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Biomedical subjects

R A Cukingnan

Publications and source records attributed to R A Cukingnan.

At least 19 recordsLinked to original sources
PubMed1995

Health status after myocardial revascularization: inferior results in women.

We followed up 1,335 patients (287 female, 1,048 male) for 2 to 18 years (mean, 4.3 years) after they had undergone coronary artery bypass grafting. A health status index was calculated on the basis of their responses to annual questionnaires. The female patients were older (64.1 +/- 0.3 versus 60.4 +/- 0.3 years) and had a higher incidence of diabetes (28.6% versus 16.1%). The risk profile of women was otherwise similar to that of men. The hospital mortality was significantly higher in the women, particularly in those younger than age 60. The probability of survival (Kaplan-Meier) at 5, 10, and 15 years was lower in female patients at each interval. The mean health status index was also lower in women at 5, 10, and 15 years, and also lower in all subsets. In nondiabetic patients, the hospital mortality and probability of survival at 10 years did not differ between the female and male patients. In the diabetic patients, the hospital mortality was 11.0% (women) and 3.6% (men); the survival at 10 years was 0.42 (women) and 0.56 (men) (p < 0.001). Thus, the health status in women is less satisfactory than that of men after myocardial revascularization, and the probability of survival is lower. The excess mortality in female patients may be due to the higher incidence of diabetes in this group.

Coronary Artery Bypass↗
PubMed1992

Quality of life after myocardial revascularization. Effect of increasing age.

The effect of increasing age on quality of life, survival, and risk of reoperation was studied in 2479 patients followed up prospectively 2 to 20 years after myocardial revascularization. Quality of life was determined from annual questionnaires, which we used to calculate a health status index from the patient's symptomatic status and subjective response to the operation, which was graded between zero and 1.00 (asymptomatic). Four age groups were studied: age 49 years or less (AG40), 50 to 59 years (AG50), 60 to 69 years (AG60), and 70 years or older (AG70). Associated problems (left ventricular aneurysm, valve disease, acute myocardial infarction) necessitating treatment were present in 17% (61/361) of AG40 patients, 19% (165 of 859) of AG50 patients, 23% (213/927) of AG60 patients, and 31% (102/332) of AG70 patients. The hospital mortality rate was higher in older patients undergoing combined procedures but not in patients undergoing coronary bypass grafts only. Probability of survival and health status indexes were calculated excluding patients with valve disease and cardiogenic shock. Probability of survival was significantly better (p less than 0.001 by the Wilcoxon test) in patients less than age 60 than in those 60 years or older, but in patients with an ejection fraction greater than or equal to 0.40, probability of survival at 12 years was 0.64 (age less than 60) versus 0.62 (age greater than or equal to 60). The actuarial risk of reoperation, calculated as the difference between probability of survival and probability of survival without reoperation, progressively increased in younger patients but not in patients aged 60 years or older. At 15 years, the reoperation rates were 26% (AG40), 14% (AG50), 5% (AG60), and 7% (AG70). Mean health status index for years 1 to 5 was 0.85 in AG40 patients, 0.84 in AG50 patients, 0.89 in AG60 patients, and 0.90 in AG70 patients; for years 6 to 10, 0.81, 0.80, 0.86, and 0.89; and for years 11 to 15, 0.77, 0.78, 0.84, and 0.84, respectively. Thus quality of life after myocardial revascularization is better, improvement lasts longer, and reoperation rate is less in patients aged 60 years or older.

Actuarial Analysis↗
PubMed1991

Transfusion therapy in cardiac surgery: impact of the Paul Gann Blood Safety Act in California.

The Paul Gann Blood Safety Act became law in California on January 1, 1990, mandating that patients be informed of the risks and alternatives of blood transfusions. To evaluate the impact of this legislation, the authors compared transfusion therapy in patients undergoing cardiac surgery during 1990 to previous years (1986 to 1987 and 1989). Surgical techniques were unchanged. Homologous component usage was 8.7 +/- 0.6 (mean +/- SE) units/patient in 1986 to 1987 (n = 373), 8.2 +/- 0.9 in 1989 (n = 219) and 4.3 +/- 0.6 in 1990 (n = 222), P less than .001 by ANOVA. Erythrocyte transfusions were 3.5 +/- 0.2, 3.2 +/- 0.2, and 2.2 +/- 0.2 units/patient (P less than .001); platelet/plasma usage was 5.2 +/- 0.5, 4.9 +/- 0.7 and 2.1 +/- 0.4 units/patient (P less than .001). The number of patients not requiring transfusions increased from 28 per cent in 1989 (61 of 219) to 47 per cent in 1990 (104 of 222). A slight but significant decrease in cardiopulmonary bypass time and perioperative blood loss occurred. The authors conclude that this legislation stimulated the surgical team to control blood loss during surgery and to avoid the anticipatory use of component transfusions.

Aged↗
PubMed1989

Myocardial rupture in expanded infarcts: repair using pericardial patch.

Myocardial rupture is found in approximately 20% of fatal infarctions, but the diagnosis is rarely made before death. Rupture occurs in "expanding" transmural infarctions. The diagnosis should be considered in any patient who develops recurrent chest pain and cardiovascular instability within the first week after infarction. Echocardiographic evidence of a dilated infarct with pericardial effusion is confirmatory. Three cases are described, and previous reports are reviewed. Because most patients have multivessel disease, we recommend pericardiocentesis and rapid cardiac catheterization. Infarctectomy may be appropriate when the edges of the lesion are obvious, but the more typical diffuse, serpiginous defects should be closed with dacron-bolstered sutures covered with a wide autologous pericardial patch. Myocardial rupture is a treatable condition, and a high index of suspicion is necessary in order to recognize it more frequently.

Aged↗
PubMed1985

Improved graft patency in patients treated with platelet-inhibiting therapy after coronary bypass surgery.

One hundred forty-seven consecutive coronary bypass patients were enrolled in a randomized, double-blind, risk-stratified, placebo-controlled prospective trial evaluating the effect on graft patency of 325 mg tid aspirin (ASA) plus 75 mg tid dipyridamole (DP) or ASA alone. One hundred twenty-seven patients (399 total grafts) underwent surgery, initiation of drug therapy 67 +/- 27 (SD) hr postoperatively, five clinic visits, and repeat angiography at 1 year. A logistic regression statistical model was used to determine the effects of 28 different measured variables on graft patency and to adjust for these effects in determining the relationship between antiplatelet therapy and graft occlusion. No patient-specific variable contributed significantly to the prediction of occlusion in either the placebo or the treated group. Six graft-specific variables (arterial diameter, severity of stenosis, graft flow, reactive hyperemia, presence or absence of collaterals, and graft type) did contribute and were included in the model. Twenty-one percent of placebo-treated grafts became occluded. Compared with placebo, the relative risk of graft occlusion with ASA was 0.47 (p = .04); with ASA + DP, it was 0.50 (p = .04). This benefit was principally due to reduction of occlusion in the most common and presumably most important groups of grafts, those in which flow exceeded 40 ml/min, or supplying arteries having luminal diameters greater than 1.5 mm. Grafts lacking reactive hyperemia had a 32% occlusion frequency in placebo-treated patients; relative risk of their occlusion averaged 0.26 (p less than .01) with platelet-inhibiting therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1983

Postoperative treadmill performance and graft patency after myocardial revascularization.

In a prospective study, a random selection of 122 patients who had coronary artery bypass grafting were studied angiographically and given treadmill tests preoperatively and one year after operation, regardless of their symptoms. A total of 397 grafts were performed (average, 3.3 grafts per patient) on all primary and secondary coronary vessels deemed graftable. Complete coronary revascularization (grafts to vessels 1.5 mm or more in diameter with 50% or greater stenosis) was achieved in 104 patients (85%); 18 patients (15%) were considered incompletely revascularized. One hundred sixteen of the 397 grafts (29%) were to the left anterior descending (LAD) coronary artery, 99 (25%) to the right coronary artery, 126 (32%) to the obtuse marginal branch, 52 (13%) to the diagonal branch of the LAD coronary artery, and 4 (1%) to the septal coronary arteries. Overall results showed that patients with positive postoperative treadmill tests had a graft patency of 64%, compared with 86% for patients with negative treadmill tests (p less than 0.001). Completely revascularized patients with all grafts patent had a 4.8% (3/62) incidence of positive treadmill performance, compared with 60% (6/10) for incompletely revascularized patients with all grafts patent (p less than 0.001). Completely revascularized patients with positive treadmill tests had a graft patency of 58% (45/78), while those with negative treadmill evaluations had a graft patency of 86% (227/264) (p less than 0.001). The patency rate for incompletely revascularized patients with positive treadmill performance was 78% (25/32) and 87% (20/23) for those with negative treadmill performance. This difference was not statistically significant. This study shows that postoperative treadmill performance is highly dependent on completeness of revascularization and graft patency. It therefore supports the prognostic importance of regular treadmill exercise testing to monitor continued graft patency.

Adult↗
PubMed1983

Early valve replacement in active infective endocarditis. Results and late survival.

In the past 14 years, 42 patients with active infective endocarditis underwent early valve replacement for severe congestive heart failure, major prosthetic dehiscence, intramyocardial abscesses, sepsis, or major embolization. Blood cultures were positive in 40 patients and the valve tissues were positive in two others. All patients received antimicrobials for from 1 to 4 weeks. Drug addiction was noted in 24%, urinary tract manipulation in 7%, dental work in 5%, contaminated prosthesis in 2%, and unknown cause in 62%. Organisms were predominantly staphylococcal (43%) and streptococcal (41%); the remainder were gram-negative (9%) or fungal (7%). The aortic valve was involved in 72%, mitral in 14%, tricuspid in 7%, and both aortic and mitral in 7%. By the New York Heart Association (NYHA) functional classification, 90% (38/42) were in Class III or IV. Operative mortality was 10% (4/42) and all four patients had preexisting renal failure necessitating dialysis. No predominant organism correlated with early deaths. In aortic valve replacement (30 patients), operative mortality was 7%. Postoperatively, 95% (35/37) were Class I or II with one lost to follow-up. Subsequent reoperation was required in five patients (13%) for recurrent endocarditis, with an operative mortality of 20% (1/5). Late death occurred in 45% (17/38). Overall probability of survival was 0.53 at 5 years. For isolated aortic valve involvement, the 5 year survival was 0.58. Survival for native valve involvement was 0.58 and for prosthetic endocarditis, 0.55. This study shows that after at least 1 week of antibiotics, early operation in patients with active endocarditis has an acceptable operative mortality. Clinical improvement is excellent in 95% and more than half survived 5 years or longer.

Adult↗
PubMed1982

Hemodynamic effect of myocardial revascularization in the impaired ventricle.

The hemodynamic effect of myocardial revascularization with saphenous vein grafts (mean 3.3 per patient) was analyzed 1 year after operation in 111 patients. Operations were performed using one continuous period of aortic cross-clamping with hyperkalemic cardioplegia for distal anastomoses in 84% of patients; 16% had arrest with topical and systemic hypothermia for myocardial protection. Group I (N = 18) had normal ventricles (ejection fraction [EF] greater than 50%; left ventricular end-diastolic pressure [LVEDP] less than or equal to 12 torr); Group II (N = 64) had ischemic ventricles (EF greater than 50%, LVEDP greater than 13 torr); and Group III (N = 30) had abnormal ventricles (EF less than 50%, LVEDP greater than 13 torr). Hemodynamic measurements were obtained before and 1 year after operation. Fifteen of 18 patients (83%) in Group I did not show significant hemodynamic changes, but in three EF decreased by greater than or equal to 10% and LVEDP increased by greater than 10% over preoperative levels. In Group II, EF was unchanged or slightly better in 89% (57/64) and worse in seven patients. Improvement in cardiac index (p less than 0.01) and LVEDP (p less than 0.001) was significant. Worsening of EF in 10 of 82 patients in Groups I and II was attributed to graft closure and/or poor myocardial protection. In Group III, significant improvement in cardiac index (p less than 0.001), EF (p less than 0.001), and LVEDP (p less than 0.01) was also noted. A subset of nine patients with EF less than or equal to 35% showed postoperative improvement in 56%. Of the remaining 20 patients with an EF of greater than 35% to less than 50%, half had greater than or equal to 20% improvement in postoperative EF. Operative mortality was 3.3% (1/30) for Group III. Late mortality was 1.5% (1/64) for Group II and 10% (3/29) for Group III. Significant improvement was noted postoperatively in 67% (57/85) of all patients who had preoperative treadmill tests (p less than 0.001). This study shows that myocardial revascularization significantly improved left ventricular performance in most patients with ischemic and abnormal ventricles. Previous studies that fail to show improvement may be related to incomplete revascularization and/or poor myocardial preservation. These data, therefore, justify the need for revascularization of the impaired ventricle.

Adult↗
PubMed1981

Cell-mediated immunity is depressed following cardiopulmonary bypass.

Sequential in vitro lymphocyte function tests in 13 patients undergoing cardiac operation were performed to determine factors that contribute to depressed cell-mediated immunity following operation. Lymphocytes were stimulated with phytohemagglutinin (PHA), pokeweed mitogen, concanavalin A (Con A), and mitomycin-treated, pooled, allogeneic lymphocytes (MLC). Mitogen responses were measured by 3H-labeled thymidine incorporation. Circulating levels of T, B, and Fc-receptor lymphocytes were determined by counting E, EAC, and EA rosettes. Serum cortisol was measured by radioimmunoassay. The T-cell-dependent lymphocyte responses (PHA, Con A, and MLC) were significantly decreased 24 hours after operation, and this was accompanied by a 60% decrease in circulating T-cell levels. The PHA, Con A, and MLC responses, and circulating T-cell levels returned to preoperative values one week following operation. Lymphocyte responses to mitogens remained significantly decreased when the number of T cells in the postoperative cultures were adjusted to preoperative levels. This indicates that the T cells remaining after operation were functionally impaired. We conclude that lymphocyte proliferative responses and antigen recognition are significantly depressed following cardiac operation, and that these responses are related to decreased numbers of circulating T lymphocytes and depressed function of the remaining T lymphocytes.

Cardiopulmonary Bypass↗
PubMed1979

Right stellate ganglion block for treatment of hypertension after cardiopulmonary bypass.

Right stellate ganglion block was performed on 24 patients in whom hypertension developed after cardiopulmonary bypass. Changes in blood pressure, central venous pressure, cardiac output, and heart rate were evaluated. Most patients evidenced a decrease in systolic blood pressure (average, 40 mm Hg) and diastolic blood pressure (average, 19 mm Hg). Systemic vascular resistance was measured in 8 patients, and 7 demonstrated a decrease (average reduction, 6.7 resistance units). Changes in cardiac output were variable. Although stellate ganglion block can be safely performed and, in most patients, markedly reduces systolic blood pressure, the results suggest that other hypotensive agents may be more advantageous in the treatment of hypertension subsequent to coronary artery operation.

Autonomic Nerve Block↗
PubMed1979

Use of activated coagulation time to monitor heparin during cardiac surgery.

Activated coagulation time (ACT) for protamine reversal was monitored in 28 consecutive patients (Group 1) and a standard heparin-protamine protocol was used for an earlier series of 28 patients (Group 2). Although Group 1 received a significantly higher total heparin dose than Group 2 (p less than 0.01), the protamine dose for reversal was significantly less for the ACT group than for the controls (p less than 0.0005). The mean ratio of protamine to total heparin was 1 : 1 (range, 0.33 to 1.44) for the ACT group and 2 : 1 (range, 1.42 to 2.59) for the controls. There were no significant differences between the two groups in operative and postoperative blood loss, transfusion requirements, hematocrit, and partial thromboplastin time. This study shows that the ACT test did not reduce postoperative bleeding significantly when compared with our standard protocol. It also indicates that there is wide individual sensitivity to heparin and that significantly less protamine is required for reversal.

Blood Coagulation Tests↗
PubMed1979

Factors influencing patency of saphenous vein grafts.

To determine factors affecting saphenous vein graft patency, 218 grafts in 66 unselected patients were studied angiographically 1 year after operation. Fourteen variables were extracted from the angiograms, electrocardiograms, and intraoperative flow measurements to assess their predictive value. Preoperative coronary vessel diameter and degree of proximal stenosis measured angiographically correlated significantly with graft patency. Graft patency for vessels greater than 1.5 mm in diameter with greater than 70% stenosis was 93% (98 out of 105). Vessel size at operation and the presence of reactive hyperemia greater than 20 ml per minute also correlated significantly with graft patency. Reactive hyperemia increased significantly as the severity of the vessel stenosis proximal to the graft increased, thus suggesting a mechanism for the improved patency rate of grafts to more stenotic vessels. The patency rate of the end-to-side component of a continuity graft (left anterior descending coronary artery and diagonal or marginal artery in 1 graft) was 100% and of the side-to-side component, 77%. This study shows that the patency rate for saphenous vein grafts compares favorably with the reported patency for internal mammary grafts when critical factors such as vessel size (greater than 1.5 mm) and degree of stenosis (greater than 70%) are considered in bypass selection.

Coronary Angiography↗
PubMed1979

Veterans Administration cooperative study of surgery for coronary arterial occlusive disease: view from a noncooperating hospital.

Wadsworth Veterans Administration Hospital (VA-W) dropped out of the VA Coronary Cooperative Study (VA-Coop) in 1971 because of difficulty adhering to selection criteria, and because of the lack of standardization of surgical methods. Comparison of results from 1972-1974 showed the following differences: cardiopulmonary bypass time per graft, 61 minutes (VA-Coop) vs 33 minutes (VA-W); perioperative myocardial infarction (MI), 18% vs 6%; hospital mortality, 6% vs 1%; revascularization index (patent grafts per patient determined by postoperative angiography divided by diseased arteries per patient), 0.55 (VA-Coop) vs 0.84 (VA-W). However, the slopes of the actuarial survival curves were similar after the first year. In a group of patients operated on at UCLA and VA-W (UC-VA) during 1969-1971, the 1-year survival rate was 85%, but the annual death rate thereafter was also approximately 2% per year. The survival of VA-Coop surgical patients with three-vessel disease without left main lesions was significantly better (p less than 0.05 by Wilcoxon test) than the medical group with the 6-month (surgical) mortality adjusted to a more acceptable level (5%). These results indicate that coronary bypass surgery produces an annual mortality of approximately 2% per year after the first year. Differences in survival rates are due primarily to variations in first-year mortality, which is influenced by operative mortality as well as morbidity, incomplete revascularization, and low graft patency rate. In our view, the surgical results reported by the VA Cooperative Study are representative of an intermediary step in the development of coronary bypass surgery. The data, however, still indicate that surgical treatment results in better survival in patients with multivessel coronary disease.

California↗
PubMed1978

Carcinoma of the esophagus.

Carcinoma of the esophagus continues to have a low 5-year cure rate despite advances in radical surgery and super-voltage radiation. Neither patient education nor newer diagnostic techniques have improved survival. The reported operative mortality is 4 to 30% for esophagogastrostomy and 10 to 44% for colon interposition. Average survival time with surgery is 11 to 28 months and 5 to 11 months with irradiation. Local recurrence is high (33 to 76%) with irradiation. The reported 5-year survival rate with preoperative irradiation followed by surgery is higher (14 to 25%). Recent reports have concentrated on improving functional rehabilitation rather than improving cure rates. Palliative surgery is more acceptable because of lowered operative morbidity and mortality and the high complication rate with radiation therapy for far advanced disease. New approaches of interest include fundoplication added to esophagogastrostomy, substernal gastric bypass with anastomosis in the neck, reversed gastric tube (Heimlich operation), the addition of postoperative rather than preoperative irradiation in patients with potentially curable lesions, the use of preoperative hyperalimentation, and the potential application of immunotherapy.

Diagnosis, Differential↗