Biomedical subjects
Publications and source records attributed to K V Arom.
This communication stepwise describes transatrial cannulation of the coronary sinus, a technique that we found to be very simple, fast, reproducible, and free of complication.
The cases of 100 consecutive patients who underwent coronary artery bypass grafting with coronary sinus (retrograde) cardioplegia (group R) without the antegrade-retrograde approach were reviewed. To evaluate the safety and the efficacy of this technique, another 100 consecutive patients who underwent a similar procedure but with conventional aortic root (antegrade) cardioplegia (group A) were used as a comparison. The two groups were similar with respect to age, male to female ratio, associated medical problems, extent of coronary artery disease, mean preoperative ejection fraction (0.56 +/- 0.13 versus 0.53 +/- 0.18), pump time (113.1 +/- 43 versus 111.7 +/- 38 minutes), aortic cross-clamp time (57.4 +/- 20 versus 60.8 +/- 23 minutes), number of grafts per patient, level of hypothermia, complication rate, rate of postoperative myocardial infarction (4% versus 3%), and mortality rate (2% versus 2%). Hemodynamic measurements were made 6 hours after operation in 59 patients in group R and 47 patients in group A. The cardiac index, left ventricular stroke work index, and right ventricular stroke work index were better in group R but not significantly so (p greater than 0.05). However, only 27% of patients in group R required a temporary pacemaker, and only 9% needed inotropic agents after 6 hours of operation in contrast to 51% and 42%, respectively, in group A (p less than 0.05). There were no complications from catheter intubation. In group R, right ventricular wall temperature (11 degrees +/- 3.6 degrees C) was higher than the septal (10.8 degrees +/- 3.2 degrees C) and left ventricular wall temperatures (9.1 degrees +/- 2.8 degrees C) (p greater than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
From October 1985 through December 1989, 92 heart transplant procedures were performed in 89 patients. Nine patients (aged 19 to 66 years; 7 male, 2 female) required mechanical circulatory support after transplantation because of primary idiopathic organ failure (n = 2), implant difficulty (2), poor organ quality (2), or acute right heart failure (3). Devices used included the intraaortic balloon pump (6), centrifugal right ventricular assist device (2), left ventricular assist (1), biventricular assists (2), and total artificial heart (1). Two patients required multiple devices. One patient underwent retransplantation. Implant time ranged from 1 to 18 days. One early death occurred owing to right heart failure 6 days after transplantation, 7 hours after removal of a right ventricular assist device, for an overall mortality of 11%. The remaining 8 patients are alive 4 months to 28 months after transplantation. The actuarial 1-year survival of 89% +/- 10% compares well with the survival of 87% +/- 4% for the entire transplant group. All surviving patients are in functional class I. Echocardiographic examination in all patients revealed left ventricular ejection fraction to be normal in 7 and depressed in 1. Extending the criteria for organ donors or difficulty with the implant procedure can lead to early organ failure, which may be reversible with circulatory assistance allowing excellent survival.
Six patients with end-stage emphysema (age 44 +/- 2 years) underwent double lung transplantation (Tx) from June 1988 through May 1990. All suffered from severe inanition and required oxygen therapy. The ischemic time was 193 +/- 28 minutes. Post-Tx immune suppression was OKT3 (14 days), cyclosporine (trough levels of 150 +/- 25 ng/ml), azathioprine to keep WBC at 3,000 to 5,000/cu mm (1 to 3.0 mg/kg/day) and following OKT3, a tapering prednisone regimen. Two rejection episodes that occurred in two patients on post-Tx day 5 and 10 were treated with bolus doses of methylprednisolone. The mean hospital stay was 32 +/- 7 days (range, 20 to 69 days). Four patients required treatment of cytomegalovirus (CMV) infection: gastritis (+donor, +recipient) in one and CMV pneumonia in two (+donor, -recipient). A fourth (+donor, -recipient) had right-sided Candida empyema six weeks post-Tx, developed CMV and staphylococcal sepsis, and died 64 days post-Tx. One patient required pyloroplasty eight weeks post-Tx and one patient underwent tracheal suture line repair at eight weeks. During a follow-up of 81 patients months (range, 8 to 24 months), one patient had developed Epstein-Barr viral (EBV) induced lymphoproliferative disease in the lung and one patient had developed EBV lymphoma. Three patients are at work, one is continuing rehabilitation, and one is at home. Double lung Tx offers a definitive benefit to patients with emphysema; however, a prolonged postoperative course can be expected. Viral infections remain serious but treatable problems.
Emergency percutaneous cardiopulmonary bypass support was instituted in 11 patients in cardiac arrest refractory to conventional resuscitation measures. Emergency percutaneous cardiopulmonary bypass support was used in five patients in whom cardiac arrest occurred as a result of a complication in the cardiac catheterization laboratory (group 1) and in six other patients in cardiac arrest (group II). A 21F cannula and a 17F cannula were percutaneously inserted into the femoral vein and artery. Flow rates of 3 to 5 L/min were achieved with restoration of mean arterial pressure to 70 mm Hg (range 50 to 75). The status of all 11 patients was improved initially both clinically and hemodynamically with percutaneous cardiopulmonary bypass. Of the group II patients, three had anatomy unsuitable for percutaneous transluminal coronary angioplasty or coronary bypass grafting, could not be weaned from cardiopulmonary support, and died; three of these patients had coronary artery bypass grafting and two survived. All five group I patients underwent successful coronary bypass grafting and survived. Of the seven patients with anatomically correctable disease, all seven were discharged from the hospital. With conventional management nearly all seven of these patients would have died. Nine of 11 patients underwent a cardiac operation and seven of the nine survived. The operative mortality rate was 22% and the overall survival rate was 64%. At follow-up (mean 7 months), all seven patients are alive and six have resumed a normal and active life-style. In conclusion, emergency percutaneous cardiopulmonary bypass support is a powerful resuscitative tool that may stabilize the condition of patients in cardiogenic shock and cardiac arrest to allow for definitive intervention.
Historically, the healing of tracheal or bronchial anastomoses has been the Achilles heel in pulmonary transplantation. In the past, steps taken to enhance healing of these structures and have allowed single-lung, double-lung, and heart-lung transplantation to be accomplished safely. This report presents a simplified technique for protection of the tracheal anastomosis in heart-lung and double-lung transplantation. This technique, wherein the pericardial fat pad from the right side is utilized to wrap the tracheal anastomosis, not only allows for excellent healing of the anastomosis but separates the aorta from the trachea. In 19 patients having heart-lung (N = 13) or double-lung (N = 6) transplantation there were no tracheal healing problems, dehiscence or stenosis found.
Records of 1,298 consecutive patients who had received the St. Jude Medical prosthesis were reviewed (713 male and 585 female patients; mean age, 61.79 +/- 13.4 years). Early mortality was 5.7% (74 patients). Ninety-three percent complete follow-up was accomplished for the 1,224 patients who left the hospital (4,306.50 patient-years). One hundred ninety-two of these patients died, a late mortality of 16.9%. Sixty-four patients experienced thromboembolic episodes (17 major and 35 permanent). Twenty-four patients had anticoagulant-related bleeding, 4 had valve thrombosis, 7 had prosthetic valve endocarditis, 9 had paravalvular leak, and 10 underwent reoperation. There was no structural valve failure in this series. Twenty-two of the 118 patients who had valve-related complications died; another 15 patients died of sudden and unknown causes. Therefore, the total number of valve-related deaths was 37. Of those patients who survived, New York Heart Association functional class improved significantly (98% in classes II and III preoperatively and 96% in classes I and II postoperatively). Linearized rates for thromboembolism, valve thrombosis, and anticoagulant-related bleeding were 1.49% +/- 0.19%, 0.09% +/- 0.05%, and 0.56% +/- 0.11%/100 patient-years, respectively. The actuarial estimate of incidence free from all complications, operative death, and valve-related death was 66.9% +/- 8.2% at the end of 9 years. In spite of old age and advanced heart disease, the patients who received the St. Jude Medical prosthesis had very good results over a 10-year period.
Neurological complications of cardiopulmonary bypass procedures are well documented. The present two-part study was undertaken to (1) determine if on-line computerized electroencephalographic changes correlated with neurological outcome and (2) compare neurological outcome with that of a second group of patients who received intraoperative interventions based on electroencephalographic data. Part 1 consisted of monitoring 50 patients. A power drop index was developed that correlated with new global neurological deficits. New global deficits occurred in 44% of the patients. In part 2, this information was used to design intervention criteria. Treatment protocols used previously accepted methods of increasing cerebral blood flow, ie, increasing pump flow, raising mean arterial pressure, and increasing CO2 content in the ventilator blend. Global neurological deficits were reduced to 5% in a group of 41 clinically similar patients (p less than 0.001). Cerebral perfusion pressures were similar in both groups. The single correlating factor was the power drop index as identified by computerized EEG. Our conclusion is that simple intervention guided by computerized EEG can reduce global neurological deficits in patients having cardiopulmonary bypass procedures.
Records of 100 consecutive patients who had received double valve replacement were reviewed (41 men, 59 women, mean age, 60.86 +/- 13.0 years). The early death rate was 6% (six patients). A completed follow-up rate of 93% was accomplished in these 94 patients who left the hospital (mean, 309.8 patient-years). Twenty-three of these patients died. The late death rate was 26.4%. Four patients experienced thromboembolic episodes (one transient and three permanent; all were minor). One patient had a paravalvular leak (mitral), and another had thrombosis of the tricuspid valve. There was no clinical evidence of hemolysis, infective endocarditis, or structural failure or anticoagulant-related bleeding. One of those 23 patients who died was the patient who had thrombosis of the tricuspid valve. Another three patients died of sudden and unknown causes, 15 of cardiac-related problems and four of noncardiac problems. Of those patients who survived, New York Heart Association functional class improved significantly (from 66% class III before to 85% class I after). Linearized rates for thromboembolism and thrombosis were 1.29 +/- 0.65 and 0.32 +/- 0.32 per 100 patient-years, respectively. The actuarial estimates of incidence free of all complications and valve-related deaths were 77.9% +/- 10.6%. Despite the advanced heart disease involving two native valves, the patients who had double valve replacement with the St. Jude Medical prosthesis had very good results over a 10-year period.
Despite the hemodynamic improvement in cardiac valve prostheses, valve-related deaths and complications have remained a substantial source of morbidity and mortality. This follow-up study was carried out in April, 1986, in a group of 816 patients who received 876 St. Jude Medical prostheses between October, 1977, and October, 1984. One hundred fifty-five patients (37%) of the 422 having aortic valve replacement (AVR) and 88 (29%) of the 300 having mitral valve replacement (MVR) had concomitant coronary artery bypass grafting, and 94 patients (12%) had miscellaneous procedures performed in addition to valve replacement. Sixty-three patients died within the operative period, an operative mortality of 7.7%. Follow-up was complete for 98% of the patients; the mean follow-up was 42 months. At that time, 87 more patients had died, a late mortality of 11.9%. There were 13 valve-related deaths (4 in the AVR group, 7 in the MVR group, and 2 in the miscellaneous group); the causes of death were thromboembolism (7), anticoagulant-related hemorrhage (2), valve thrombosis (2), prosthetic valve endocarditis (1), and perivalvular leak (1). There were 37 thromboembolic episodes (1.78/100 patient-years) and 67 anticoagulant-related hemorrhages (3.22/100 patient-years), 46% of which necessitated transfusion. The incidence of valve thrombosis was 0.6% (4 patients). Perivalvular leak and prosthetic valve endocarditis occurred in 7 patients (1.0%) and 5 patients (0.7%), respectively. Reoperation was carried out in 6 patients (0.8%), but only for perivalvular leak. There were no deaths, no complications, and no clinical evidence of malfunction of the prosthetic valve.(ABSTRACT TRUNCATED AT 250 WORDS)
A prospective randomized trial was conducted comparing the effect of three antibiotics: cefamandole (CM), cefazolin (CZ), and vancomycin (V), used as prophylaxis for prosthetic valve surgery, on the prothrombin (PT) response to warfarin (W) on the third day of anticoagulant therapy. Twenty patients, with normal preoperative PTs, were randomized to each antibiotic. Their PTs were not significantly different at 2 hours after operation and the morning before W was begun. The three groups received similar W doses for 2 days, and the PT, as percentage of activity, on the morning of the third day demonstrated that V (51 +/- 18%) was significantly greater (p less than 0.005) than CM (29 +/- 14%) or CZ (38 +/- 18%). CM had a significantly greater percentage of change in PT (64 +/- 14%, p less than 0.0001) from the first to third day than either CZ (51.1 +/- 18%) or V (44.6 +/- 19%). CM also had a greater number of patients (6) with PTs greater than or equal to 30 seconds on day 3 than either CZ (1) or V (1). The antibiotic influence on the PT response to W in this study is ranked as CM greater than CZ greater than V.
The efficacy of cefamandole and cefuroxime in preventing postoperative wound infections was compared in 3037 patients undergoing open-heart surgery. Antibiotic prophylaxis in 1467 patients having coronary artery bypass and valve replacement surgery was cefamandole 2 g iv preoperatively followed by 2 g q6h for five days postoperatively; 1570 patients received cefuroxime 1.5 g iv preoperatively then 1.5 g iv q 12h for three days postoperatively. Postoperative wound infections (sternal and leg wounds) were studied in each treatment group. In the cefamandole study group, 27 patients (1.8 percent) developed postoperative wound infections (9 sternal and 18 leg wounds). In the cefuroxime treatment group, 19 patients (1.2 percent) developed postoperative wound infections (9 sternal and 10 leg wounds). Overall, no statistical difference was found between the two antibiotics in preventing postoperative wound infections. However, in patients having valve replacement surgery, cefuroxime was found statistically more effective than cefamandole prophylaxis in preventing sternal wound infections (no infections in 284 patients compared with five infections in 205 patients, respectively, p = 0.01). The most common organism isolated from infected wounds with cefamandole was Staphylococcus aureus followed by S. epidermidis compared with cefuroxime which had S. epidermidis followed by S. aureus. Cefuroxime was found to be as effective as cefamandole and considerably less expensive in preventing postoperative wound infections in patients undergoing open-heart surgery.
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The cases of 680 consecutive patients who underwent valve replacement with the St. Jude Medical prostheses by one group of surgeons from October 1977 through October 1983 were reviewed. The operative mortality for the entire group was 6.6% (3.7% for aortic valve replacement [AVR], 1.6% for AVR and coronary artery bypass [CAB], 14.3% for AVR and miscellaneous procedures; 7.9% for mitral valve replacement [MVR], 15.5% for MVR and CAB, 33% for MVR and miscellaneous procedures; 5% for double valve replacement [DVR], 8.3% for DVR and CAB, and 0% for DVR and miscellaneous procedures). Warfarin (Coumadin) anticoagulation was recommended for all the patients. The mean follow-up of 24 months was completed in 95% of the patients (14,737 patient-months). The overall late mortality was 7.7% (6.2% for AVR, 6.3% for AVR and CAB, 8.3% for AVR and miscellaneous procedures; 7.9% for MVR, 6.7% for MVR and CAB, 33% for MVR and miscellaneous procedures; 15.8% for DVR, 18.2% for DVR and CAB, and 0% for DVR and miscellaneous procedures). There were no cases of mechanical prosthetic failure. Clinically significant hemolysis occurred in only five patients (less than 1%) with paravalvular leak after MVR. Only three patients (less than 0.5%) experienced prosthetic infection. Incidence of embolization was 0.7 per 100 patient-years in the patients who underwent AVR and 2.2 per 100 patient-years in those who underwent MVR.(ABSTRACT TRUNCATED AT 250 WORDS)
From 1968 to 1978, 14 patients were treated for major tracheal or bronchial injury. Five injuries resulted from blunt trauma and nine from penetrating injury. Of the 5 patients with injury due to blunt trauma, three had avulsions of the right main bronchus from the trachea. In 2 of them, the injury was associated with stellate tears of the distal trachea and bronchus. The simple avulsion was repaired by a primary anastomosis of the right main bronchus to the distal trachea. For the other 2 patients, treatment consisted of right pneumonectomy. The remaining 2 patients in this group had complete transection of the trachea and underwent primary repair. Of the 9 patients with a penetrating injury, 4 had lacerations of the cervical trachea which were treated with neck exploration and tracheostomy. Three patients with partial transections of the cervical or upper mediastinal trachea were treated by primary closure. The other 2 patients had gunshot wounds to the distal right lateral trachea, which were treated by right thoracotomy and primary closure. There were no deaths, and the subsequent course was generally good in all patients.
Every week, 8 conscious, chronically instrumented dogs underwent left ventricular (LV) function studies before, during, and after cardiac irradiation with cobalt 60 (myocardial dose of 5,000 rads at 200 rads per day through a 5 X 5 cm port). During the weekly LV function studies, left atrial pressures were raised by rapid infusion of balanced saline solution. Heart rate, aortic pressures, left and right atrial pressures, LV pressure, left ventricular end-diastolic pressure (LVEDP), and maximum rate of rise of LV pressure were recorded. Electrocardiograms were made. Cardiac outputs were obtained by thermodilution. Stroke volume, LV stroke work, and LV minute work were calculated. LV function curves were constructed each week. All dogs lost weight and became irritable after approximately 800 rads. The electrocardiograms showed signs of myocardial injury after 1,200 rads. All variables were slightly depressed during the first 8 weeks following irradiation. At the eleventh week, both left atrial pressure and LVEDP increased significantly and LV function declined. There was also clinical evidence of LV failure at rest and after volume loading. This study documents that external cardiac irradiation, in a therapeutic dose and schedule range, causes depression of LV function. These functional changes were partially reversed when the follow-up study was continued to six months after irradiation.
During the 10-year period ending 1 March 1978, 100 consecutive patients with penetrating cardiac wounds entered the Bexar County Hospital with some sign of life. The early and late mortality rate, 11%, declined to 8% during the last 4 years. Noncardiac injuries were responsible for six of the eleven deaths. Complications occurred in 17. The most frequently injured chambers were the right ventricle (46) and left ventricle (30). Sixty-nine patients had stab wounds and 26 had gunshot wounds. Pericardiocentesis was falsely positive or negative in 12 of 47 patients. Two distinct syndromes were apparent, hemorrhagic shock and cardiac tamponade. Patients with shock had immediate thoracotomy. Patients with suspected tamponade had a subxiphoid pericardial window, under local or light general anesthesia, for diagnosis and decompression before endotracheal intubation and sternotomy. Most wounds were repaired by direct suture. Cardiopulmonary bypass and thoracotomy before arrival in the operating room were rarely indicated.
This study was undertaken to determine if the production of pulsatile flow by the intra-aortic balloon pump during cardiopulmonary bypass has any beneficial effect on coronary flow, regional myocardial flow, myocardial metabolism, and left ventricular function. Thirty-six conditioned dogs were subjected to one hour of total normothermic cardiopulmonary bypass. They were divided into the following five groups: (1) controls, beating heart and femoral inflow; (2) balloon, beating heart, and femoral inflow; (3) balloon, beating heart, and aortic inflow; (4) control, fibrillating heart and femoral inflow; and (5) balloon, fibrillating heart, and femoral inflow. Total coronary flow, left ventricular flow, coronary sinus flow, and the endocardial-to-epicardial flow ratio increased in group 3. This increase in flow may have been in part due to increased resistance to flow in the descending aorta by the balloon. No differences in flow were noted in the other groups, all of which were perfused via the femoral artery. No significant differences in myocardial metabolism or left ventricular contractility could be demonstrated between balloon-treated and control groups in these normal hearts.