The Starr valve revisited.
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Heart Valve Prosthesis↗
Biomedical subjects
J R Pluth
Publications and source records attributed to J R Pluth.
Early and late results after isolated coronary artery bypass surgery in 159 patients aged 80 years and older.
We have studied 159 patients 80 years of age or older who have had isolated coronary artery bypass grafting (CABG) since 1977. Eighty-seven percent have had surgery since 1984. Two thirds of the patients were male, and the mean age was 82 years. Most patients (97%) were in New York Heart Association (NYHA) functional class III or IV, 89% had unstable/postinfarction angina pectoris, and 67% had rest pain. Almost half (47%) required preoperative admission to the coronary care unit, 6% required preoperative use of an intra-aortic balloon pump, and 20% were operated on emergently. Significant left main coronary artery disease (greater than or equal to 50% stenosis) was present in 41%. Ten patients (6.3%) died within 30 days of surgery, with seven more patients dying during the same hospital admission or soon after transfer to another institution. This resulted in an overall hospital mortality of 10.7%. The median hospital stay was 10 days. On univariate analysis, the significant predictors of hospital mortality were NYHA IV, angina at rest, preoperative admission to the coronary care unit, emergency operation, ejection fraction less than 0.50, and the presence of mitral regurgitation. On multivariate analysis, ejection fraction less than 0.50 was the only significant risk factor (p less than 0.01). Of hospital survivors, 98% have been followed for a mean of 29 months. The estimated 5-year survival (+/- SEM) of all patients was 71 +/- 4.5%, and for hospital survivors, 80 +/- 4.5%. The most important predictor of adverse survival was an ejection fraction less than 0.50. Seventy-nine percent are angina-free, and 89% are in NYHA classes I and II. The majority of patients felt that they were improved by surgery. We conclude that CABG in patients 80 years or older, although associated with increased operative risk, gives excellent relief of symptoms and good 5-year survival. Patients should not be denied CABG because of age alone.
Aged↗
Thrombotic obstruction of disc valves: clinical recognition and surgical management.
Twenty-seven patients underwent reoperation because of thrombotic obstruction of a disc-type cardiac valve prosthesis. Preoperative clinical features included effort dyspnea in 81%, new-onset angina in 44%, a new murmur in 89%, and an abnormal opening or closing sound associated with the prosthetic valve in 56%. Symptoms were present for 1 week or more before reoperation in 86%, although many patients were referred only after acute exacerbation of heart failure and development of pulmonary edema. Noninvasive studies confirmed prosthetic valve malfunction in only 33%, but cardiac catheterization documented thrombotic obstruction in all 15 patients in whom it was performed. In 14 of the 27 patients, prothrombin time was in the therapeutic range at the time of admission. Prompt reoperation for valve replacement or thrombectomy was performed with an operative mortality of 11%, and long-term outcome was satisfactory in all but 1 hospital survivor. These findings emphasize the importance of considering the diagnosis of thrombosed heart valves in patients with mechanical heart valves who are seen with nonspecific symptoms.
Adult↗
The outcome of surgical treatment of hypertrophic obstructive cardiomyopathy. Experience over 15 years.
From 1972 through 1987, 115 patients between the ages of 1 and 83 years (mean, 44.5 years) underwent operation for hypertrophic obstructive cardiomyopathy. Methods of relief of left ventricular outflow obstruction were septal myectomy/myotomy (n = 109), mitral valve replacement (n = 4), and myectomy/myotomy plus mitral valve replacement (n = 2); concomitant procedures included coronary artery bypass (n = 19) and aortic valve replacement (n = 9). Systolic gradient (peak-to-peak) from the left ventricle to the aorta decreased from 70 +/- 38 mm Hg (mean +/- standard deviation) to 9 +/- 11 mm Hg. There were six hospital deaths, for an overall operative risk of 5.2%; one death occurred among 83 patients less than age 65 years (operative risk, 1.2%), and five deaths occurred in 32 older patients (operative risk, 15.6%; p = 0.008 for difference between age groups). Four (22.2%) of 18 patients with a residual gradient greater than 15 mm Hg died, compared with two (2.1%) of 97 patients with a lower gradient (p = 0.003). Follow-up ranged from 0.5 to 16 years (mean, 5.1 years), and 5-year actuarial survival rate, including hospital deaths, was 84% +/- 4%. The 5-year survival rate was decreased in patients who had operative procedures other than myectomy/myotomy (69% versus 91%, p less than 0.005) and in patients aged 65 years or older (54% versus 93%, p less than 0.005). No correlation was found between preoperative symptoms, functional class, left ventricle-aorta pressure gradient, or mitral valve insufficiency and operative or late mortality. Preoperative symptoms were relieved in 57 (76%) of 75 patients with dyspnea, 49 (83%) of 59 patients with angina, and 22 (96%) of 23 patients with syncope. This experience confirms the effectiveness of operation for relief of symptoms in patients with the obstructive form of hypertrophic cardiomyopathy. The current operative mortality rate is low, especially in patients less than 65 years of age (1.2%). Our experience suggests that incomplete relief of left ventricular outflow obstruction may increase the risk of early postoperative death.
Adolescent↗
Surgical treatment of ascending aortic aneurysms associated with aortic valve insufficiency.
From 1965 to 1978, 111 patients underwent combined operation for ascending aortic aneurysms and aortic valve insufficiency. Fifteen patients had direct coronary implantation (Group 1). In 25 patients operated on between 1972 and 1977, the aortic root was retained (Group 2). An additional 71 patients operated on between 1965 and 1972 were included (Group 3): 40 who had synthetic graft replacement and retention of the aortic root and 31 who had aortoplasty and associated aortic valve repair. In 8 patients in Group 3, recurrent aneurysms were detected an average of 6.5 years after operation. The mortality rate for repaiajor complication after incomplete resection of the aortic root. Total exclusion of the aneurysm should be considered.
Adolescent↗
Renal transplantation: patients with previous saphenous vein-coronary artery bypass grafts.
2 patients underwent saphenous vein-coronary artery bypass grafting before successful renal transplantation. Both patients were able to undergo appropriate therapy for various complications, which further emphasizes the resilience that these patients can have after adequate coronary revascularization.
Adult↗
Functional evaluation of cardiac sarcoplasmic reticulum and mitochondria in human pathologic states.
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Adenosine Triphosphatases↗
Modified continuous suture technique for mitral valve replacement.
A modified continuous suture technique for mitral valve replacement is described which retains desirable features of the less expedient interrupted suture technique. An initial experience with this technique in more than 300 patients has encouraged its continued use.
Heart Valve Prosthesis↗
Efficacy of dopamine, dobutamine, and epinephrine during emergence from cardiopulmonary bypass in man.
Hemodynamic effects of dobutamine and dopamine (both 5, 10, 15 microgram/kg/min) and epinephrine (0.04 microgram/kg/min) were studied immediately following cessation of cardiopulmonary bypass in 34 patients with preoperative evidence of left ventricular dysfunction. Significant increases in mean cardiac index were seen with dobutamine (15, 25, and 26% respectively), and epinephrine (30%). The largest increases occurred with dopamine (44, 53, and 64 percent respectively). Responses varied from patient to patient, however. Seven patients developed marked output increases without concomitant increases in arterial pressure, whereas seven others showed "satisfying" increases in arterial pressure without appreciable output increases. Heart rate increases were small and few arrhythmias were noted. We conclude that dopamine, epinephrine, and dobutamine all are effective inotropic agents during the immediate post-bypass period, with variations discussed in detail. None possess the disturbing chronotropic and arrhythmogenic effects of isoproterenol (previously studied). Efficacy of administration of inotropic drugs seems best assessed by serial output measurements during this period.
Arrhythmias, Cardiac↗
Regional myocardial wall thickening response to nitroglycerin. A predictor of myocardial response to aortocoronary bypass surgery.
The peak rate of systolic wall thickening (p +/- dTw/dt) in regions of the left ventricle (LV) was determined preoperatively by biplane roentgen videometry in 18 patients before and after sublingual administration of nitroglycerin (NTG) and 3-23 months (median 12) after aortocoronary bypass surgery. The regional LV response to NTG was a reliable predictor for postoperative improvement in regional wall dynamics after successful aortocoronary bypass grafting. The ejection fraction response to NTG or surgery will not predict the regional myocardial response to NTG or surgery, nor will the regional response predict the global response. Subendocardial myocardial infarction is another cause of unimproved regional myocardial function after NTG and aortocoronary bypass surgery.
Adult↗
Perioperative myocardial infarction in patients with coronary artery disease with and without aorta--coronary artery bypass grafts.
The incidence of perioperative myocardial infarction (MI) was examined in 148 patients with known coronary artery disease (CAD) who underwent 226 noncardiac surgical procedures. In 168 operations in 99 patients who had prior coronary artery bypass grafting (CABG) there were no perioperative MI's whereas in the 49 patients who had not undergone prior CABG who underwent 58 noncardiac operations, there were three MI's (5 percent). The lower (p less than 0.02) incidence of perioperative MI in patients with CAD who had had prior CABG suggests a protective effect for subsequent noncardiac operation, which could not be explained by other differences in cardiac status between the groups. All three MI's occurred in patients with three-vessel CAD, evidence that this should be added to prior MI as a significant risk factor. The study indicates also that patients with prior CABG have less risk of MI during and following anesthesia and noncardiac operation than do patients without CABG who have had a previous MI.
Adult↗
The Marfan syndrome and cardiac surgery.
Of 31 patients with Marfan's syndrome and cardiovascular complications, 25 had ascending aortic aneurysms, five with aortic dissection; 26 had aortic regurgitation, two with aortic stenosis; and eight had mitral regurgitation, five with aortic regurgitation. Surgery included prosthetic aortic valve replacement in 24 patients and aortic valvular bicuspidization in two; 19 had resection of aneurysm with Dacron tube replacement, three had lateral aneurysmorrhaphy, and two had circumferential strip excision with end-to-end anastomosis. Four patients underwent mitral valve replacement. Operative complications occurred in 10 patients. There were nine (29 percent) hospital deaths, but only one death occurred in 12 patients operated upon since 1970. Late complications included prosthetic leak in six patients (23 percent) with reoperation in five; all survived. Five late deaths occurred (16 percent); one was unrelated and one was of unknown cause. Although risk of cardiac surgery remains high, our recent results support an aggressive surgical approach, particularly in patients with advanced or deteriorating cardiovascular complications.
Adolescent↗
Partial anomalous pulmonary venous connection (intact atrial septum) associated with mitral regurgitation.
The association of partial anomalous pulmonary venous connection with intact atrial septum and isolated severe nonrheumatic mitral regurgitation is rare, this combination of lesions having been reported on only one other occasion. Two such cases have been presented, with each patient having experienced an episode resembling subacute bacterial endocarditis. At operation, however, the mitral valve had a congenital cleft in one case and was normal in the other. One patient underwent mitral valvuloplasty and the second patient had mitral valve replacement. The diagnosis of associated partial anaomalous pulmonary venous connection was established at cardiac catheterization, and successful surgical correction was achieved in each case by diversion of the anamolaous pulmonary venous drainage to the left atrium via a pericardial tunnel through a surgically created atrial septal defect.
Adult↗
The performance of the Braunwald-Cutter aortic prosthetic valve.
Four hundred seventy-five patients underwent aortic valve replacement with the Braunwald-Cutter ball-valve prosthesis at two institutions. The early (30-day) hospital mortality was 4.7% for those with isolated aortic valve replacement and 6.9% for the entire group. For the former, 5-year actuarial survival of the hospital survivors was 72 +/- 5.7%; for the latter group it was 71 +/- 4.4%. Eleven patients (5 since the date of follow-up inquiry) have suffered poppet escape, 9 of whom died. The actuarial incidence of known poppet escape is 4 +/- 2.6% at 47 months; when the 5 patients suffering poppet escape since the date of follow-up inquiry are included, with certain assumptions, the incidence is 3.7 +/- 1.14%. The projected probability of poppet escape using all 11 patients is 12.2% at 5 years; the 70% confidence bands of projected probability of poppet escape separate from those of the risk of re-replacement at 61 months. This and other analyses indicate that in general, patients with the Braunwald-Cutter aortic prosthesis should have it replaced 4 1/2 to 5 years after its insertion.
Alabama↗
A critical look at temporary ventricular pacing following cardiac surgery.
The effect of atrial, ventricular, and atrioventricular (A-V) sequential pacing on cardiac output (CO) was evaluated in patients within 24 hours after cardiac surgery. In patients with normal sinus rhythm, ventricular pacing reduced CO by as much as 42% (average, 14%), whereas atrial and A-V sequential pacing at the same rate increased CO by averages of 13% and 19%, respectively. In patients with junctional rhythm, increase of the heart rate by ventricular pacing produced an increase in CO, however, and an additional 25% increase in CO could be obtained by atrial or A-V sequential pacing at the same rate. Atrial or A-V sequential pacing was superior to ventricular pacing at the same rate and they are the preferred methods for temporary carciac pacing in the postoperative period. In suitable cases elective A-V sequential pacing is an effective method for increasing CO after cardiac surgery.
Adult↗
Survival predictors in coronary artery disease. Medical and surgical comparisons.
Linear discriminant function analysis was used to test the independent prognostic value of nine variables in patients with coronary artery diseaase. For 68 medically treated patients who met the criteria for inclusion in the discriminant function analysis, the most reliable predictor of 2-year survival status was the left ventricular ejection fraction. The prognostic value of the ejection fraction was not improved by the addition of the number of vessels diseased. Comparisons of the survival of 130 medical and 284 surgical patients were made using subsets based on the ejection fraction. When the ejection fraction was greater than or equal to 50%, the probability of 4-year survival was high for both medical (91%) and surgical (96%) groups. When the ejection fraction was less than 25%, the probability of 2-year survival was low in both groups. However, for patients with ejection fraction 25 through 49%, the surgical patients had a better chance (P less than 0.05) for a 3-year survival (89%) than did medical patients (68%). This study emphasizes the prognostic significance of the left ventricular ejection fraction, which should be considered in any comparison of survival in medically and surgically treated patients.
Age Factors↗
Another prosthetic heart valve?
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Animals↗