors; 3) a lesser but highly significant stress response corresponds to awakening from anesthesia; and 4) glucagon plays a minor role in intraoperative hyperglycemia; the rise at 24 h is unexplained.

Aged↗
PubMed1988

Clinical performance of Bjork-Shiley mechanical heart valves: a perspective on outlet strut fractures in the 60 degrees and 70 degrees convexo-concave disc models.

The convexo-concave disc model of Bjork-Shiley mechanical heart valve is a significant improvement over the spherical disc model and compares favourably to other valves, including bioprostheses, with respect to hemodynamics, thromboembolism, anticoagulant related hemorrhage and prosthetic endocarditis. A small number of the 60 degrees and 70 degrees welded outlet strut Bjork-Shiley convexo-concave valves are at risk of sudden structural failure. The risk is constant or decreasing with time. Elective explanation is not recommended. The integral outlet monostrut 70 degrees Bjork-Shiley convexo-concave valve demonstrates further improvements in design and durability, and is recommended for use in patients who are appropriate candidates for mechanical cardiac prostheses.

Aortic Valve↗
PubMed1979

Giant left atrial V-waves in post-myocardial infarction ventricular septal defect.

A 54-year-old man developed a post-myocardial infarction ventricular septal defect with a 4:1 shunt. The first cardiac catheterization showed left atrial V-waves of 70 mm Hg. Assessment of the presence or absence of mitral regurgitation was not possible because of ventricular irritability and rapid runoff from left ventricle to right ventricle. At the second catheterization two months later, the left atrial V-waves had fallen to 34 mm Hg. The absence of mitral regurgitation was shown by observing the time difference in appearance of indocyanine green in the right ventricle and the left atrium after left ventricular injection. The defect was repaired by right ventriculotomy with subsequent normalization of left atrial V-waves. This case shows that very large left atrial V-waves may occur in postinfarction ventricular septal defects without mitral regurgitation and that these V-waves may decrease with time, probably reflecting increased left atrial compliance.

Cardiac Catheterization↗
PubMed1978

Computer-assisted reporting system for the follow-up of patients with prosthetic heart valves.

The implantation of large numbers of prosthetic heart valves carries with it the responsibility for continual reassessment of all aspects of patient management. Experience with more than 2,000 prosthetic valve operations since 1963 led to the development of a comprehensive computer-assisted data collection, management and reporting system. Over a 5 year period, data forms were developed for the detailed documentation of preoperative, intraoperative and postoperative information. These were designed in the form of checklists suitable for direct computer entry with use of mark-sense document readers. Special emphasis was placed on preoperative assessment of ventricular function, valve selection, intraoperative myocardial preservation, postoperative rehabilitation and prosthetic valve-related complications. This system makes possible rapid computer generation of a variety of reports to the referring physician regarding the individual patient and to the clinical investigator in relation to patient group statistics. Also, questionnaires to patients of physicians, or both, to update patient data can be produced by the computer at appropriate intervals after valve surgery. Experience indicated that a computer-assisted methodology is the only practical way to provide adequate follow-up of large groups of patients. Additionally direct access to relevant information helps to create an environment in which essential research can be carried out in the face of a demanding clinical practice.

Follow-Up Studies↗
PubMed1977

Subannular mitral prosthesis in aortic position.

Björk-Shiley subannular mitral prostheses have been used in the aortic position in 36 patients with calcific aortic annulus. We believe that the flange in the sewing ring of these prostheses offers added protection against perivalvular leakage; over an 18-month period there have been no instances of periprosthetic leakage in these patients.

Aortic Valve Stenosis↗
PubMed1976

Echocardiographic features of an unusual case of aortic valve endocarditis.

In a patient with aortic valve endocarditis a myocardial abscess, complete heart block and acute aortic regurgitation developed. Echocardiography gave evidence of large aortic valve vegetations, and at operation vegetations were found to have destroyed the right coronary cusp and part of the noncoronary cusp. Following surgery the patient recovered. Echocardiography may prove to be a useful noninvasive technique to aid in the timing of surgical therapy in patients with valvular vegetations.

Adult↗
PubMed1976

Evolving indications for preoperative intraaortic balloon pump assistance.

Over a two-year period about 1,000 operations were performed with cardiopulmonary bypass. Intraaortic balloon pump assistance (IABP) was employed on 150 occasions, and a review of these has permitted clarification of the indications for its use. Sixty patients had IABP for carcinogenic shock either after infarction or cardiotomy, and 37 (62%) survived. Preoperative IABP in 90 high-risk patients resulted in survival for 79 (88%). The indications for prophylactic IABP included: (1) relief of severe pain, which occurred in 42 patients with acute coronary insufficiency, (2) improvement in the coronary perfusion pressure, which was accomplished in 20 patients with significant left main coronary artery occlusion or its equivalent, and (3) protection of left ventricular function, which war carried out in 28 patients with an LV ejection fraction of less than 0.40. The significance of the preoperative endocardial viability ratio (EVR) in relation to prophylactic IABP was also assessed: an EVR below 0.70 appears to be an indication for preoperative IABP.

Assisted Circulation↗
PubMed1976

Prognostic significance of endocardial viability ratio in aortocoronary bypass surgery.

Although aortocoronary bypass (ACB) for patients with stable angina carries a low mortality, some unexpected deaths do occur. Since in patients with normal coronary arteries the endocardial viability ratio (EVR) can be correlated with subendocardial perfusion, with a ratio of 0.7 or less indicating ischemia of the left ventricular subendocardium, and since the EVR postoperatively is useful in determining the need for intra-aortic balloon pump assist (IABPA), it was decided to ascertain whether the EVR might have prognostic value in patients with stable angina scheduled for standard ACB. Three groups of patients were studied: 50 with stable angina, 24 who had died after ACB, and 18 who required IABPA for cardiogenic shock after surgery for stable angina. No significant differences were found for cardiac index, left ventricular end-diastolic pressure, left ventricular ejection fraction and pre- and postoperative artery scores, but there were significant differences in the EVR between the first and second groups and between the first and third groups (P less than 0.01 in each instance). These findings suggest that the left ventricular EVR may indeed be of prognostic value in patients scheduled to undergo ACB and that use of IABPA, which produces an increase in EVR, may be useful in patients with EVRs of less than 0.7, even if other parameters of cardiac function are normal.

Angina Pectoris↗
PubMed1976

Surgical management of complicated acute coronary insufficiency.

Acute coronary insufficiency (ACI) has a one year mortality rate approximating 40 percent with medical treatment alone. This report reviews our experience over 24 months with preoperative intra-aortic balloon pump assist (IABPA) in 42 patients with ACI. Abnormal left ventricular (LV) hemodynamics were present in the majority of patients; the ejection fraction was less than 40 percent in 14 patients. The endocardial viability ratio (EVR) was less than 0.7 in eight patients. The mean coronary artery score was 13, compared to 9 in an otherwise comparable group of patients with stable angina. Left main coronary stenosis greater than 75 percent was present in seven patients and combined with significant stenosis (less than 72 percent) in the dominant right system in four patients. Four patients had proximal stenoses greater than 90 percent in all three major coronary arteries. IABPA was initiated in 11 patients prior to angiography because of refractory rest pain. One of these six patients died. Twenty-five other patients were supported before and six after induction of general anesthesia. Thirty-three of 36 revascularized patients survived. Of four patients with perioperative myocardial infarctions (12 percent), three had IABPA after induction of general anesthesia. Inotropic support and duration of stay both in intensive care and in the hospital were less than in similar patients treated before the use of IABPA.

Acute Disease↗
PubMed1976

Intra-aortic balloon pump assist: adjunct to surgery for left ventricular dysfunction.

Intra-aortic balloon pump assist (IABPA) was used intraoperatively and postoperatively in 34 patients with severe left ventricular dysfunction: the mean ejection fraction was 0.29 and all patients had angiographic grade IV left ventricular contractility. There were three groups of patients: 11 patients with acute coronary artery insufficiency--10 of whom survived vein bypass surgery (group 1); 16 patients with crescendo-type unstable angina--of whom 15 survived surgery (group 2); 7 patients with single (6) or multivalvular (1) replacement (combined with vein bypass in 3)--of whom 5 survived (group 3). Overall survival was 88%. The mean duration of 1:1 IABPA was 40 hours. Inotropic support was not required, hemolysis was insignificant and hemostasis remained secure. Two patients required tracheostomy and one required dialysis. One patient had a peripheral embolus in the leg used for IABPA. IABPA improves subendocardial perfusion during induction of anesthesia, during cardiopulmonary bypass and into the postoperative period; left ventricular work is decreased with a concomitant increase in coronary artery and vein graft blood flow. Use of IABPA may also improve survival and lessen morbidity in patients with left ventricular dysfunction due to the beneficial effects on myocardial performance and is thus a valuable adjunct to cardiac surgery in high-risk patients.

Adult↗