Intraoperative placement of endovascular stents.
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Female↗
Biomedical subjects
J Coles
Publications and source records attributed to J Coles.
Abnormalities in von Willebrand factor and antithrombin III after cardiopulmonary bypass operations for congenital heart disease.
In patients with congenital heart disease two poorly understood postoperative complications are pulmonary hypertensive crises after repair of large atrioventricular or ventricular septal defects and right atrial and pulmonary thrombi after the Fontan operation. In this study we assessed whether cardiopulmonary bypass in these patients is associated with the release of agents that might induce platelet aggregation and vasoconstriction, such as biologically active von Willebrand factor and platelet-activating factor. In addition, we measured levels of anticoagulants such as antithrombin III and proteins C and S. Three groups of patients with congenital heart disease undergoing cardiopulmonary bypass were monitored through the perioperative period for secundum atrial septal defects, large atrioventricular or ventricular septal defects, and tricuspid atresia or univentricular heart (Fontan candidates). Control values were obtained from age-matched patients; patients requiring major noncardiac operations and those with cardiac disease not requiring cardiopulmonary bypass were also studied. After cardiopulmonary bypass in all three groups biologic activity of von Willebrand factor increased markedly in the immediate and early postoperative periods compared with preoperative values, whereas antithrombin III values were decreased. Platelet-activating factor was detected in only two patients with congenital heart disease, both in the early postoperative period. In contrast, patients who did not have cardiopulmonary bypass did not show these abnormalities. All measured parameters normalized at late follow-up (6 to 18 months after operation). Although cardiopulmonary bypass in these patients resulted in increased von Willebrand factor activity and decreased antithrombin III, changes that may predispose the patient to platelet aggregation and thrombus formation, absolute values in individual patients alone were not predictive of pulmonary hypertensive crises or detectable thrombi. This suggests that these hematologic abnormalities may contribute to but are not by themselves a cause of morbidity in the early postoperative period. Moreover, the increased von Willebrand factor biologic activity seen postoperatively in patients with congenital heart disease suggests that use of synthetic vasopressin may be ineffective and potentially detrimental.
Antithrombin III↗
Early nosocomial infections in pediatric cardiovascular surgery patients.
All patients undergoing cardiovascular surgery between July 1, 1987 and February 29, 1988 were followed from admission to the pediatric ICU (PICU) daily by an intensivist/anesthetist. Patients were characterized by surgical procedure and PRISM score on ICU admission. Of 310 patients, 40 patients (nosocomially infected patient ratio 12.9) developed 78 infections (nosocomial infection ratio 25.2), of which 28% (n = 22) were wounds, within 2 months of surgery. Early wound infection followed 8% of closed, nonpump cases and 6.7% of open, pump cases. Wound infection was more likely if the sternum was open on the ward (elective or emergency) (27.6% open vs. 5.0% closed, p less than .001) or if the PRISM score was greater than or equal to 10 on PICU admission (10.7% greater than or equal to 10 vs. 2.3% less than 10, p less than .01). The causative agents in wound infections in closed cases were Staphylococcus aureus (70%) and coagulase negative staphylococci (CONS) (30%) while in open, pump cases the agents were CONS (33%), Pseudomonas aeruginosa (27%), Candida spp. (27%), and S. aureus (20%). Nonwound infections accounted for 72% of infections (n = 56). The number of bacteremias and other central and arterial line-related infections approximated wound infection in incidence at 6.8/100 patients. Wound infections are more likely if the sternum has been left open on the ward, if the patient has a high PRISM score on PICU admission, and after specific surgical procedures.
Cardiac Surgical Procedures↗
Psoas abscess as a complication of subclavian venous catheterization.
A 76 year old woman developed a psoas abscess from vascular seeding of an infected subclavian venous catheter. The presentation was insidious and diagnosis delayed. Despite adequate surgical drainage, the case proved to be fatal. Venous catheters should be regarded as a potential source of septicaemia and occult abscess formation.
Abscess↗
Iliofemoral arterial complications of balloon angioplasty for systemic obstructions in infants and children.
The medical and radiological records of 64 consecutive infants and children who underwent transfemoral balloon dilation of the aorta or aortic valve were reviewed to determine the incidence, nature, and post-treatment outcome of acute iliofemoral complications. Balloon dilation angioplasty or balloon valvotomy was performed with 8F and 9F catheters without an arterial sheath. Patients ranged in age from 5 days to 15.4 years (mean, 6.4 years). Of 64 patients, 29 (45.3%) had an acute iliofemoral complication, including thrombosis (18 of 64), complete disruption (five of 64), incomplete disruption (three of 64), and arterial tear (three of 64). The arterial pathology was confirmed in 23 of 29 patients by one or a combination of surgical exploration and repair (18 of 29), angiography (six of 29), and magnetic resonance imaging (three of 29). Of eight patients, three with arterial disruption had acute hypotension requiring transfusion and immediate surgery; the other five had absent pedal pulses after the procedure. Of these five, three developed bleeding during thrombolytic therapy and underwent surgical exploration, and two were diagnosed by angiography after ineffective thrombolytic therapy. Angiography in three patients with iliac artery avulsion showed tapered occlusion in two and an aneurysm in one. In patients with iliofemoral thrombosis, angiography showed occlusion from the puncture site to the origin of the external iliac artery. Eleven patients (17% of the entire group and 38% of the group with acute iliofemoral complications) had reduced or absent pedal pulses at the time of discharge. A significant correlation was found between increased incidence of iliofemoral thrombosis and disruption (as well as abnormal pedal pulses at hospital discharge) and low patient weight.
Angioplasty, Balloon↗
Course of tricuspid atresia in the Fontan era.
Tricuspid atresia is an uncommon form of congenital heart disease and long-term survival was rare before the Fontan era. It was thought that the long-term survival of patients with tricuspid atresia would be improved by the introduction of the Fontan procedure and its subsequent modifications. This study reviews the clinical course of 84 patients with tricuspid atresia identified in the first year of life in the Fontan era. Prior palliative operations, their results and their ultimate application for the Fontan procedure were considered. Eleven patients died before surgical intervention and 5 did not undergo catheterization or echocardiographic confirmation before death. Five children underwent the Fontan procedure without prior palliation and 1 child does not require palliation at the present time. Sixty-seven patients (80%) had surgical procedures before evaluation for the suitability of a Fontan operation. Thirty-four patients had a second surgical palliation and 9 patients had a third palliation. The surgical mortalities for the first, second and third palliative surgery were 17.9, 17.6 and 0%, respectively. Thirty-two patients (38%) underwent the Fontan procedure and 2 deaths occurred (6%). An estimate of the probability of surviving for 1 year was 64% (95% confidence limits 54 to 74%) and that of 8 years was 55% (95% confidence limits 44 to 66%).
Blood Vessel Prosthesis↗
An echocardiographic study of the association of ventricular septal defect and right ventricular muscle bundles with a fixed subaortic abnormality.
Since 1983, 36 patients with the combination of right ventricular muscle bundles and a perimembranous ventricular septal defect have been studied in our institution to address the incidence of on associated subaortic abnormality. Of that total 32 (88%) had echocardiographic evidence of such an abnormality (29 had a typical subarotic ridge protruding from the crest of the interventricular septum and the remaining 3 had an echodense area in the same location). Surgical confirmation of the presence or absence of a subaortic abnormality was available in 26. There was correlation between the surgical and echocardiographic findings in all patients. A resting Doppler gradient of greater than or equal to 10 mm Hg was present in only 10. During the study period, 6 patients had Doppler evidence of progression of their gradient. The incidence of subaortic abnormalities in right ventricular muscle bundles and ventricular septal defects appears to be far greater than previously suspected. The exact significance of this finding in the absence of a pressure gradient is still unclear.
Child, Preschool↗
Plication of the diaphragm for infants and young children with phrenic nerve palsy.
Phrenic nerve palsy (PNP) is seen in infants and young children usually resulting from operative trauma or birth injury. Spontaneous recovery usually occurs, but occasionally surgical plication is necessary. Twenty-three cases of PNP over a 10-year period were managed surgically. Patient ages ranged from 1 day to 30 months (median, 4 months), 18 were male and five female. Cause was operative trauma in 18 (17 cardiac surgery, one neuroblastoma), birth trauma in two, and idiopathic in three. The right side was involved in 14, the left in eight, and both in one. Indications for plication were inability to wean from the ventilator (group 1, 16 patients), recurrent pneumonia (group 2, four patients), and respiratory distress (group 3, three patients). The 16 patients in group 1 were intubated for a median of 18.5 days from onset of PNP to plication. Postoperatively, three had continuing congestive heart failure (one died at 16 days of age, one was still chronically ventilated at 22 months, one was extubated at nine days); the other 13 were extubated at a median of two days postoperatively. All the patients in groups 2 and 3 were extubated within two days of surgery. Twelve plications were transthoracic and 11 were transabdominal. Postoperative complications included pneumonia (2), wound infection (1), pneumothorax (2), and mucous plug with pulmonary collapse (1). One patient died of cardiac failure at 16 days. One patient in group 3 developed recurrent respiratory distress 4 months postoperatively; he had a recurrent elevated hemidiaphragm requiring a second plication.(ABSTRACT TRUNCATED AT 250 WORDS)
Cardiac Surgical Procedures↗
A six-year study of the Omniscience valve in four Canadian centers.
Stimulated by the recent controversy over the Omniscience valve, we conducted a follow-up study on 413 hospital survivors in whom this prosthesis was implanted at four Canadian centers from 1979 to 1985. One hundred forty-seven underwent aortic valve replacement (AVR), 203 had mitral valve replacement (MVR), 10 had tricuspid valve replacement (TVR) and 53 underwent multiple valve replacement (45 AVR + MVR, 5 MVR + TVR, and 3 AVR + MVR + TVR). The mean age was 50.8 +/- 13 years (range, 2 months to 75 years). Follow-up of 96% was achieved for a mean of 2.6 years and a maximum of 6 years with a total of 1,076 patient-years. Complications were defined and graded according to severity. Analyses were performed to yield linearized and actuarial rates for complications. There were 30 late deaths (2.8% per patient-year). At 5 years, the actuarial survival was 89 +/- 3% (AVR, 89 +/- 3% and MVR, 91 +/- 3%). Percentages for freedom from each complication are as follows: endocarditis, 96 +/- 1% (AVR, 96 +/- 2% and MVR, 98 +/- 1%); periprosthetic leak, 99 +/- 0.6% (AVR, 98 +/- 1% and MVR, 99 +/- 0.6%); thrombotic complications, 87 +/- 3% (AVR, 84 +/- 6% and MVR, 90 +/- 3%); valve thrombosis 99.4% (AVR and MVR, 100%); anti-coagulant-related hemorrhage, 94 +/- 2% (AVR, 97 +/- 2% and MVR, 94 +/- 2%); and all valve-related complications, 77 +/- 3% (AVR, 77 +/- 6% and MVR, 79 +/- 4%). Reoperation was required at the rate of 1.2% per patient-year.(ABSTRACT TRUNCATED AT 250 WORDS)
Aortic Valve↗
Six year clinical study of use of the Omniscience valve prosthesis in 219 patients.
A 6 year experience of cardiac valve replacement with the Omniscience prosthesis is described. A total of 253 valves were inserted in 219 patients. The survivors were followed up for a total of 536 patient-years and for a mean of 2.8 years. The follow-up was 97.6% complete. Analyses were performed in accordance with recommended criteria regarding definitions of complications and grading thromboembolic events for severity and analysis of anticoagulant status. Results are described both in terms of actuarial and linearized rates. For the patients at risk, actuarial survival at the end of 5 years was 87.9 +/- 3.1% overall, 90.4 +/- 3.0% for single valve (aortic 88 +/- 5%, mitral 93.3 +/- 4%) replacement and 71 +/- 11% for multiple valve replacement. The actuarial rates of freedom from complications were as follows: endocarditis 95.7 +/- 1.8% (aortic 94 +/- 3.5%, mitral 100%), periprosthetic leak 98 +/- 1% (aortic 96.2 +/- 2.6%, mitral 100%), thromboembolism 95.2 +/- 2.3% (aortic 90.9 +/- 4.6%, mitral 96.7 +/- 3.3%), valve thrombosis 98.7 +/- 0.9% (aortic 100%, mitral 100%), anticoagulant-induced bleeding 90.3 +/- 2.6% and all valve-related complications 79.4 +/- 3.6% (aortic 78.8 +/- 3.6%, mitral 85.9 +/- 4.5%). The functional improvement in patients was very satisfactory and the risk of reoperation was 1.1% per patient-year. Over a 6 year time frame, the Omniscience valve has given excellent clinical performance.
Actuarial Analysis↗
Two-dimensional and pulsed Doppler echocardiography in the postoperative evaluation of total anomalous pulmonary venous connection.
The role of combined two-dimensional and pulsed Doppler echocardiography in the postoperative assessment of patients with total anomalous pulmonary venous connection was evaluated. Twenty-two cases with a median age of 9.5 weeks at the initial examination were evaluated. Serial ultrasound examinations were performed throughout the study period. The ultrasound results were compared with chest radiographs obtained during the same period. Of the 22 patients, 16 had normal pulmonary venous flow profiles characterized by low-velocity laminar flow. Of this group 12 had persistent radiographic postoperative pulmonary edema that cleared in all by 4 months. Six patients with pulmonary venous obstruction were identified, the diagnosis being confirmed at catheterization or autopsy. The venous flow pattern in this group was uniformly high velocity and turbulent. It was possible to localize the site of obstruction in each case. Although pulmonary edema was present in each patient, the chest radiograph did not provide reliable information as to the exact site of obstruction. Combined two-dimensional and Doppler echocardiography is a useful adjunct in the postoperative evaluation of patients with total anomalous pulmonary venous connection.
Child, Preschool↗
The child in the intensive care unit.
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Child↗
Collection and analysis of kinetic data from a stopped-flow spectrophotometer using a microcomputer.
A method of interfacing an inexpensive microcomputer to a stopped-flow kinetics spectrophotometer is described. It allows software-selectable sampling frequencies between 0.1 ms and 8 s and large numbers of data points to be collected. Machine language routines to use the interface are described and these allow the sampling frequency to be altered during data collection to ensure adequate numbers of points in critical regions of the kinetic profile. BASIC programs for collection and analysis of multicomponent kinetic data using this system are also described. Due to the large number of data points that can be collected and the ability to selectively sample transmittance values in regions where the signal is rapidly changing with time, relatively unsophisticated methods of data analysis can be used. These methods are suitable for use by microcomputers and mean that data analysis and acquisition can be performed on the same microcomputer in real time. To illustrate this, multicomponent analysis of kinetic transients is performed on simulated data and on the dissociation kinetics of the ethidium-DNA complex.
Automation↗
Computerised nursing-workload systems.
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Humans↗