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Biomedical subjects

J T Walls

Publications and source records attributed to J T Walls.

At least 19 recordsLinked to original sources
PubMed1992

Time to first pulse after automatic implantable cardioverter defibrillator implantation.

Should automatic implantable cardioverter defibrillator (AICD) power sources be explanted and discontinued if they have not pulsed during the first generator life? We have followed 59 patients an average of 23 months (range, 3 days to 8.4 years) after AICD implantation. The indication for AICD implantation was based on clinical dysrhythmia, history of sudden death, and findings at electrophysiologic study. Thirty-eight of 59 patients (64%) had experienced sudden death and 52/58 (90%) were inducible at electrophysiologic study. Excluding 5 inappropriate pulsing episodes, 31 of 59 patients (53%) had 235 pulses (range, 1 to 36; median, 2 pulses). The time to first pulse after implantation ranged from 1 day to 3.5 years with a median time of 2 months. In 6 patients, the first pulsing occurred later than 1 year after AICD implantation. Fifteen generators demonstrating impending power source failure have been replaced in 11 patients. Power source depletion occurred at an average of 24.1 months (range, 8 to 40 months). In 3 patients, the first pulsing occurred after generator depletion and replacement. By univariate analysis, none of 13 variables (sex, age, cardiac disease process, functional class, previous myocardial infarction, sudden death history, ejection fraction, type of dysrhythmia, inducibility with electrophysiologic testing, number of extra stimuli required for induction, left ventricular aneurysm resection, endocardial resection, or concomitant operation) was found to be a predictor of pulsing (p greater than 0.05). We conclude that the majority of patients with pulses after AICD implantation will have them during the first 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Adolescent↗
PubMed1992

Heparin-induced thrombocytopenia in open heart surgical patients: sequelae of late recognition.

Most patients undergoing open heart operations have had exposure to heparin for diagnostic and/or therapeutic procedures. Heparin antibody formation and heparin-induced thrombocytopenia with repeat heparin administration can cause high morbidity and mortality from thrombotic complications, especially when delay in diagnosis occurs. From 1981 to 1991, heparin-induced thrombocytopenia was diagnosed in 82 of 4,261 open heart surgical patients (1.9%). Platelet counts less than 100 x 10(9)/L (100,000/microL) or new or recurring thrombotic events prompted suspicion of heparin-induced thrombocytopenia. Heparin-dependent antibody was diagnosed preoperatively in 12 patients (group I) and postoperatively in 70 patients (group II). Heparin was not given postoperatively in group I patients, and complications in this group were limited to bleeding in 3 patients. There were no thromboembolic events and all patients survived. Group II patients had late recognition of heparin-dependent antibody postoperatively, and heparin exposure was continued for varying periods postoperatively. Thirty-seven group II patients (53%) had bleeding complications and 31 (44%) had thromboembolic complications. These complications led to death in 23 group II patients (33%). Heparin-dependent antibody may occur in patients having open heart operations and is a major cause of morbidity and mortality if not diagnosed early with cessation of heparin therapy.

Acute Kidney Injury↗
PubMed1992

Experience with the Sarns centrifugal pump in postcardiotomy ventricular failure.

The reported clinical use of the Sarns centrifugal pump (Sarns, Inc./3M, Ann Arbor, Mich.) as a cardiac assist device for postcardiotomy ventricular failure is limited. During a 25-month period ending November 1988, we used 40 Sarns centrifugal pumps as univentricular or biventricular cardiac assist devices in 27 patients who could not be weaned from cardiopulmonary bypass despite maximal pharmacologic and intraaortic balloon support. Eighteen men and nine women with a mean age of 60.4 years (28 to 83) required assistance. Left ventricular assist alone was used in 12 patients, right ventricular assist in 2, and biventricular assist in 13. The duration of assist ranged from 2 to 434 hours (median 45). Centrifugal assist was successful in weaning 100% of the patients. Ten of 27 patients (37%) improved hemodynamically, allowing removal of the device(s), and 5 of 27 (18.5%) survived hospitalization. Survival of patients requiring left ventricular assist only was 33.3% (4/12). Complications were common and included renal failure, hemorrhage, coagulopathy, ventricular arrhythmias, sepsis, cerebrovascular accident, and wound infection. During 3560 centrifugal pump hours, no pump thrombosis was observed. The Sarns centrifugal pump is an effective assist device when used to salvage patients who otherwise cannot be weaned from cardiopulmonary bypass. Statistical analysis of preoperative patient characteristics, operative risk factors, and postoperative complications failed to predict which patients would be weaned from cardiac assist or which would survive.

Adult↗
PubMed1991

The effect of muscle-sparing versus standard posterolateral thoracotomy on pulmonary function, muscle strength, and postoperative pain.

Increased interest in alternative approaches to thoracotomy has developed because of the considerable morbidity associated with the standard posterolateral technique. We conducted a prospective, randomized, blinded study of 50 consecutive patients to compare postoperative pain, pulmonary function, shoulder strength, and range of shoulder motion between the standard posterolateral and the muscle sparing thoracotomy techniques. Pulmonary function (forced expiratory volume in 1 second and forced vital capacity), shoulder strength, and range of motion were measured preoperatively and at 1 week and 1 month postoperatively. Pain was quantitated by postoperative narcotic requirements, the visual analogue scale, and the McGill pain questionnaire. Morbidity, mortality, and hospital stay were compared between the standard posterolateral and muscle-sparing techniques. There were no differences in postoperative pulmonary function, shoulder range of motion, extent of lung resection, surgical approach time, mortality, or hospital stay. There was significantly less postoperative pain in the muscle-sparing group. The narcotic requirement was less in the first 24 hours (p = 0.0169), and visual analogue scale scores were significantly lower (p less than 0.05) throughout the first postoperative week. Shoulder girdle strength was decreased at 1 week in the standard incision group whereas the strength was preserved with the muscle-sparing approach. Muscle strength had returned to preoperative levels by 1 month in both groups. Morbidity was identical in the two groups with the exception of postoperative seromas. The prevalence of seroma was 23% in the muscle-sparing group and 0% in the standard incision group (p = 0.0125). We have demonstrated that the muscle-sparing incision may be a reasonable alternative to the standard posterolateral approach.

Double-Blind Method↗
PubMed1991

Centrifugal pump support for repair of thoracic aortic injury.

Spinal cord ischemia and the potential for paraplegia are always of concern during operations for repair of traumatic thoracic pseudoaneurysm. Patients who experience hypotension, loss of intercostal blood supply, or normothermic aortic cross clamp times greater than 30 minutes are more likely to become paraplegic. The preservation of renal perfusion is also a concern.

Adolescent↗
PubMed1991

Impact of unstable angina on operative mortality with coronary revascularization at varying time intervals after myocardial infarction.

We have performed a retrospective study of patients undergoing coronary artery bypass grafting for postinfarction angina in an effort to determine the influence of recency of myocardial infarction and unstable angina on operative mortality. Time from myocardial infarction to bypass was arbitrarily divided into five intervals. Nine hundred ninety-three patients having isolated coronary bypass for postinfarction angina were analyzed, and a significant trend of increased operative mortality with recency of myocardial infarction was found (p less than 0.001). When patients were operated on during the time interval zero to 24 hours after infarction, the operative mortality rate was 18.6%. In the interval from 1 day to 1 week after infarction, the operative mortality rate was 7.4%; 1 week to 3 weeks, 5.9%; and 3 weeks to 3 months, 2.7%. In patients operated on more than 3 months after infarction, the operative mortality rate was 3.9%. The operative mortality rate in 360 patients with postinfarction stable angina was 0.83% compared with 7.3% in 633 patients with postinfarction unstable angina (p less than 0.001). Of 18 risk factors tested, 12 were found by univariate analysis to be independent predictors of operative mortality, including recency of myocardial infarction and unstable angina. Stepwise logistic regression analysis of independent predictive variables revealed that unstable angina, previous surgical revascularization, preoperative hypotension, nonelective surgery, preoperative cardiac arrest, and female sex were the strongest predictors of mortality; recency of myocardial infarction was not a factor. When acute surgical reperfusion is not the primary treatment strategy for patients with myocardial infarction, operative mortality with coronary bypass is increased with the recency of myocardial infarction. The reason for this increase in operative mortality is a patient selection process in which those with persistent or intermittent myocardial ischemia, as reflected in the clinical syndrome of unstable angina, are selected for operation. Unstable angina is a major determinant of operative mortality after myocardial infarction. In patients with stable angina, operative mortality is not increased by the recency of myocardial infarction.

Adult↗
PubMed1990

Internal mammary artery graft to pulmonary vasculature fistula: a cause of recurrent angina.

Recurrent angina pectoris developed in a 59-year-old man 3 years after coronary artery bypass grafting using the left internal mammary artery. Cardiac catheterization showed a fistula between the left internal mammary artery and the pulmonary vasculature. This is an unusual documented case of postoperative internal mammary artery graft to pulmonary vasculature fistula after coronary artery bypass grafting. Division of this fistulous communication resulted in resolution of the patient's angina.

Angina Pectoris↗
PubMed1990

Heparin-induced thrombocytopenia in patients who undergo open heart surgery.

To determine whether heparin-dependent antiplatelet antibodies (HAAb) have an effect on morbidity and/or mortality rates, we reviewed the cases of 3438 patients who underwent open heart surgery from 1981 to 1989. Forty-six patients (1.3%) had HAAb. The patients were divided into two groups: those patients who were known to have HAAb before surgery (group I) and those patients who were diagnosed with HAAb after surgery (group II). Group I patients (n = 5) were pretreated with platelet-inhibiting drugs before reexposure to heparin during cardiopulmonary bypass and were maintained with strict abstinence from heparin afterward. Their lowest observed platelet counts ranged from 42,000/mm3 to 89,000/mm3 (median, 63,00/mm3). Thromboembolic complications did not occur, and all patients survived. Group II patients (n = 41) who were diagnosed to have HAAb after surgery had not been pretreated with platelet-inhibiting drugs before surgery. Lowest platelet counts ranged from 11,000/mm3 to 128,000/mm3 (median, 42,000/mm3). Bleeding complications occurred in 21 patients (51%), and thromboembolic complications occurred in 13 patients (32%). Hospital mortality in group II patients was 37%. Late recognition of HAAb was associated with an increase in morbidity and mortality rates. Thromboembolic complications of HAAb, which had been diagnosed before surgery, were eliminated, and bleeding was reduced by pretreatment with platelet-inhibiting drugs and strict abstinence from heparin after surgery.

Acute Kidney Injury↗
PubMed1989

Adverse effects of permanent cardiac internal defibrillator patches on external defibrillation.

At the time of left ventricular aneurysm resection, antiarrhythmic operations or other open-heart operative procedures in patients with ventricular dysrhythmia, permanent internal defibrillator patches may be inserted. Insertion of the energy source may be delayed due to its unavailability or to a desire for postoperative electrophysiologic study before its insertion. To assess the effects of permanent internal defibrillator patches on external defibrillation, 7 anesthetized calves were studied. Fibrillation-defibrillation studies were performed before and after insertion of permanent internal defibrillator patches (model L67, 27 cm2, Intec Systems), one on each ventricle. The values of percent successful defibrillation obtained before insertion of the patches, although much lower than values that would be expected in humans, are consistent with the results of an extensive earlier study involving this calf model. Similar values obtained after insertion of the patches are appreciably lower than the values obtained before implantation of the patches, and appreciably lower than the results predicted by the earlier study. A significant decrease in the percent of successful defibrillations (p less than 0.001) was observed for a shock intensity of approximately 400 J. Permanent internal cardiac defibrillator patches on the right and left ventricles reduce the probability of achieving successful defibrillation externally with unidirectional shocks. The wisdom of implanting permanent large internal cardiac defibrillator patches without the energy source is questioned.

Animals↗
PubMed1989

Elevated hemidiaphragm after cardiac operations: incidence, prognosis, and relationship to the use of topical ice slush.

We have reviewed chest roentgenograms of 745 patients before hospital dismissal after cardiac operations and serially to determine the incidence and prognosis of elevated hemidiaphragm and any relationship to the use of topical ice slush (TIS) in myocardial preservation. All patients had similar myocardial preservation techniques including moderate systemic hypothermia and 4 degrees C saline solution poured over the heart at aortic clamping. During a 12-month period, TIS was added to the saline bath. Two (2.4%) of 84 patients before TIS and 5 (2.5%) of 201 consecutive patients operated on since discontinuing TIS had elevated hemidiaphragm on the predismissal roentgenogram. Of 460 patients in whom TIS was employed, 109 (23.7%) had elevated hemidiaphragm (p less than 0.001). When TIS was employed, elevated hemidiaphragm developed in 72 (26%) of 280 patients without internal mammary artery takedown versus 13 of 33 patients (39.4%) with takedown of the internal mammary artery (p = 0.047). Ninety-nine patients with elevated hemidiaphragm were available for follow-up at 1 month, at which time 79 (79.8%) continued to have elevated diaphragm. At 1 year, 14 (21.9%) of 64 patients had persistent diaphragm elevation. We conclude that TIS predisposes to elevated diaphragm and that the incidence is increased when the internal mammary artery is harvested.

Coronary Artery Bypass↗
PubMed1989

Sarns centrifugal pump for repair of thoracic aortic injury: case reports.

A new centrifugal pump (Sarns), originally designed for ventricular assist, was successfully used in two patients during repair of traumatic pseudoaneurysm of the descending thoracic aorta. The distal thoracic aorta was perfused without heparinization to avoid spinal cord and visceral ischemia, reduce afterload on the heart, and avoid clamp injury to the aorta. Distal mean aortic pressure was maintained above 50 mm Hg with a mean pump flow of 1.75 liter/minute. Proposed structural advantages of the Sarns centrifugal pump for perfusion of the distal thoracic aorta without heparin are resistance to thrombus formation, air embolus, and hemolysis.

Accidents, Traffic↗
PubMed1989

Bronchopulmonary sequestration.

Bronchopulmonary sequestration is an area of lung parenchyma that is devoid of normal connection to the trachebronchial tree. Arterial supply is from an aberrant systemic artery, usually a branch of the aorta. There are two broad types of bronchopulmonary sequestration: intralobar and extralobar. The former shares a common pleura with the lung while the latter is separated by its own pleura. Definitive therapy requires pulmonary resection.

Bronchopulmonary Sequestration↗
PubMed1987

Transluminal balloon dilatation for discrete subaortic stenosis.

Ten children, 10 weeks to 18 years old, with discrete subaortic stenosis (DSS) underwent transluminal balloon dilatation of the subaortic obstruction. The DSS was visualized by 2-dimensional echocardiography and cineangiography. Six patients had a thin discrete "membrane" immediately below the aortic valve (group I) and 4 patients had a thicker fibromuscular ring about 1 cm below the aortic valve (group II). In group I, the mean gradient decreased from 82 +/- 49 mm Hg (range 35 to 164) to 22 +/- 15 mm Hg (range 5 to 40); in group II, it decreased from 155 +/- 18 mm Hg (range 132 to 177) to 85 +/- 44 mm Hg (range 60 to 150). Three patients had follow-up cardiac catheterization 1 year later. Their mean gradient soon after the procedure was 37 +/- 23 mm Hg. On follow-up, it was still 37 +/- 19 mm Hg, indicating persistence of relief of the obstruction. Because of the high residual gradient in group II, 3 patients had surgical relief of the obstruction. The degree of aortic regurgitation present before the dilatation in all 10 patients did not change after the procedure. The mechanism of relief of the obstruction was by tearing of the subaortic membrane. Our data suggest that relief of subaortic obstruction is more favorable in the thin, membranous DSS.

Adolescent↗
PubMed1987

Comparative survival following permanent ventricular and dual-chamber pacing for patients with chronic symptomatic sinus node dysfunction with and without congestive heart failure.

To determine whether survival following permanent ventricular demand pacing differs from survival following permanent dual-chamber pacing in patients with symptomatic sinus node dysfunction (unexplained sinus bradycardia, subsidiary rhythms, sinus arrest, sinoatrial block, or the bradycardia/tachycardia syndrome), we followed 79 patients who received a VVI pacemaker (group 1) and 49 patients who received a DVI or DDD pacemaker (group 2) for 1 to 5 years. There was no significant difference in sex distribution, mean age, or the incidence of coronary heart disease, hypertension, valvular heart disease, diabetes mellitus, stroke, or renal failure between groups 1 and 2. Overall, the predicted cumulative survival rates at 1, 3, and 5 years were 89%, 82%, and 74%, respectively, for group 1 and 94%, 86%, and 78%, respectively, for group 2. In patients with preexistent congestive heart failure (CHF), predicted cumulative survival rates at 1, 3, and 5 years were 78%, 69%, and 57%, respectively, for group 1 (n = 23) and 90%, 83%, and 75%, respectively, for group 2 (n = 16). Five-year predicted cumulative survival was significantly lower in group 1 patients with CHF than in group 2 patients with CHF (p less than 0.03). There was no significant difference in 5-year cumulative survival rates between groups 1 and 2 in patients without CHF. The results suggest that permanent dual-chamber pacing enhances survival to a greater extent than permanent ventricular demand pacing in patients with chronic symptomatic sinus node dysfunction and CHF.

Aged↗
PubMed1987

Morphologic effects of percutaneous balloon pulmonary valvuloplasty.

Five patients with pulmonary valve stenosis and other cardiac anomalies had elective operative repair after percutaneous balloon pulmonary valvuloplasty. Four had reduction in pulmonary valve gradients from 67 +/- 9 mm Hg to 39 +/- 9 mm Hg (P less than .01), whereas one patient with a dysplastic pulmonary valve did not. Operative evaluation of the pulmonary valves revealed the morphologic effects of the balloon forces on the stenotic valves to be commissure splitting in one patient, cusp tear in one patient, and a combination of commissure splitting and cusp avulsion in two patients. There were no deaths. Patients with combined infundibular and pulmonary valve stenosis have a high potential for cusp avulsion due to fixation of the balloon in the infundibulum and retraction of the balloon into the ventricle during systole. Echocardiography, cardiac catheterization pressure gradients, and cineangiography should be used to assess infundibular stenosis and avoid percutaneous balloon angioplasty in patients who have combined pulmonary valve stenosis and infundibular pulmonary stenosis.

Child, Preschool↗
PubMed1987

Operative balloon pulmonary valvuloplasty.

Closed operative pulmonary valvulotomy for relief of critical pulmonary valve stenosis can be performed effectively by intraoperative use of a balloon catheter without inflow occlusion or hemodynamic instability and with minimal blood loss. Follow-up evaluation indicates adequate growth of the valve.

Angioplasty, Balloon↗