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Biomedical subjects

J M Matloff

Publications and source records attributed to J M Matloff.

At least 19 recordsLinked to original sources
PubMed1992

Results of early repair of ventricular septal defect after an acute myocardial infarction.

A 10-year experience with early operation for postinfarction ventricular septal defect is reviewed. Twenty-two patients underwent surgical repair; operative mortality was 36% (< 30 days). The actuarial survival was 64% at 1 month, 59% at 1 year, and 47% at 5 years. Risk factors predictive of operative mortality were diabetes (p = 0.001), elevated preoperative right atrial pressure (p = 0.02), the absence of a preoperative intraaortic balloon pump (p = 0.006), and a short time interval between infarct and operation (p = 0.018). Long-term survival was adversely related to diabetes (p = 0.030), elevated preoperative right atrial pressure (p = 0.005), and, surprisingly, survival was better in patients with a greater extent of coronary artery disease (p = 0.023). There were 14 operative survivors (64%) and 11 long-term survivors (3 months to 10 years, mean 6.0 +/- 3.5 years). Six of eleven survivors were in functional New York Heart Association class I, one was in class II, and four were in class III.

Aged↗
PubMed1992

Interaction of age and preoperative risk factors in predicting operative mortality for coronary bypass surgery.

BACKGROUND: Models for predicting operative mortality for coronary bypass surgery assume that preoperative risk factors affect mortality to the same extent in all patients groups. METHODS AND RESULTS: To determine whether certain preoperative risk factors disproportionately increase operative mortality in the elderly, 663 consecutive elderly patients (age 75 years or older) and 1,464 younger patients (age 65 or younger) undergoing isolated coronary bypass surgery between 1982 and 1990 were studied. Hospital mortality was significantly greater in the elderly patients than in younger patients (7.5% versus 1.8%; relative risk, 4.5). Univariate analysis identified age, prior coronary artery bypass grafting, congestive heart failure, left main disease, New York Heart Association functional class, hypertension, prior myocardial infarction (MI), and preoperative atrial fibrillation as associated with mortality. Multivariate analysis was then used to construct a model to describe the risk of operative mortality in terms of selected risk factors. However, comparison of observed mortality rates with those predicted by the model revealed problems with the model's goodness of fit. Further testing revealed that young patients without prior MI had a mortality rate lower by an order of magnitude than either younger patients with prior MI or elderly patient groups with and without MI. Two separate models were therefore constructed stratifying by the presence of prior MI. This resulted in a significant improvement in the fit of the models to the observed data. CONCLUSIONS: These results suggest that the impact of risk factors on the elderly may be significantly different from the effect of these risk factors on younger patients. Models for predicting outcome after bypass surgery should be tested for potential interactions between age and risk factors.

Adult↗
PubMed1992

Comparative efficacy of ring and suture annuloplasty for ischemic mitral regurgitation.

BACKGROUND: Patients with ischemic mitral regurgitation (MR) represent a therapeutic challenge, and results after combined valve replacement and revascularization have been poor. Valve repair is a promising approach, but the optimal method of repair is not known. METHODS AND RESULTS: In 60 patients with coronary artery disease and 3+ or 4+ MR, we used intraoperative Doppler echocardiography to study the efficacy of Carpentier-Edwards ring (n = 27) and commissural suture (n = 33) annuloplasty. Patients with ruptured papillary muscles, torn chordae, and ballooning or scalloping of the leaflets were excluded. Ring and suture groups were similar in preoperative ejection fraction (35 +/- 14% and 34 +/- 17%), MR grade (3.5 +/- 0.5 and 3.4 +/- 0.6), and acuity of MR (41% and 33% acute) (p = NS). Postoperatively, the ring group achieved a lower residual MR grade than the suture group (0.5 +/- 0.5 versus 1.5 +/- 1.1; p < 0.001), and the mitral annular diameter was reduced to a greater extent in the ring group (by 1.5 +/- 0.5 cm versus 0.5 +/- 0.4 cm; p < 0.001). Success (> or = 2 grade MR reduction) was more frequent in the ring than in the suture group (96% versus 67%, p < 0.01). One-year survival was similar (74 +/- 9% ring, 71 +/- 8% suture). Follow-up Doppler studies showed a higher mean gradient (4.0 +/- 1.2 mm Hg) and smaller valve area (2.1 +/- 0.5 cm2) in the ring group, but the postoperative New York Heart Association class was similar in both groups (83% versus 74% class I-II). CONCLUSIONS: Ring annuloplasty provides a more effective reduction of ischemic MR and a higher success rate than the suture technique. This may be related to uniform rather than localized shortening of the annulus and a greater reduction in annulus diameter.

Aged↗
PubMed1991

Excimer laser angioplasty during aortocoronary bypass grafting.

Laser coronary angioplasty using the 308-nm Excimer laser was successfully performed intraoperatively during coronary artery bypass grafting. It achieved a reduction of the left anterior descending artery stenosis from 99% to 25% as seen on angioscopy, without evidence of vascular perforation or intimal disruption. The Excimer laser offers the opportunity for intraoperative endovascular remodeling and recanalization and has a potential role as an adjunct to existing standard coronary artery bypass grafting protocol.

Angioplasty, Laser↗
PubMed1991

Morbidity and mortality after coronary artery bypass in octogenarians.

One hundred fifty seven consecutive octogenarians (mean age +/- standard deviation, 82.4 +/- 1.9 years) underwent coronary artery bypass grafting with hypothermia (mean temperature, 21.8 degrees +/- 1.8 degrees C), hyperkalemic cardioplegia, and cardiopulmonary bypass in a 9-year period. Sixty-six percent were male. Preoperatively, 115 patients (73%) were in New York Heart Association functional class IV, with the remainder being in either class III (23%) or class II (4%). Twenty percent of the patients had major complications including postoperative hemorrhage (15), sepsis (9), cerebrovascular accident (6), third-degree heart block (5), renal failure requiring dialysis (1), and pulmonary embolism (1). The 30-day or in-hospital mortality rate was 7.0%. Mean total hospital stay was 26.1 +/- 17.9 days. One-year and 5-year actuarial survival rates were 85% and 62%, respectively. Higher mortality was seen to be associated with New York Heart Association class IV, left ventricular ejection fraction less than 0.40, and lesser values for cardiac output and cardiac index. At the 6-month postoperative follow-up, 73% of the survivors reported that their general health had improved as compared with before operation. This experience demonstrates that for select octogenarians with unmanageable angina pectoris, coronary artery bypass grafting is an effective therapeutic option.

Aged↗
PubMed1991

Vascular rejection and graft eosinophilia in rat lung allografts.

Allogeneic lung transplantation was performed using a rat model in order to assess the pathologic changes that developed during the process of rejection. The left lungs of 38 BN rats (RT-1n) were orthotopically transplanted into LEW rats (RT-1). The allografts developed the well-known changes of perivascular, peribronchial, and interstitial lymphocytic infiltrates resulting in necrosis of the pulmonary parenchyma at 7-8 days after transplantation. In addition, we document two findings that have not been reported previously in lung transplantation: vasculitis and eosinophilic infiltrates. Vasculitis with swelling and vacuolization of the endothelial cells was observed in transplants as early as 3 days following transplantation. Vasculitis with fibrinoid necrosis of the vessel wall was prominent at 7-8 days after grafting. The allografts also exhibited eosinophilia at 2 to 4 days following transplantation. The density of eosinophils in the inflammatory infiltrate reached a peak of 20% on Day 3 post-transplantation. These findings suggest an important role of humoral immunity and a possible involvement of eosinophils in lung allograft rejection.

Animals↗
PubMed1990

Ten-year experience with the St. Jude Medical valve for primary valve replacement.

The St. Jude Medical valve is a bileaflet prosthesis with excellent hemodynamic characteristics, but the long-term surgical experience with this valve, its durability, and its biocompatibility are unknown. During a 10-year period from March 1978 to 1988, 690 prostheses (290 aortic, 252 mitral, and 74 double aortic-mitral) were inserted as the initial valve replacement substitute in 616 patients (mean age 63 years). Coronary atherosclerosis was present in 58%. Follow-up totaled 2031 patient-years (mean 3.3 years) and was 95% complete (32 lost). Early (30-day) mortality rates were 5.2%, 11.9%, and 8.1% after aortic, mitral, and double valve replacement; 5- and 9-year actuarial survival rates were 71% +/- 3% and 51% +/- 8%, 59% +/- 4% and 41% +/- 6%, and 69% +/- 6% and 47% +/- 15%, respectively. Deaths were associated with extensive coronary atherosclerosis (p less than 0.001), older age (p less than 0.001), advanced preoperative New York Heart Association functional class (p less than 0.05), and malignant ventricular arrhythmias (p less than 0.05). No structural failures have been observed. Embolism (40 events) occurred at a rate of 2.0%/pt-yr (2.3% aortic, 1.6% mitral, 2.0% double). There were six cases of valve thrombosis (0.3%/pt-yr; one fatal). Hemorrhage was the most frequent complication (2.6%/pt-yr); 13 (25%) of 52 events were fatal, accounting for 62% of all valve-related deaths. After the target prothrombin time ratio was lowered, the rate of hemorrhage decreased by 44% (2.7% to 1.5%/pt-yr), while the combined rate of embolism and valve thrombosis increased slightly (2.2% to 2.5%/pt-yr, a 14% change). In summary, the St. Jude Medical valve remains a durable valve substitute. Survival was strongly related to the presence of associated coronary atherosclerosis. The most common complication has been hemorrhage; a less intensive warfarin regimen may reduce hemorrhagic risk while maintaining thromboembolic protection.

Adolescent↗
PubMed1989

Tricuspid valve repair. Operative and follow-up evaluation by Doppler color flow mapping.

Severe tricuspid regurgitation may produce significant morbidity and mortality if not corrected, but commonly used methods of intraoperative assessment may be unreliable. Tricuspid regurgitation was evaluated by a new intraoperative technique, Doppler color flow mapping, in 85 patients before and after cardiopulmonary bypass. Regurgitation grade by intraoperative color Doppler mapping correlated well with right ventricular angiography (kappa value = 0.92, p less than 0.01; n = 8) and with preoperative color Doppler studies (kappa = 0.71, p less than 0.05; n = 51). The right atrial V wave correlated poorly with the severity of tricuspid regurgitation intraoperatively, both before (r = 0.30) and after (r = -0.05, p = no significant difference) cardiopulmonary bypass. Advanced (3+ or 4+) tricuspid regurgitation was found in 40% (21) of 52 patients requiring mitral valve repair or replacement. Tricuspid annuloplasty with a prosthetic ring provided a significant (greater than or equal to 2 grade) reduction in regurgitation severity in 94% (17/18; p less than 0.05). Without repair, tricuspid regurgitation decreased to a similar degree after mitral valve operations in 14% (5/36); only one of the five patients had advanced tricuspid regurgitation prepump. Fluid filling of the arrested right ventricle after the surgical procedure did not predict regurgitation severity (false negative rate 50%, 2/4; false positive rate 22%, 2/9). Regurgitation grade remained unchanged after the initial postpump study, up to 60 weeks postoperatively. In conclusion, color Doppler flow mapping provides more accurate intraoperative assessment of tricuspid regurgitation than the right atrial V wave or fluid filling of the right ventricle. This semiquantitative technique aids in the selection of patients appropriate for surgical repair of the tricuspid valve and is useful in judging the adequacy of tricuspid valve repair before chest closure. Advanced (3+ or 4+) tricuspid regurgitation is a common occurrence in patients undergoing mitral valve repair or replacement and rarely responds to conservative (nonoperative) management. Ring annuloplasty provides a highly effective and durable reduction in tricuspid regurgitation.

Adult↗
PubMed1988

Determinants of wound infection incidence after isolated coronary artery bypass surgery in patients randomized to receive prophylactic cefuroxime or cefazolin.

In this open-label, randomized drug study, we compared two cephalosporin prophylactic regimens, one using cefazolin and one using cefuroxime, in 100 patients having coronary bypass surgery. Additional epidemiological data were collected to identify the patient at higher risk for acquiring an infection. Patients were categorized into four groups: (1) no infection; (2) clinically determined infection without a culture or prescription of additional antibiotics; (3) clinical infection with no or negative wound culture and prescription of additional antibiotics; and (4) clinical infection with positive culture and need for additional antibiotics. Seven cefuroxime patients (13.5%) and 9 cefazolin patients (18.8%; p = 0.471) had a wound that became clinically infected (Groups 2-4). In a univariate analysis, 11 variables were statistically associated with the development of a wound infection. A logistic regression model defined 3 variables at an alpha level of 0.05 and 3 at an alpha level of 0.10 that predicted a wound infection. Patients were identified at high risk of wound infection if they had postoperative weight gain, long operative hospitalization, prolonged use of a Foley catheter, postoperative use of blood products, and operation performed by two specific surgeons. Our results indicated that closer observation of the high-risk patients and a definition of the mechanism of the infections are needed.

Cefazolin↗
PubMed1988

Reduction in sudden late death by concomitant revascularization with aortic valve replacement.

To determine the impact of coronary atherosclerosis and myocardial revascularization on survival after aortic valve replacement, we reviewed our experience with single aortic valve replacement between 1969 and 1984. Of 474 patients (mean age 62 +/- 13 years), 185 (39%) had no associated coronary artery disease, 233 (49%) had coronary artery bypass grafting, and 56 (12%) had unbypassed coronary artery disease. Early (30-day) mortality rates were 2.2%, 8.2%, and 7.1%, respectively (p less than 0.01, coronary disease absent versus present). Actuarial survival rates at 10 years were 77% +/- 4%, 41% +/- 6%, and 26% +/- 11% (p less than 0.001, coronary disease absent versus present), with 1 to 177 months of follow-up (mean 56 +/- 40). Preoperative angina (39%) did not predict the presence of coronary artery disease (61%). Multivariate logistic regression analysis showed that early deaths were associated with advanced preoperative New York Heart Association functional class (p less than 0.001), advanced age (p less than 0.05), more extensive coronary artery disease (p less than 0.05), and lack of cardioplegic myocardial protection (p less than 0.05). Complete revascularization did not increase operative risk when coronary artery disease was present (early mortality 6.8%, p = not significant). Late deaths were strongly associated with the presence of coronary artery disease (p less than 0.001) and reduced left ventricular ejection fraction (less than or equal to 55%, p less than 0.01). Late cardiac mortality was most commonly attributable to sudden death (30/71, 42%), especially in the unbypassed coronary disease cohort (9/14, 64%). The actuarial rate of freedom from sudden death at 10 years was 52% +/- 17% in the unbypassed coronary artery disease group (p = 0.009), compared with 90% +/- 3% and 91% +/- 3% in the revascularized and no coronary disease patients, respectively. Thus, coexistent coronary atherosclerosis has a detrimental impact on early and late survival after aortic valve replacement. Revascularization does not increase operative risk when associated coronary artery disease is present and significantly reduces the occurrence of late sudden death. Strategies that minimize operative risk when associated coronary artery disease is present include use of cardioplegia and complete revascularization.

Adolescent↗
PubMed1987

Intraoperative Doppler color flow mapping for assessment of valve repair for mitral regurgitation.

The ability of color Doppler flow mapping to provide intraoperative information about mitral regurgitation (MR) severity and to evaluate adequacy of mitral valve repair was assessed by performing color Doppler echocardiography immediately before and after cardiopulmonary bypass, with the transducer placed directly on the epicardium. In 56 patients, the degree of MR by intraoperative color Doppler correlated well with left ventricular angiography (kappa = 0.80) and with closed-chest preoperative color Doppler (kappa = 0.84) and had good interobserver reproducibility (kappa = 0.88). Good correlation was also seen between closed-chest color Doppler and angiography (kappa = 0.75). After mitral valve repair in 18 patients (15 ischemic MR, 3 cleft valves), color Doppler was used to assess severity of residual MR intraoperatively and postoperatively. Intraoperative color Doppler identified satisfactory repair (MR less than or equal to 2+) in 15 patients and failure (MR greater than or equal to 3+) in 3, whereas conventional surgical assessment of MR by fluid filling of the arrested ventricle failed to provide reliable differentiation. MR severity on subsequent closed-chest color Doppler follow-up did not change significantly compared with intraoperative evaluation after repair. Intraoperative color Doppler provides accurate grading of MR severity, offers instantaneous evaluation of the adequacy of mitral valve repair before chest closure, and appears to predict the degree of postoperative MR seen on subsequent closed-chest follow-up studies.

Blood Flow Velocity↗
PubMed1987

Comparison of esmolol and nitroprusside for acute post-cardiac surgical hypertension.

Because acute systemic hypertension early after cardiac surgery has been linked to catecholamine elevation, an open-label, randomized, crossover study was performed to compare the efficacy of esmolol, a new ultra-short-acting intravenous beta-blocking agent, to nitroprusside, the standard therapy. Controlled drug infusions to maximal dosage (esmolol, 300 micrograms/kg/min, and nitroprusside, 10 micrograms/kg/min) were titrated to achieve at least a 15% reduction in systolic pressure. The blood pressure (BP) endpoint was achieved with esmolol (within 29 +/- 14 minutes) in 18 of 20 patients (90%), compared with 19 of 20 (95%) with nitroprusside infusion (within 21 +/- 15 minutes, difference not significant [NS]). Systolic BP decreased from 170 +/- 13 to 136 +/- 12 mm Hg (mean +/- standard deviation) with esmolol and from 170 +/- 13 to 141 +/- 13 mm Hg with nitroprusside infusion (both p less than 0.05). Diastolic BP was reduced from 71 +/- 12 to 64 +/- 11 mm Hg with esmolol and from 71 +/- 12 to 52 +/- 13 mm Hg with nitroprusside infusion (both p less than 0.05). Esmolol infusion resulted in decreased heart rate, cardiac index and stroke volume index and increased right atrial pressure (all p less than 0.05), whereas nitroprusside infusion resulted in increased heart rate and cardiac index and decreased right atrial pressure, pulmonary arterial wedge pressure and systemic vascular resistance (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenergic beta-Antagonists↗
PubMed1987

Experimental evaluation of technetium-99m red blood cell radionuclide ventriculography for detecting pericardial bleeding.

Abnormal loculated or diffuse blood pools adjacent to the heart have been observed in patients with pericardial bleeding who have been imaged by gated equilibrium radionuclide ventriculography (RNV). To study the scintigraphic appearance of fresh pericardial blood, we performed equilibrium RNV in six dogs with measured volumes (10, 30, or 50 ml) of intrapericardial blood. Loculated and diffuse pericardial blood was simulated by injecting the blood either into an intrapericardial balloon, or freely into the pericardial space. Ability to detect pericardial blood was determined by blinded review, and blood volume analysis was attempted by measuring its scintigraphic thickness, brightness (relative to the left ventricle), extent, and background-subtracted count rate and a peak count index. Detection rates for 10, 30, and 50 ml were all 100% for loculated pericardial blood, and 67%, 100% and 100% for free pericardial blood, with the use of three scintigraphic views. Visually determined "extent" of the abnormal blood pool was the most reliable indicator of pericardial blood volume. When the volume was 30 ml or more, at least 40% of the heart was surrounded in 26 of 27 cases (96%); the specificity of this finding was 90%. We conclude from this animal study that RNV should be a sensitive method for detecting pericardial bleeding; visual appearance permits qualitative assessment of the volume of accumulated labeled blood.

Animals↗
PubMed1987

The St. Jude valve: analysis of thromboembolism, warfarin-related hemorrhage, and survival.

From March 1978-86, 590 St. Jude prostheses (232 aortic, 232 mitral, and 63 double aortic-mitral) were implanted in 527 patients (mean age 63 years) and followed for up to 8 years (mean 33 months; three lost; 99% complete). The early (30-day) mortality rate was 8.9% and was strongly associated with preoperatively depressed left ventricular function (ejection fraction less than 0.55), ischemic mitral regurgitation, and advanced functional class (IV) (p less than 0.05). Actuarial survival rates at 5 years were 72% +/- 4%, 72% +/- 8%, and 63 +/- 4% after aortic, double, and mitral valve replacement (p less than 0.01). There have been no structural failures. Embolism (28 events, 2.1%/patient-year) was less common with warfarin treatment (1.5%/patient-year; n = 492) than with antiplatelet (3.2%/patient-year; n = 19) or no drug therapy (18.9%/patient-year; n = 16) (p less than 0.01). One embolic event was fatal (3.6%). Warfarin-treated patients remained 91% +/- 1% free of emboli after 8 years. Valve thrombosis (six events; 0.4%/patient-year) occurred exclusively in patients not treated with effective warfarin therapy; one (17%) died. The most common complication was hemorrhage (39 events; 2.9%/patient-year); nine (23%) were fatal, and these constituted 82% of 11 valve-related late deaths. In warfarin-treated patients (target prothrombin time ratio 1.5 to 2.5), hemorrhage was twice as frequent (2.9%/patient-year) as embolism (1.5%/patient-year).(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗
PubMed1987

Thrombosed, ruptured atheromatous plaques in saphenous vein coronary artery bypass grafts: ten years' experience.

During the past decade the number of patients undergoing saphenous vein coronary artery bypass grafting (CABG) has increased worldwide. With a rate of late graft occlusion approximating 4% each year, the number of patients at risk for late graft occlusion continues to increase. Whereas in 1976 only 0.8% of the CABGs performed at our institution were reoperations for occluded grafts, by 1985 repeat procedures comprised 12.4% of the CABGs performed. Excised, occluded saphenous vein grafts from 52 of 119 (44%) of these patients showed thrombosis superimposed on ruptured atheromatous plaques. Ten autopsy patients showed similar lesions in their occluded grafts. The lesion was present in grafts excised as early as 3 years and as late as 14 years after bypass surgery; most occurred 5 to 10 years after implantation. Neither age at first bypass, sex, nor coronary artery bypassed permitted prediction of the occurrence of the lesion. Thrombosed, ruptured atheromatous plaque is a common, clinically significant mechanism of late graft occlusion. It is associated with recurrent symptoms that necessitate repeat revascularization and may result in death. The lesion may also be amenable to thrombolytic therapy, angioplasty, or both.

Acute Disease↗
PubMed1987

Treatment of severe platelet dysfunction and hemorrhage after cardiopulmonary bypass: reduction in blood product usage with desmopressin.

Impairment of platelet function commonly occurs after cardiopulmonary bypass, and may result in substantial bleeding. Because desmopressin acetate (a synthetic analogue of vasopressin) shortens bleeding time in a variety of platelet disorders, a controlled clinical trial of intravenous desmopressin was performed in 39 patients with excessive mediastinal bleeding (greater than 100 ml/h) and a prolonged template bleeding time (greater than 10 minutes) more than 2 hours after termination of cardiopulmonary bypass. Twenty-three desmopressin recipients and 16 control patients (no desmopressin) were similar in surgical procedure, pump time, platelet count, template bleeding time and amount of bleeding before therapy (p = NS). Compared with the control group, the patients receiving desmopressin (20 micrograms; mean 0.3 micrograms/kg) utilized fewer blood products (29 +/- 19 versus 15 +/- 13 units/patient; p less than 0.05), especially platelets (12 +/- 9 versus 4 +/- 7 units/patient; p = 0.004), while achieving a similarly effective reduction in mediastinal bleeding (4.8- and 4.3-fold, p = 0.001 for both). Severe platelet dysfunction was partially corrected within 1 hour after desmopressin infusion, during which interval no blood products were administered: the template bleeding time shortened (from 17 to 12.5 minutes, p less than 0.05), whereas the platelet count remained unchanged (at 96 +/- 35 and 105 +/- 31 X 10(3)/mm3, p = NS). The plasma levels of two factor VIII components increased: procoagulant activity (VIII:C) from 0.97 +/- 0.43 to 1.52 +/- 0.74 units/ml (p less than 0.05) and von Willebrand factor (VIII:vWF) from 1.28 to 1.78 units/ml (p less than 0.05); these increases correlated with the shortening of the bleeding time (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Platelet Disorders↗