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Biomedical subjects

M A DeRobertis

Publications and source records attributed to M A DeRobertis.

15 recordsLinked to original sources
PubMed2000

Twenty-year follow-up of patients with new perioperative Q waves after coronary artery bypass grafting.

It is unclear whether the development of new Q waves on the electrocardiogram after coronary artery bypass grafting (CABG) is associated with an adverse prognosis. We analyzed the 20-year survival of 227 patients who underwent CABG, and found that new perioperative Q waves had no impact on long-term survival; therefore, conservative management may be appropriate for uncomplicated patients with new Q waves after CABG.

Coronary Artery Bypass↗
PubMed2000

Regression of hypertrophy after Carpentier-Edwards pericardial aortic valve replacement.

BACKGROUND: The purpose of this study was to determine whether significant regression of left ventricular hypertrophy is seen after implantation of small sizes (19 to 23 mm) of the Carpentier-Edwards (CE) pericardial valve, a stented pericardial valve. METHODS: Echocardiograms and electrocardiograms (ECGs) were performed at least 1 year after surgery (mean 18 months) in patients with 19-, 21-, and 23-mm CE pericardial aortic valves and compared with preoperative echocardiograms and ECGs. RESULTS: A total of 41 patients, mean age 79 +/- 9 years (range 46 to 93 years), were studied, including 7 19-mm, 22 21-mm, and 12 23-mm patients. The mean postoperative gradient was 22 +/- 7 mm Hg for 19-mm valves, 18 +/- 5 mm Hg for 21-mm valves, and 16 +/- 4 mm Hg for 23-mm valves. The postoperative valve areas were 1.1 +/- 0.3 cm2 for the 19-mm, 1.3 +/- 0.3 cm2 for the 21-mm, and 1.5 +/- 0.4 cm2 for the 23-mm valves. Left ventricular end diastolic diameter, end systolic diameter, septal thickness, and posterior wall thickness all decreased significantly (p <0.05) postoperatively. The proportion of patients with significant left ventricular hypertrophy on ECG decreased from 63% to 47% (p = 0.001). Left ventricular mass decreased significantly by echocardiography from 265 g preoperatively to 208 g postoperatively (p = 0.004). Left ventricular mass decreased for each valve size, and the greatest absolute reduction in mass occurred in the 19-mm valve recipients. CONCLUSIONS: Implantation of the 19-, 21-, and 23-mm CE pericardial valves results in significant reductions in left ventricular mass. These findings suggest that stented pericardial valves can be used in the small aortic root without the need for aortic root enlargement procedures.

Aged↗
PubMed1998

Postinfarction ventricular septal defect.

Despite improved screening and diagnostic capabilities for the presence of coronary artery disease (CAD), with the promise of improved outcomes from earlier therapeutic interventions, postinfarction ventricular septal perforation (VSD) continues to be a very difficult therapeutic challenge. In our experience with VSD, the incidence of this complication per year has decreased, almost certainly related to earlier and more effective medical therapy in patients with CAD. By contrast, the outcomes of surgical repair have not improved, even with an aggressive strategy about bypassing involved coronary arteries. Furthermore, the earliest possible surgical approach and the incorporation of a number of technical advances, especially those relating to myocardial preservation, have not had an apparent effect. Because the number of patients who underwent operation is small, it is not possible from our single-institutional experience to define statistical significance to our continuing observations of this condition, suggesting that the clinical spectrum of postinfarction VSD is still evolving. Important changes appear to be associated with an increase in the number of female patients observed (60%), in contrast to their lesser frequency of uncomplicated coronary bypass (18%) and a change in the anatomic substrate, with posterior infarctions and rupture now accounting for 73% of cases at Cedars-Sinai. For the present, earliest possible surgical intervention to minimize the severity of multi-organ failure and use all of the advanced therapeutic modalities of cardiac support and surgical therapy that are available continues to be indicated. For the long term, continuing advances in the earlier diagnosis and more aggressive management of CAD, especially in females, may hold the best promise for a continued decrease in the occurrence of this very difficult-to-treat postinfarction complication.

Aged↗
PubMed1997

Cardiac operations in patients 90 years of age and older.

BACKGROUND: Growth of the elderly population worldwide, and specifically in the United States, will continue to accelerate and will have a profound impact on the cost and delivery of health care resources in the future. A medical strategy that allows the elderly to live independently is essential to most cost-effective use of our resources. The question remains as to what will be the future of surgical therapy for this increasing population. METHODS: We retrospectively studied the cases of 30 consecutive nonagenarians (mean age, 92.3 +/- 1.8 years) who underwent a cardiac operation within a 9-year period. All patients were in New York Heart Association class III or IV and underwent operation urgently or emergently. RESULTS: The 30-day mortality rate was 10%, and the actuarial survival rates were 81% +/- 8% and 75% +/- 9% at 1 year and 2 years, respectively. Seventy-eight percent of survivors were in New York Heart Association class I or II within 2 years after operation and had an improved quality of life. The cost of providing care in this age group was 24% higher than in octogenarians. CONCLUSIONS: Advanced age in and of itself (>90 years) should not be a contraindication to an open-heart operation, although morbidity, mortality, and cost may be higher. However, selective criteria identifying risks and benefits for individual patients should be applied. The aging of our population will have a profound impact on the cost and delivery of health care resources in the future. This issue must be addressed in the current debate on the provision of expensive procedures under a realigned national health-care system.

Actuarial Analysis↗
PubMed1994

Ten-year experience of cardiac surgery in patients aged 80 years and over.

Five hundred twenty-eight consecutive patients aged 80 years and over (mean age, 83.1 +/- 2.7 years) underwent cardiac operations with hypothermia (mean, 21.9 degrees +/- 2.2 degrees C), hyperkalemic cardioplegia, and cardiopulmonary bypass in a 10-year period. Fifty-six percent of the patients were male. Preoperatively, 68% of the patients were in New York Heart Association functional class IV, and 31% were in class III. Among them, 303 patients had isolated coronary artery bypass grafting (CABG) (group I), 132 had aortic valve replacement only or combined with CABG (group II), 42 had mitral valve replacement only or combined with CABG (group III), 31 had mitral valve repair and CABG (group IV), and 20 had double-valve procedure only or combined with CABG (group V). The 30-day or in-hospital mortality was 8.3% in group I, 4.5% in group II, 29% in group III, 23% in group IV, and 30% in group V. Total 30-day or in-hospital mortality was 10.6%. One-year and 5-year actuarial survival rates were as follows: group I, 82% and 62%; group II, 85% and 58%; group III, 61% and 37%; group IV, 56% and 19%; and group V, 63% and 15%. Total 1-year and 5-year actuarial survival were 79% and 54%. At follow-up (mean, 2 years), 70% of overall survivors reported that their general health had improved. Our experience demonstrates that for select patients aged 80 years and over with unmanageable cardiac symptoms, CABG and aortic valve replacement groups had better results in improving quality of life as compared with patients having mitral or combined procedures.

Actuarial Analysis↗
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↗
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↗
PubMed1987

Comparative clinical experience with porcine bioprosthetic and St. Jude valve replacement.

From 1976 to 1984, 656 patients underwent aortic, mitral, or double valve replacement with a Hancock or Carpentier-Edwards porcine bioprosthesis (POR; n = 293) or with a St. Jude bileaflet valve (SJ; n = 363). Recipients of the St. Jude valve were of more advanced NYHA class preoperatively, required smaller prosthetic sizes, and more often had associated coronary artery disease necessitating bypass grafting (p less than .05). Despite these differences, POR and SJ recipients demonstrated similar 30-day mortality (7.5 vs 10.2 percent), five-year freedom from embolism (92 +/- 2 percent vs 92 +/- 2 percent), freedom from all valve-related complications (79 +/- 3 percent vs 79 +/- 4 percent), and survival (72 +/- 3 percent vs 71 +/- 3 percent) (p = NS). Structural failures occurred exclusively in POR recipients (3.0-4.5 percent/pt-yr after four years), and endocarditis was more common (1.0 vs 0.5 percent/pt-yr); as a result, the reoperation rate was three times higher in POR than SJ recipients (1.4 vs 0.46 percent/pt-yr, p less than .05). Warfarin-related bleeding (2.5 percent/pt-yr) was the most common complication in SJ recipients, but occurred equally frequently in POR recipients requiring anticoagulation; seven (44 percent) of 16 valve-related late deaths were warfarin-related. In properly anticoagulated patients, the thromboembolic rate was low (2.0 percent and 1.1 percent/pt-yr, POR and SJ); this rate increased significantly in SJ recipients receiving antiplatelet drugs alone (4.2 percent/pt-yr; n = 16) or no anticoagulant or antiplatelet therapy (26.4 percent/pt-yr; n = 18) (p less than .05), but increased only slightly in POR recipients (to 1.5 percent/pt-yr, n = 108, and 2.0 percent/pt-yr, n = 63, respectively). Postoperatively, NYHA class 1 was more often achieved in SJ than POR recipients (60 vs 39 percent, p less than .05), perhaps because of the better hemodynamic performance of the SJ valve. Thus, despite differences in patient selection and the nature of complications observed with each prosthetic type, porcine and St. Jude valves provide similar early and late survival, frequency of embolism, total complication rate, and freedom from valve-related morbidity and mortality after five years of follow-up. Limited durability, susceptibility to infection, and inferior hemodynamics remain drawbacks to use of the porcine bioprosthesis. The necessity for warfarin anticoagulation and the frequency of resultant bleeding complications are the major shortcomings of the St. Jude valve.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1986

Combined valve and coronary artery bypass procedures in septuagenarians and octogenarians: results in 120 patients.

A consecutive series of 96 septuagenarians (mean age, 74) and 24 octogenarians (mean age, 83) underwent coronary artery bypass (CAB) and valve operations using hypothermia and hyperkalemic cardioplegia in a 45-month period; there was a mean of 2.6 grafts per patient. Most patients were in New York Heart Association (NYHA) class IV (57% of the septuagenarians and 88% of the octogenarians) preoperatively. The early deaths were 19% for septuagenarians and 37% for octogenarians; late deaths were 9% and 6%, respectively, after a mean of 25 months. Of 92 survivors, 78% of the septuagenarians and 87% of the octogenarians improved by one or more NYHA class postoperatively. Of 58 patients with combined CAB and aortic valve replacement, 12 (21%) died; of 38 with combined CAB and mitral valve replacement 19 (50%) died; 2 of 9 (22%) with combined CAB and double valve replacement died; and 2 of 11 (18%) with CAB and MV repair died. In comparison, of patients with isolated valve replacement in the same period, 2 of 30 (7%) in the AVR group died, 5 of 17 (29%) died in the MVR group, 2 of 7 (33%) in the DVR group died. The risk of combined valve procedures and bypass surgery was significantly increased in the elderly and may warrant a less aggressive procedure, especially in the mitral position.

Aged↗
PubMed1986

Hemodynamic differentiation of pathologic and physiologic stenosis in mitral porcine bioprostheses.

Porcine bioprostheses are physiologically stenotic valves. Degenerative calcification leading to pathologic stenosis is an increasingly recognized serious late complication of mitral valve replacement with a porcine bioprosthesis. Hemodynamic differentiation of pathologic from physiologic stenosis is important for identification of porcine bioprosthetic valve dysfunction. In 42 patients with a normal Hancock porcine bioprosthesis (standard model, sizes 27 to 33 mm), mean diastolic flow (65 to 461 ml/s), mean gradient (2.0 to 13.4 mm Hg) and effective orifice area (1.1 to 4.4 cm2) were determined at rest, during epicardial pacing (90, 110 and 130/min) and with isoproterenol infusion. A statistically significant increase in mean gradient occurred with increases in flow and decreases in valve size (p less than 0.05). Effective orifice area increased significantly as flow rate increased and as valve size increased (p less than 0.05). These measurements were compared with those in 16 patients with pathologically confirmed porcine bioprosthetic valve stenosis: 8 patients with reoperation (1.1% per patient-year) 3 to 8.5 years after mitral valve replacement and 8 previously reported abnormal cases. Stenotic failure rate was inversely related to valve size (2.1, 1.4, 0.5 and 0% per patient-year for sizes 27 to 33 mm). Stenotic and normal bioprostheses were not accurately differentiated on the basis of a single value for gradient or effective orifice area. A mathematical model that related flow to the square root of the mean gradient allowed complete separation of stenotic from normal prosthetic valve function, after valve size was accounted for and normal confidence limits were established (r = 0.74 to 0.94, sizes 27 to 33, p less than 0.0001). The effective orifice area-flow relation did not provide accurate differentiation of abnormal from normal function. Thus, normal mitral bioprostheses have significant transvalvular gradients whose magnitude depends on flow. Risk of stenotic failure is increased in the smaller valves, which have a larger gradient at implantation. Differentiation of pathologic from physiologic stenosis cannot be made on the basis of a single value for gradient or effective orifice area. Accurate hemodynamic differentiation is achieved by relating mean gradient to mean diastolic flow rate and valve size.

Bioprosthesis↗
PubMed1984

The St. Jude Medical bileaflet valve prosthesis. A 5 year experience.

A 5 year experience with the bileaflet St. Jude Medical valve is reported. Between March, 1978, and June, 1982, 198 patients received 233 such valves (90 mitral, 73 aortic, and 35 double mitral-aortic valve replacements). Total follow-up was 4,896 patient-months; survivors were followed up for 1 to 5 years (mean 35 months). Early (30 day) mortality was 6.6% overall and 11.1% after mitral, 2.7% after aortic, and 2.9% after double valve replacement. Total late mortality was 15.2%; the actuarial survival rate at 4 years was 67% after mitral, 79% after aortic, and 79% after double valve replacement. Ischemic mitral valve disease was associated with an early mortality of 26.7% and a 4 year survival rate of 34%; without this high-risk subset, early mortality was 3.3% and the 4 year survival rate was 77% after mitral valve replacement. A multivariate logistic regression model identified three preoperative patient characteristics associated with increased postoperative mortality: ischemic mitral valve disease (p less than 0.001), a depressed left ventricular ejection fraction (less than 55%; p less than 0.05), and advanced New York Heart Association class (IV; p less than 0.05). Valve-related complications occurred in 14 patients (3.4% per patient-year). There were no instances of primary structural failure or hemolysis. Thromboembolism (nine patients, 2.2% per patient-year) occurred more frequently after double (3.7% per patient-year) or mitral valve replacement (2.3% per patient-year) than after aortic valve replacement (1.3% per patient-year) and more frequently in 12 patients receiving aspirin and dipyridamole (6.5% per patient-year) than in 173 patients receiving warfarin (1.9% per patient-year). No thromboembolic event was fatal. Reoperation was necessary because of one valve thrombosis, one valve erosion, and two perivalvular leaks due to endocarditis; three of the four patients survived reoperation (one valve-related death, 0.5%). Of 154 patients alive at latest follow-up, 85% were in New York Heart Association Class I or II, and 90% had improved by at least one class. This intermediate experience with the St. Jude Medical valve indicates that, in addition to its previously demonstrated excellent hemodynamic performance, there have been no instances of primary structural failure or hemolysis. Warfarin anticoagulation is recommended in all patients.

Adolescent↗
PubMed1984

Mitral valve replacement: impact of coronary artery disease and determinants of prognosis after revascularization.

From 1969 to 1982, 419 patients underwent single mitral valve replacement; of these, 48% had associated coronary artery disease (9% single vessel, 8% double vessel, 28% triple vessel, 3% left main). In 216 patients with no associated coronary disease, in 179 patients with coronary disease that was revascularized, and in 24 patients with coronary disease that was not revascularized, the 30 day mortalities were 4.2%, 13.9%, and 29.2% (p less than .05) after valve replacement. Actuarial survivals at 8 years were 68%, 44%, and 15%, respectively (p less than .01), with 1 to 165 months of follow-up (mean 52). After matching the three cohorts of patients in age, sex, left ventricular ejection fraction, and valve lesion, the presence of associated coronary artery disease decreased long-term survival and revascularization improved survival (p less than .05 for both). Incidental coronary disease in patients with rheumatic mitral valve disease had a significant negative influence on survival if left unbypassed (p less than .05); after revascularization and valve replacement, the 30 day mortality was 7.3% and the 8 year survival was 52%. Coronary disease etiologically related to ischemic mitral regurgitation identified a high-risk group of patients, with a 30 day mortality of 19.6% and an 8 year survival of 37% after the combined procedure. A multivariate logistic regression model was used to determine which preoperative and intraoperative variables predicted early and late outcome after combined mitral valve replacement and coronary revascularization. Predictors of early death were advanced age (greater than 60 years), New York Heart Association functional class (IV), an ischemic etiology of the mitral valve disease, and a depressed left ventricular ejection fraction (less than 55%). Predictors of late death were triple-vessel or left main coronary disease, increased left ventricular end-diastolic volume (greater than 120 ml/m2), and depressed left ventricular ejection fraction (less than 55%). These findings highlight the important etiologic and prognostic role of coronary artery disease in patients requiring mitral valve replacement.

Adolescent↗
PubMed1983

Regional distribution of pulmonary blood volume: an index of pulmonary capillary wedge pressure determined from blood pool scintigraphy.

Progressive redistribution of pulmonary blood flow to the lung apices occurs with increasing degrees of left ventricular failure, and correlates with increasing pulmonary capillary wedge pressure (PCWP). If similar changes in pulmonary blood volume (PBV) occur, then technetium-99m equilibrium blood pool scintigraphy, by assessing relative distribution of PBV, may allow prediction of PCWP. Therefore 30 patients being monitored with pulmonary artery balloon flotation catheters underwent imaging. PCWP was compared with the average radioactive count density arising from apical (A) and basal (B) regions of interest within the right lung, expressed as an A/B ratio. Correlation was strong for patients imaged erect, either posteriorly (r = 0.864, p = 0.001) or in the 45 degrees left anterior oblique position (r = 0.842, p = 0.001), and only slightly less impressive for patients imaged supine (r = 0.678, p = 0.001). Especially when imaging was performed with patients erect, an A/B ratio greater than unity identified with high sensitivity (100%) and specificity (83 to 88%) an abnormally elevated PCWP (greater than 12 mm Hg). Moreover, directional changes in the A/B ratio reflected concomitant changes in PCWP after intervention. Thus, analysis of lung A/B radioactive count ratios obtained by equilibrium blood pool scintigraphy may be used to evaluate PCWP.

Adult↗
PubMed1983

Noninvasive detection of active pericardial bleeding using cardiac blood pool scintigraphy.

The diagnosis of active pericardial bleeding has traditionally depended on an invasive documentation by needle aspiration, angiography, or direct inspection. Blood pool scintigraphy performed in 2 patients just before and after the development of hemopericardium revealed unique images in which acute pericardial bleeding manifested itself by an additional blood pool adjacent to the cardiac chambers. With appropriate attention to technical factors, such distinctive images should be highly specific for active bleeding into the pericardial sac.

Aged↗