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Biomedical subjects

M Kirsh

Publications and source records attributed to M Kirsh.

18 recordsLinked to original sources
PubMed1992

Cardiogenic shock complicating acute myocardial infarction: the use of coronary angioplasty and the integration of the new support devices into patient management.

Conventional therapy for cardiogenic shock complicating acute myocardial infarction continues to be associated with a high in-hospital mortality rate. Hemodynamic support with new mechanical devices and emergency coronary revascularization may alter the long-term prognosis for patients with this complication. Between July 1985 and March 1990, 68 patients presented to the University of Michigan with acute myocardial infarction and cardiogenic shock. Interventions performed included thrombolytic therapy (46%), intraaortic balloon pump counterpulsation (70%), cardiac catheterization (86%), coronary angioplasty (73%), emergency coronary artery bypass grafting/ventricular septal defect repair (15%), Hemopump insertion (11%), percutaneous cardiopulmonary support (4%) and ventricular assist device (3%). The 30-day survival rate was significantly better in patients who had successful angioplasty of the infarct-related artery than in patients with failed angioplasty (61% vs. 7%, p = 0.002) or no attempt at angioplasty (61% vs. 14%, p = 0.003). This difference was maintained over the 1-year follow-up period. The only clinical variable that predicted survival was age less than 65 years. The early use of the new support devices in 10 patients was associated with death in 8 (80%), but this poor outcome may reflect a selection bias for an especially high risk population. Collectively, these recent data continue to suggest that emergency revascularization with angioplasty may reduce the mortality rate, but further study is required to define optimal utilization and integration of new support devices.

Aged↗
PubMed1992

Outcome of endocardial resection in 33 patients with coronary artery disease: correlation with ventricular tachycardia morphology.

The results in 33 patients with ventricular tachycardia (VT) treated by endocardial resection were reviewed, with special emphasis on the presence of single or multiple morphologies preoperatively and intraoperatively. Multiple VT morphologies were induced in 16 patients and a single VT morphology was induced in the remaining 17. Intraoperative programmed stimulation failed to induce VT in eight patients and visually-directed endocardial resection was performed. The remaining patients underwent map-guided resection. The surgical success rate did not correlate with any morphologic characteristics of the VT, such as bundle branch block pattern or axis. In addition, concordance of VT morphologies preoperatively and intraoperatively before resection did not correlate with the surgical success rate. However, patients in whom multiple morphologies of VT were induced intraoperatively had a significantly higher success rate (100%) compared with those patients in whom only a single morphology was induced intraoperatively (50%, p < 0.05). Long-term follow-up was maintained in 26 patients. Ventricular tachycardia recurred in two patients and VF recurred in two others who did not have inducible VT 1 week after endocardial resection. In conclusion, neither the preoperative morphologic characteristics of VT nor discordance between the morphologies of VT induced preoperatively and in the operating room influenced the outcome of endocardial resection. However, the surgical success rate is higher when multiple morphologies of VT are inducible in the operating room than when only one VT morphology is inducible.

Adult↗
PubMed1992

Clinical outcome of patients with advanced coronary artery disease after viability studies with positron emission tomography.

OBJECTIVE: The aim of this study was to determine the prognostic significance of perfusion-metabolism imaging in patients undergoing positron emission tomography for myocardial viability assessment. BACKGROUND: Positron emission tomography using nitrogen-13 ammonia and 18fluorodeoxyglucose to assess myocardial blood flow and metabolism has been shown to predict improvement in wall motion after coronary artery revascularization. The prognostic implications of metabolic imaging in patients with advanced coronary artery disease have not been investigated. METHODS: Eighty-two patients with advanced coronary artery disease and impaired left ventricular function underwent positron emission tomographic imaging between August 1988 and March 1990 to assess myocardial viability before coronary artery revascularization. RESULTS: Forty patients underwent successful revascularization. Patients who exhibited evidence of metabolically compromised myocardium by positron emission tomography (decreased blood flow with preserved metabolism) who did not undergo subsequent revascularization were more likely to experience a myocardial infarction, death, cardiac arrest or late revascularization due to development of new symptoms than were the other patient groups (p less than 0.01). Concordantly decreased flow and metabolism in segments of previous infarction did not affect outcome in patients with or without subsequent revascularization. Those with a compromised myocardium who did undergo revascularization were more likely to experience an improvement in functional class than were patients with preoperative positron emission tomographic findings of concordant decrease in flow and metabolism. CONCLUSIONS: Positron emission tomographic myocardial viability imaging appears to identify patients at increased risk of having an adverse cardiac event or death. Patients with impaired left ventricular function and positron emission tomographic evidence for jeopardized myocardium appear to have the most benefit from a revascularization procedure.

Aged↗
PubMed1992

Warm glutamate/aspartate-enriched blood cardioplegic solution for perioperative sudden death.

This report describes an initial experience applying warm glutamate/aspartate substrate-enriched blood cardioplegic solution to resuscitate hearts in 14 patients with witnessed perioperative arrest. Ten patients were in stable hemodynamic condition in the catheterization laboratory (n = 3) or intensive care unit when sudden irreversible fibrillation developed. It progressed to electromechanical arrest in six patients. In patients with preoperative or postoperative arrest, conventional cardiopulmonary resuscitation and defibrillation were unsuccessful and extracorporeal circulation was started 22 to 150 minutes after arrest. The left ventricle was vented, the aorta clamped, and warm (37 degrees C) aspartate/glutamate blood cardioplegic solution was given at a rate of 150 ml/min for 20 minutes. All bypass grafts were open with good flows in patients who had had coronary bypass, and coronary bypass was done in the three patients who had preoperative arrest. Eleven of 14 hearts resumed normal sinus rhythm after aortic unclamping, only two electrocardiographically proved infarctions occurred, and 13 patients had complete hemodynamic recovery with improved ejection fraction. Three patients died: one of progressive cardiogenic shock, another of mediastinitis, and the third of irreversible neurologic damage. Eleven patients were discharged from the hospital and are well after a follow-up period between 3 and 9 months. We conclude that witnessed perioperative arrest with intractable ventricular fibrillation should be treated aggressively by administering cardiopulmonary resuscitation during prompt transfer to the operating room for total vented bypass and delivery of warm substrate-enriched blood cardioplegic solution. This treatment may salvage hearts thought to be damaged irreversibly and may be a feasible approach to intractable witnessed cardiac arrest, provided cardiopulmonary resuscitation maintains satisfactory cerebral perfusion pressure.

Aged↗
PubMed1991

Risk factors for nosocomial pneumonia after coronary artery bypass graft operations.

We attempted to determine risk factors for nosocomial pneumonia in patients undergoing a coronary artery bypass graft operation. We reviewed the microbiology and medical records for any patient with a sputum culture who had undergone a coronary artery bypass graft operation in 1988 to identify patients with pneumonia according to a standard clinical definition. We found 19 cases of pneumonia through our initial review; complete medical records were found on 15 cases. Gram-negative bacilli predominated as the most common etiologic agent causing pneumonia in this cohort. There were no clusters noted. Mortality was 26.6%. Pneumonia occurred approximately 4 days after the operation. Thirty-six controls were randomly selected from patients undergoing coronary artery bypass graft operations in 1988. Logistic regression analysis revealed that a history of chronic obstructive lung disease, duration of more than 2 days of mechanical ventilation after operation but before diagnosis of pneumonia, and receipt of gastric acid inhibitors (antacids or H2-blockers) were independent risk factors for nosocomial pneumonia. Only the last risk factor was amenable to intervention at the time of operation.

Case-Control Studies↗
PubMed1991

Mediastinitis following coronary artery bypass surgery: a 3-year review.

Twenty cases of mediastinitis after coronary artery bypass graft operations in 1985-1987 were reviewed to determine risk factors. Two distinct clusters with a methicillin-resistant Staphylococcus aureus (MRSA) strain occurred in 1986. One resident was exposed to six cases but to only 5 of 24 controls (P less than .008). Cultures of his nares in January and November 1986 revealed the same MRSA strain as that of the cases. An attempt to eradicate the resident's nasal carriage of MRSA in January 1986 failed; eradication of his carrier state was achieved only after treatment with mupirocin. In a case-control study examining patients exposed to the resident, a prolonged duration of surgery (P less than .05) and a preoperative albumin level of less than 3.0 g/dl (P less than .009) were associated with mediastinitis with this MRSA. For the other 14 mediastinitis patients, who were not exposed to the resident, a preoperative albumin level of less than 3.0 g/dl was also a risk factor (8/14 cases vs. 8/43 controls, P less than .009). Thus, this study suggests that it is important to follow MRSA disseminators and to recognize that preoperative serum albumin levels are a risk factor for mediastinitis.

Carrier State↗
PubMed1984

Factors affecting survival in prosthetic valve endocarditis. Review of the effectiveness of prophylaxis.

We review factors affecting survival of 44 episodes of prosthetic valve endocarditis occurring in 39 patients from 1965 to 1982. The mortality was 31.8 percent (14/44), and 21.6 percent (8/37) if the fungal cases are excluded. The development of a new murmur of valvular regurgitation in 18 patients led to valve replacement or death in every patient. Streptococcal endocarditis in 11 patients resulted in no deaths and only two valve replacements; staphylococcal infections had a mortality of 27.1 percent (6/22). Length of medical therapy before valve replacement did not relate to a successful outcome. Eight cases of early staphylococcal endocarditis occurred in which the organism was susceptible to the prophylactic antibiotic therapy. Changes in prophylaxis have led to no cases of early endocarditis over the past three years in 261 valve replacements.

Adult↗
PubMed1983

Assessment of mediastinal widening associated with traumatic rupture of the aorta.

In order to best determine the reliability and usefulness of widening of the mediastinum (WMED) and other radiographic abnormalities in the selection of trauma patients for aortography to detect traumatic rupture of the aorta (TRA), we designed a blind study in which a panel of radiologists and surgeons reviewed 149 chest films of trauma victims who subsequently underwent aortography to rule out TRA. Sixteen patients had TRA. Panelists identified mediastinal widening (WMED) in 83 of 93 observations on films in cases of TRA (89%). There was a significant association between WMED and TRA found both for the panel as a whole and for each panelist individually (p = 0.0000), making this an extremely reliable sign both in terms of detectability and in signalling the need for aortography. Significant associations with TRA were also found overall for six other radiographic abnormalities but none of these was reliable for all panelists or was as sensitive as WMED in the detection of TRA. Despite the reliability of these signs, panelists making decisions based on the chest film alone failed to recommend aortography in seven of 93 instances of TRA. Direct mediastinal measurements varied by at least 2 cm among panelists in one half of the cases of TRA, and 25% of these (4/16) had at least two measurements of mediastinal width of 7 cm or less. Of all the radiographic signs associated with TRA, widening of the mediastinum is the most reliable, but in this study all observers would not have detected all cases of ruptured aorta using radiographic signs alone. Clinical judgment and consideration of the forces involved in the injury must continue to play an important role in the selection of patients for aortography.

Aortic Rupture↗
PubMed1983

Aortic valve replacement in the elderly.

In order to determine the risk of aortic valve replacement in the elderly, 77 patients over the age of 60 who had undergone this procedure were reviewed. Hypothermic-hyperkalemic cardioplegia was used in all patients. In 55 patients with isolated aortic valve replacement there were three deaths (5.5 per cent). In the entire series of 77 patients there were 13 deaths (13 per cent). In seven patients of an organ other than the heart. In only two patients did the operative death have a myocardial cause. Ninety-two per cent of the patients were in functional class I or II following surgery. Patients should come to surgery before reaching class IV. Aortic valve replacement can be carried out safely in the elderly, and the indications should be the same as for younger patients.

Aged↗
PubMed1981

Bronchogenic carcinoma and postoperative empyema: is survival really enhanced?

From 1959 to 1974, 542 patients underwent curative resection for bronchogenic carcinoma. Postoperative empyema occurred in 17 of these patients. The overall 5-year survival of these 17 patients was only 18%, compared with 27% in the 525 patients without empyema. We were unable to demonstrate by our study or by a review of the literature that postoperative empyema favorably influences survival in patients who have had pulmonary resection for bronchogenic carcinoma.

Aged↗
PubMed1980

Comparison of the effect of blood cardioplegia to crystalloid cardioplegia on myocardial contractility in man.

The myocardial protection achieved by blood cardioplegia was compared to that achieved by crystalloid cardioplegia in a randomized prospective series of patients having coronary bypass operations. Group BCP (n = 15) was protected with 10 degrees C blood containing potassium, 30 mEq/L; Group KCP (n = 9) by an electrolyte solution at 4 degrees C with mannitol, 25 gm/L, and potassium, 26 mEq/L, and group MgKCP (n = 9) by an electrolyte solution at 4 degrees C containing magnesium, 30 Meq/L, and potassium, 19.6 mEq/L. The three groups were comparable in regard to age, sex, preoperative left ventricular function, symptoms, propranolol use, previous myocardial infarction, number of vessels bypassed, and duration of ischemic arrest. In each patient cardiac output, left ventricular end-diastolic pressure (LVEDP), and maximum contractile element velocity (Vpm) were recorded before and after the ischemic period. All operations were performed in an identical manner with one continuous period of aortic cross-clamping averaging 52.9 minutes. No significant alterations in myocardial function were observed after ischemia within the BCP or KCP groups. However, patients receiving MgKCP had significant (p = 0.02) depression in Vpm from 2.86 +/- 7.8 to 2.04 +/- 3.6 second-1 and increase (p < 0.05) in LVEDP from 9.4 +/- 2.2 to 13.4 +/- 5.2 mm Hg. Analysis of variance between groups showed that Vpm decreased significantly (p < 0.05) and LVEDP increased significantly (p < 0.05) in the MgKCP group by comparison to the BCP group. Patients receiving BCP experienced spontaneous defibrillation more frequently (p < 0.02) and received nitroprusside postoperatively more often (p < 0.05) than patients in the other two groups. From these results we conclude that blood cardioplegia provides excellent protection during myocardial ischemia, probably better than one of the two crystalloid solutions tested but no better than the other crystalloid solution. Because the three solutions differed from one another in several respects, no conclusion can be reached about the efficacy of any one ingredient.

Adult↗
PubMed1978

Salmonella typhimurium peptidase active on carnosine.

Wild-type Salmonella typhimurium can use carnosine (beta-alanyl-L-histidine) as a source of histidine, but carnosine utilization is blocked in particular mutants defective in the constitutive enzyme peptidase D, the product of the pepD gene. Biochemical evidence for assigning carnosinase activity to peptidase D (a broad-specificity dipeptidase) includes: (i) coelution of carnosinase and dipeptidase activity from diethylaminoethyl-cellulose and Bio-Gel P-300 columns; (ii) coelectrophoresis of carnosinase and dipeptidase on polyacrylamide gels; and (iii) inactivation of carnosinase and dipeptidase activities at identical rates at both 4 and 42 degrees C. Genetic evidence indicates that mutations leading to loss of carnosinase activity map at pepD. Several independent pepD mutants have been isolated by different selection procedures, and the patterns of peptide utilization of strains carrying various pepD alleles have been studied. Many pepD mutations lead to the production of partially active peptidase D enzymes with substrate specificities that differ strikingly from those of the wild-type enzyme. The growth yields of carnosinase-deficient strains growing in Difco nutrient broth indicate that carnosine is the major utilizable source of histidine in this medium.

Carnosine↗