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J M Craver

Publications and source records attributed to J M Craver.

At least 19 recordsLinked to original sources
PubMed1995

In-hospital and long-term outcome after reoperative coronary artery bypass graft surgery.

BACKGROUND: Increasingly over the past several years, patients have returned after coronary surgery for reoperative procedures, and the experience has become substantial. In this report, we describe immediate- and long-term outcomes after reoperative coronary artery bypass graft surgery. METHODS AND RESULTS: The source of data was the clinical database at Emory University. The surgical procedure and statistical methods were standard. Data were collected prospectively and entered into a computerized database. Follow-up was by letter, telephone, or hospital records documenting additional events resulting in readmission. In-hospital correlates of survival were determined by logistic regression, and long-term correlates were determined by Cox model analysis. There were 2030 patients with a mean age of 61 and a mean of 7.8 +/- 4.1 years since the first surgery. The mean ejection fraction was close to 50%, and the majority had three-vessel or left main disease. Urgent or emergency surgery was required in 16.6%. The internal mammary was used in 60.1%. Q-wave myocardial infarctions occurred in just over 5%. Neurological events increased from 1.2% at less than age 50 to 4.1% at more than age 70. The hospital mortality increased from 5.7% at less than age 50 to 10% at more than age 70, with an overall rate of 7.0%. Mortality was 5.7% for elective, 10.9% for urgent, and 16.4% for emergency cases. Angina was noted at follow-up in 41.3%. Urgent or emergency surgery, reduced ejection fraction, hypertension, older age, and female sex were univariate and multivariate correlates of in-hospital death. Diabetes was a univariate correlate only. Five- and 10-year survival rates were 76% and 55%, respectively. Five- and 10-year myocardial infarction-free survival rates were 63% and 40%, respectively. By 12 years, few patients were free of cardiac events. The univariate and multivariate correlates of long-term mortality were older age, reduced ejection fraction, hypertension, diseased vessels, presence of diabetes, congestive failure, and emergency surgery, with a strong trend for female sex. The use of the internal mammary artery was not a correlate for long-term mortality. CONCLUSIONS: Patients undergoing reoperative procedures have higher mortality initially and at long term than patients undergoing a first procedure. Expected mortality based on covariates may help in the decision of whether to perform reoperative coronary artery bypass graft surgery.

Age Factors↗
PubMed1995

Coronary artery bypass grafting in patients after failure of intracoronary stenting.

BACKGROUND: Intracoronary stents are being used to treat acute and threatened closure after percutaneous transluminal coronary angioplasty and to prevent restenosis. METHODS: The outcomes of 68 patients having coronary artery bypass grafting after stent placement were reviewed. The mean age was 60.5 +/- 9.7 years, and 71% were male. Thirty-seven percent had hypertension, 13% had diabetes, 62% had class III or IV angina, 60% had multivessel disease, and 40% had sustained a prior myocardial infarction. Fifty-three patients underwent emergency operation, 22 with hemodynamic collapse immediately after percutaneous transluminal coronary angioplasty, and 7 others required urgent revascularization within 24 hours of angioplasty. Seventeen underwent coronary artery bypass grafting for acute closure of the stented vessel several days after the angioplasty procedure. RESULTS: There was no correlation between urgency of the procedure, previous infarction, or previous coronary artery bypass grafting with successful procedure. The in-hospital mortality was 4.4%, 21% had a Q-wave myocardial infarction, and 1.5% sustained a stroke. Ejection fraction was the only correlate of long-term mortality. CONCLUSIONS: Coronary artery injury for which stents are placed for acute or threatened occlusion or to prevent restenosis but then fail, thus necessitating coronary artery bypass grafting, can be treated successfully. Although the rate of Q-wave myocardial infarction is substantial and related to the initial ischemic insult, the long-term survival and event rates are excellent with prompt surgical revascularization.

Aged↗
PubMed1992

Emergency coronary artery bypass surgery for failed percutaneous coronary angioplasty. A 10-year experience.

Six hundred ninety-nine patients have required emergency coronary artery bypass after failed elective percutaneous coronary angioplasty during the decade September 1980 through December 1990. This represents 4% of 9860 patients having 12,146 elective percutaneous coronary angioplasty procedures during this interval. Emergency coronary artery bypass was required for acute refractory myocardial ischemia in 82%. Hospital mortality rate for all patients was 3.1%; 3.7% in patients with refractory myocardial ischemia but 0.8% in patients without refractory myocardial ischemia, p = 0.08. Postprocedural Q-wave myocardial infarctions were observed in 21% versus 2.4%, p less than 0.0001, and intra-aortic balloon pumping was required in 19% with versus 0.8% without refractory myocardial ischemia, p less than 0.0001. Multivessel disease, p = 0.004, age older than 65 years, p = 0.005, and refractory myocardial ischemia, p = 0.08, interacted to produce the highest risk of in-hospital death. Follow-up shows that there have been 28 additional late deaths, including 23 of cardiac causes for a 91% survival at 5 years. Freedom from both late death and Q-wave myocardial infarction at 5 years was 61%. In the group going to emergency coronary artery bypass with refractory myocardial ischemia, the late cardiac survival was 90%, and in those without ischemia, 92% at 5 years, p = not significant. The MI--free survival in the group with refractory ischemia, however, was 56% versus 83% in the group without ischemia, p less than 0.0001. Multivariate analysis showed the highest late event rates for patients with Q-wave myocardial infarction at the initial emergency coronary artery bypass, age older than 65 years, angina class III or IV, and prior coronary bypass surgery. In spite of a continuing high incidence of early acute myocardial infarction and an increasing operative mortality rate (7%) in the latest 3 years cohort of patients, excellent late survival and low subsequent cardiac event rates demonstrate the lasting effectiveness of prompt, successful emergency coronary bypass surgery for failed percutaneous coronary angioplasty.

Actuarial Analysis↗
PubMed1991

Late follow-up after repair of left ventricular aneurysm and (usually) associated coronary bypass grafting.

This study assesses clinical and operative data (LV) aneurysm was repaired to determine factors that might predict in-hospital and long-term outcome. Long-term follow-up study was obtained in 296 of 298 patients undergoing LV aneurysm repair with or without coronary artery bypass grafting between 1974 and 1986. No patient had sustained a myocardial infarction within 2 weeks of surgery or was undergoing other concurrent cardiac surgery. The average age of the study patients was 57 +/- 9 years and the average ejection fraction was 35 +/- 13%. Ninety percent of the patients underwent concurrent bypass grafting, with an average of 2.2 +/- 1.3 grafts placed. Fourteen (5%) patients died in the hospital, with most deaths attributable to LV dysfunction. Advanced age and less extensive revascularization were correlates of in-hospital mortality. The 10-year survival was 57%, myocardial infarction-free survival 43%, and freedom from death, myocardial infarction and reoperative coronary surgery 41%. Advanced age, systemic hypertension, significant left main coronary artery narrowing and emergent operative status were multivariate correlates of long-term mortality. A low-risk population was defined by the absence of these risk factors, and high-risk by the presence of greater than or equal to 1 risk factors. The 10-year survival was 71% in the low-risk and 41% in the high-risk groups (p = .0006). The 10-year myocardial infarction free survival was 55% in the low-risk and 31% in the high-risk groups (p = 0.0017). LV aneurysm repair may be performed with acceptable in-hospital mortality, and the long-term risk may be stratified.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1991

Multiple reoperative coronary artery bypass grafting.

Initial reoperative coronary artery bypass grafting is being performed commonly, and an increasing number of patients are being referred for subsequent reoperative coronary artery bypass grafting. From January 1980 through June 1990, 53 patients (52 male, 1 female) underwent a third or fourth coronary artery bypass operation and were retrospectively reviewed. This represented 0.3% (53/17,102) of the coronary artery bypass procedures done during that time period. The mean age was 59 +/- 8 years. The number of grafts placed ranged from one to four with an average of 2.6 per patient. Internal mammary artery grafts were used in 30 patients (57%). The mean left ventricular ejection fraction was 0.52 +/- 0.13. Intraaortic balloon pump support was necessary in 10 patients postoperatively. There were no intraoperative deaths, although 4 patients died in the postoperative hospitalization period. Perioperative myocardial infarctions were diagnosed in 6 patients, 13 patients had perioperative dysrhythmias, and 2 patients sustained a stroke. Superficial wound infections occurred in 5 patients. Late follow-up in 49 patients revealed that 2 other patients have since died, and no further myocardial infarctions have been reported in the survivors. Postoperative 3-year survival is 85%, whereas 3-year myocardial infarction-free survival is 70%. Although there is increased risk of operative complications and early death after multiple reoperative coronary artery bypass grafting, both in-hospital and long-term results suggest that it is an appropriate therapeutic strategy.

Coronary Artery Bypass↗
PubMed1991

Coronary bypass surgery: is the operation different today?

Patients undergoing coronary bypass grafting have undergone an evolution in recent years. To document this change, we analyzed two groups of patients in 1981 (n = 1586) and 1987 (n = 1513) to document preoperative and postoperative variables important in determining immediate morbidity and mortality after isolated coronary bypass. Between 1981 and 1987, patients were found to be older (greater than or equal to 70 years, 8.7% versus 21.8%, p less than 0.0001), more often diabetic (15% versus 24%, p less than 0.0001), have a greater prevalence of triple vessel disease (14.5% versus 46.1%, p less than 0.0001), and have more left ventricular dysfunction (ejection fraction 0.60 +/- 14 versus 0.54 +/- 13, p less than 0.0001). To facilitate analysis and because of overlap between subgroups, we subdivided patients into three subgroups for statistical comparison of the years 1981 and 1987: subgroup I, no prior procedure (n = 1546 in 1981 and 1396 in 1987); subgroup II, optimal group (n = 503 in 1981 and 292 in 1987, and defined as no prior procedure, ejection fraction greater than or equal to 0.50 and age less than 65 years); subgroup III, patients having reoperations (n = 40 in 1981 and 117 in 1987). Internal mammary artery grafting was infrequently used in 1981 but was used in 72.1% in 1987. Major postoperative morbidity between the 2 years for the total population increased significantly: need for intraaortic balloon pumping, 1.4% versus 4.7%, p less than 0.0001; myocardial infarction 3.5% versus 5.5%, p less than 0.008; stroke, 1.4% versus 2.8%, p less than 0.008; and wound infection, 1.0% versus 3.0%, p less than 0.001. Wound infection (all types) in 1987 was increased sevenfold in patients having a perioperative myocardial infarction (0.7% versus 5%, p less than 0.0001). For young patients with good left ventricular function (subgroup II), there was no increase in these morbid events between 1981 and 1987. Hospital mortality in the total population increased significantly between 1981 and 1987 from 1.2% to 3.1% (p less than 0.0002), respectively. It was lowest for the patients in optimal condition (subgroup II) in both years, 0.8% versus 1.1%, and highest for reoperative patients, 5.3% versus 4.3%. In 1981, 58% of patients (503/870) were in the optimal group compared with 35% (292/828) in 1987 (p less than 0.0001). The last six years have seen a progressive trend in surgically treating older, sicker patients who have more complex disease, with a significant reduction in the best candidate group.(ABSTRACT TRUNCATED AT 400 WORDS)

Age Factors↗
PubMed1991

Influence of age on results of coronary artery surgery.

Coronary surgery is being used increasingly in older and more seriously ill patients. To evaluate the importance of age in predicting complications and mortality after coronary surgery, the results in 13,625 patients undergoing coronary surgery were evaluated. There were 321 patients under the age of 40, 1,758 were 40-49, 4,167 were 50-59, 5,049 were 60-69, 2,184 were 70-79, and 146 were over 80. As patients aged the proportion of women increased, the prevalence of severe angina and congestive heart failure increased, and the severity of the distributions of the coronary stenoses increased. The incidence of the complications of neurological events, wound infections, and death rose in every decade after the age of 40 years. The incidence of death was 0.6% for patients aged 40-49, 1.5% for those aged 50-59, 1.9% for those aged 60-69, 5.0% for those aged 70-79, and 8.3% for those aged 80-89. Advanced age was the most significant independent correlate of neurological events, wound infections, and death. The other multivariate correlates of neurological events were diabetes, hypertension, and, surprisingly, angina class. Again surprisingly, the only other multivariate correlate of wound infections was angina class. The other multivariate correlates of death were emergent surgery, female gender, ejection fraction, severity of coronary disease, diabetes, and a history of congestive heart failure. Of interest, periprocedural Q wave myocardial infarction was independent of age. The most predictive and significant correlate of periprocedural myocardial infarction was emergent surgery; hypertension, absence of a previous myocardial infarction, and a normal ejection fraction were weaker correlates. The ability to predict any complication was relatively weak compared with the ability to predict death. The relative infrequency of coronary surgery over the age of 80 years suggests that there is already strong selection against surgery in octogenarians. In addition, the risk of death, and to some extent other complications, may be predicted in advance based on extensive patient experience.

Adult↗
PubMed1990

Aortic valve debridement by ultrasonic surgical aspirator: a word of caution.

Aortic stenosis was relieved in 11 patients by ultrasonic debridement of the valve and annulus, while 102 other patients underwent valve replacement for aortic stenosis during 1988. Debridement was selectively applied based on findings of small annulus size (19 mm or less) and extensive calcification. Additional patient characteristics were mean transvalvular gradient of 78 mm Hg, advanced age, and marked left ventricular hypertrophy. Six patients had no residual gradient and 5 others a mean gradient less than 10 mm Hg. There were no complications related to the debridement process. Intraoperative transesophageal Doppler echocardiography demonstrated improved leaflet mobility and elimination of the gradient in all patients and elimination of associated valvular insufficiency in 2 patients. Follow-up echocardiography demonstrated late onset of new valvular regurgitation in 5 patients that was progressive and required reoperation in 3. Thickened, hardened, and retracted valve leaflets with loss of central coaptation were found in all 3 patients who underwent reoperation. Ultrasonic debridement can effectively relieve aortic stenosis, provide an excellent immediate hemodynamic result, and decrease operative time. However, the early occurrence of aortic insufficiency in a high percentage of patients makes it an unacceptable alternative to valve replacement, and the technique should be abandoned as a treatment for severe calcific aortic stenosis.

Aged↗
PubMed1990

Ten-year experience with the porcine bioprosthetic valve: interrelationship of valve survival and patient survival in 1,050 valve replacements.

The porcine bioprosthetic valve was used in 440 patients having isolated mitral valve replacement (MVR), 522 patients having isolated aortic valve replacement (AVR), and 88 patients having MVR + AVR between 1974 and 1981. Patients with associated surgical procedures were excluded. Mean follow-up was 8.3 years. At 10 years, there was no difference in patient survival between those having AVR and those having MVR. Reoperations were performed on 192 patients. Endocarditis was the reason for reoperation in 3.7% of patients who had MVR and 10.6% of those who had AVR. Structural valve degeneration was the reason for reoperation in 89.7% of MVR patients and 78.8% of AVR patients (p = 0.04). Hospital mortality among patients having valve reoperations was 4.7%. At 10 years, the freedom from valve reoperation for all causes and from structural valve degeneration was significantly better for the AVR group than the MVR group (74% +/- 3% versus 61% +/- 4%, p = 0.004; and 79% +/- 3% versus 63% +/- 4%, p = 0.0006, respectively). For patients in their 60s, the 10-year freedom from reoperation was 92% +/- 2% for AVR and 80% +/- 6% for MVR (p = not significant). At 10 years, freedom from cardiac-related death and valve reoperation was best for both MVR and AVR patients in their 60s. Patients 70 years old or older rarely had reoperation but died before valve failure occurred. The 10-year freedom from all major valve-related events (cardiac-related death, reoperation, thromboembolism, endocarditis, and anticoagulant-related bleeding) was practically the same for both MVR and AVR patients (48% +/- 3% versus 49% +/- 3%, respectively). The porcine bioprosthetic valve is the valve of choice only for patients 60 years old or older. Patients in their 70s have an extremely low rate of reoperation but a high rate of cardiac-related death and do not outlive the prostheses.

Adolescent↗
PubMed1990

Case-matched comparison of mitral valve replacement and repair.

Carpentier's techniques of prosthetic ring mitral valve repair for mitral regurgitation offer the potential for immediate and long-term improvement in valve function without the necessity of replacing the native valve with a prosthesis. A consecutive, case-matched series of 65 patients with prosthetic ring mitral valve repair was compared with 65 patients undergoing mitral valve replacement for mitral regurgitation. The aortic cross-clamp time was 57 +/- 33 minutes in the repair operations and 41 +/- 25 minutes in the replacement operations (p = 0.003). The cardiopulmonary bypass time was 154 +/- 44 minutes in the repair operations and 113 +/- 41 minutes in the replacement operations (p = 0.0001). There were no myocardial infarctions in the hospital in either group. Hospital death was noted in 1.5% of repairs and 4.6% of replacements (p = not significant). Survival at 4 years was 0.84 for repairs and 0.82 for replacements (p = not significant). Freedom from reoperation to replace the mitral valve at 4 years was 62 of 65 patients in the repair group and 64 of 65 patients in the replacement group (p = not significant). In-hospital and midterm results in a closely matched population show that mitral valve repair yields results comparable with those of replacement despite a more difficult procedure. The benefits of maintaining the native valve with chordal and papillary muscle structure intact and avoidance of prosthetic valve implantation may then become apparent with longer follow-up.

Adult↗
PubMed1990

Results of coronary surgery after failed elective coronary angioplasty in patients with prior coronary surgery.

The results of coronary artery bypass surgery after failed elective coronary angioplasty in patients who have undergone prior coronary surgery are unknown. Coronary angioplasty may be performed to relieve angina after surgery either to the native coronary vessels or to grafts. Failure of attempted coronary angioplasty may mandate repeat coronary surgery, often in the setting of acute ischemia. From 1980 to 1989, 1,263 patients with prior coronary bypass surgery underwent angioplasty; of these patients, 46 (3.6%) underwent reoperation for failed angioplasty during the same hospital stay. Of the 46 patients who underwent reoperation, 33 had and 13 did not have acute ischemia. In the group with ischemia, 3 patients (9.1%) died and 14 (42.4%) died or had a Q wave myocardial infarction in the hospital compared with no deaths (p = NS) and no deaths or Q wave myocardial infarction (p = 0.005) in the group without ischemia. At 3 years, the actuarial survival rate was 88 +/- 6% in the group with ischemia, whereas there were no deaths in the group without ischemia (p = NS), and freedom from death or myocardial infarction was 51 +/- 10% in the group with ischemia, versus no events in the group without ischemia (p = 0.006). In most patients with prior coronary bypass surgery, coronary angioplasty was performed without the need for repeat coronary bypass surgery. Should coronary angioplasty fail, reoperation in patients without acute ischemia can be performed with overall patient survival comparable to that of elective reoperative coronary bypass without coronary angioplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1990

Failed elective percutaneous transluminal coronary angioplasty requiring coronary artery bypass surgery. In-hospital and late clinical outcome at 5 years.

This study was performed to define the in-hospital and late clinical outcome at 5 years in 430 patients who had a failed elective percutaneous transluminal coronary angioplasty (PTCA) and underwent coronary artery bypass graft (CABG) surgery during their hospitalization. This group comprised 5.9% of 7,246 patients undergoing elective PTCA. CABG surgery was performed in 346 patients with ongoing myocardial ischemia (80.5%) and in 84 patients without ischemia (19.5%). Their mean age was 56 +/- 9 years, and 76.3% were male. One-vessel disease was present in 72.3%, and the mean left ventricular ejection fraction was 59 +/- 11%. Overall, 1.9 +/- 0.9 bypass grafts were placed. There was increased use of the internal thoracic artery in the nonischemic group. A new nonfatal postprocedural Q wave myocardial infarction occurred in 21.2% and occurred more frequently in the ischemic (25.4%) than in the nonischemic (3.6%) group (p less than 0.0001). There were six in-hospital deaths (1.4%), an incidence that did not differ between the two groups. Follow-up was 99.8% complete. There were 25 deaths (93.2 +/- 1.5%, 5-year survival), including 16 of cardiac cause (95.3 +/- 1.3%, 5-year cardiac survival). Q wave myocardial infarction occurred in 111 patients (91 in-hospital), and freedom from cardiac death or nonfatal myocardial infarction at 5 years was 71 +/- 3%. In the group going to CABG surgery with ongoing ischemia, the 5-year cardiac survival was 94.9 +/- 1.6%, and in the group without ischemia, the corresponding survival was 96.2 +/- 2.2%. By multivariate analysis, the presence of preoperative myocardial ischemia, pre-PTCA diameter stenosis less than 90%, and the presence of multiple-vessel disease correlated with the occurrence of cardiac death or nonfatal myocardial infarction at 5 years. At this large-volume center with extensive PTCA operator and surgical experience, the excellent survival and low event rates over 5 years support the concept that despite the failed elective PTCA procedure, there was little effect on long-term survival provided the patient underwent prompt successful surgical revascularization.

Aged↗
PubMed1988

Left atrial tumor embolization during pulmonary resection: review of literature and report of two cases.

In the past 10 years, 2 patients were seen with metastatic sarcoma to the lower lobe of the lung and extension into the left atrium. In both patients, an attempt to squeeze the intracardiac portion of the tumor into the lung at the time of lobectomy ended in near-catastrophic complications: In the first patient, a saddle embolus occluded both femoral arteries, and in the other, obstruction of the mitral valve orifice and cardiac arrest occurred. This approach is mentioned only to condemn it. Our recommended approach is outlined to prevent this technical mistake in the future.

Adult↗
PubMed1988

Trends in invasive treatment of single-vessel and double-vessel coronary disease.

We examined our practice of invasive therapy for one- and two-vessel coronary disease to assess the impact of the randomized trials of coronary surgery and the current use of angioplasty. We first reviewed our results with coronary artery bypass graft in equivalent patients in the Coronary Artery Surgery Study with one- and two-vessel disease between 1976 and 1981. Among 1376 patients, hospital mortality was 0.07%, and 5-year survival was 95.2% +/- 0.8%. To define trends in invasive therapy, which have since occurred, we compared 100 patients with one- and two-vessel disease in each of three groups: 1979 coronary artery bypass graft, 1984 coronary artery bypass graft, and 1984 percutaneous transluminal coronary angioplasty. Preoperative characteristics in the average 1979 and 1984 patients were similar; however, in 1984, patients who had a coronary artery bypass graft were older than patients who had percutaneous transluminal coronary angioplasty (61.5 versus 56.7 years, p less than 0.01), they required more heart medications (2.1 versus 1.5, p less than 0.01), had more previous infarctions (0.8 versus 0.5, p less than 0.01), and more patients had an ejection fraction of less than 50% (34% versus 7%, p less than 0.01). Patients who had angioplasty had a shorter postoperative stay (median number of days 7, 7, 2, p less than 0.01). Freedom from major complications was similar among the groups (91%, 87%, 85%). Unstable symptoms were the most frequent indication for invasive therapy (approximately 80%), whereas long-term symptoms, those considered in the randomized trials, occurred in relatively few patients. The number of patients without at least one definite indication for invasive therapy was 13%, 3%, and 11%, p less than 0.05, suggesting that the indications for the 1984 coronary artery bypass graft group have become more restrictive since the 1979 coronary artery bypass graft group. Indications for the 1984 percutaneous transluminal coronary angioplasty group remained less restrictive, being similar to those for the 1979 coronary artery bypass graft group. A continuing trend toward the use of percutaneous transluminal coronary angioplasty was evident, as 56% of the 1979 coronary artery bypass graft group of patients and 32% of the 1984 coronary bypass group of patients would be offered percutaneous transluminal coronary angioplasty rather than coronary artery bypass graft on the basis of 1986 percutaneous transluminal coronary angioplasty criteria. The p values were obtained with analysis of variance or chi 2 test.

Angioplasty, Balloon↗