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Biomedical subjects

R K Brawley

Publications and source records attributed to R K Brawley.

At least 19 recordsLinked to original sources
PubMed1988

Aortic disease associated with pregnancy.

Our experience with the management of two patients with life-threatening aortic disease during pregnancy is presented with a review of the literature. One of our patients had intimal disruption caused by trauma; the other had probable Ehlers-Danlos type IV syndrome, causing an acute dissection of the descending thoracic aorta and eventually requiring replacement of the aorta from the left subclavian artery to common iliac arteries. The challenge of treating both the pregnant woman and the fetus was managed successfully by an emergent cesarean section followed by Dacron graft replacement of the descending thoracic aorta. The literature reviewed disclosed that aneurysm expansion producing symptoms and dissection is most common during the third trimester and during labor and delivery in patients with or without Marfan's syndrome. Half of the aortic dissections in women less than 40 years of age occur in association with pregnancy. The available evidence indicates that patients with known valvular or aortic disease should have surgical repairs during the first or second trimester and thereafter have delivery by cesarean section. However, patients with acute aortic problems near term appear to be better managed by cesarean section followed promptly by treatment of the aortic disease.

Adult↗
PubMed1986

Septal geometry in the unloaded living human heart.

Right ventricular loading leads to diastolic septal flattening in man without necessarily requiring right ventricular pressure to exceed left ventricular pressure. This observation suggested that the unstressed septal configuration is flat and that its normal concave shape is due to the left-to-right transseptal pressure gradient. To examine this hypothesis, we studied septal configuration by two-dimensional echocardiography in nine patients with normal global and regional left ventricular function during surgery for coronary artery disease. The transseptal pressure gradient was obtained from pulmonary capillary wedge pressure minus right atrial pressure. Measurements were obtained at control (open chest, intact pericardium [C]), with the pericardium open (OP), on cardiopulmonary bypass (CPB), and after cardiac arrest (CA). There were no changes in any measurements between C and OP or between CPB and CA. Left ventricular end-diastolic cavity area decreased from 16.5 +/- 2.1 cm2 at C to 11.1 +/- 4.5 cm2 after CPB, and further decreased to 8.9 +/- 3.5 cm2 after CA (p less than .001), yet the septum flattened, as shown by an increase in its radius of curvature from 1.7 +/- 0.5 cm during C to 2.5 +/- 0.7 cm after CPB, and to 2.9 +/- 1.0 cm after CA (p less than .001), or from 0.4 +/- 0.1 to 0.8 +/- 0.4 to 1.1 +/- 0.5 U (p less than .001) when normalized for cavity area. Diastolic transseptal pressure gradient was reduced from 4.1 +/- 2.3 mm Hg during C to 1.1 +/- 1.8 mm Hg after CPB, and to 0.5 +/- 1.4 mm Hg after CA (p less than .01).(ABSTRACT TRUNCATED AT 250 WORDS)

Blood Pressure↗
PubMed1983

Left ventricular aneurysmectomy. Factors influencing postoperative results.

One hundred consecutive patients who underwent resection of aneurysms of the left ventricle were reviewed. Eighty-four of these patients had resection or plication of an aneurysm of the anterior left ventricular wall either alone or in combination with coronary artery bypass grafting. In 27 patients who had little or no congestive heart failure, the primary indication for operation was disabling angina pectoris. In them the early mortality was 4% and late mortality, 4%. In nine other patients the primary indication for operation was life-threatening ventricular arrhythmias. In this group the early mortality was 56% and late mortality, 0%. Severe congestive heart failure was the primary indication for aneurysmectomy in 48 patients. In these patients the early mortality was 21% and late mortality, 34%. When the primary indication for operation was severe congestive heart failure, overall survival and postoperative results were best in patients in whom the nonaneurysmal left ventricle had good function preoperatively and was supplied by coronary arteries either unobstructed or favorable for bypass grafting; results were poorest in those patients with three-vessel coronary artery disease who had impaired motion of the lateral left ventricular wall and distal lateral wall vessels that were unfavorable for bypass grafting. It is concluded that patients with left ventricular aneurysms form a heterogeneous group in which the prognosis varies markedly. The probability of a good postoperative result can be predicted by careful preoperative analysis of a patient's symptoms, ventricular function, and coronary artery anatomy.

Adult↗
PubMed1982

Fatal pulmonary hemorrhage complicating Swan-Ganz catheterization.

A case of fatal pulmonary hemorrhage secondary to catheterization with a balloon-tipped catheter is described, and the literature describing possible mechanisms for this complication is reviewed. A common denominator in patients suffering pulmonary hemorrhage is pulmonary hypertension. Recommendations for management of this complication are discussed.

Cardiac Catheterization↗
PubMed1981

Diagnosis and management of postoperative pericardial effusions and late cardiac tamponade following open-heart surgery.

The clinical and laboratory findings of 28 patients identified as having late pericardial effusions were examined. Eleven of these patients were asymptomatic; 9 patients had moderate symptoms including fatigue, malaise, weight gain, and dyspnea on exertion, and 8 patients with similar symptoms had evidence of cardiac tamponade. Ten patients underwent right heart catheterization in the intensive care unit; normal hemodynamics were confirmed in 4 and cardiac tamponade in 6 patients. Pericardiocentesis was effective in decompressing cardiac tamponade in 7 of 8 patients. One patient required operative subxiphoid drainage after unsuccessful pericardiocentesis. In addition, 5 patients with moderate clinical symptoms and pericardial effusions, who did not have cardiac tamponade, underwent pericardiocentesis because of a need for chronic anticoagulant therapy. The remaining patients were managed successfully by observation, discontinuation of warfarin when possible, fluid restriction, and diuretic therapy. All but 1 patient was symptomatically improved. A diagnostic and therapeutic schema is presented as an aid to early recognition of this troublesome and potentially lethal complication.

Adult↗
PubMed1981

Clinical and hemodynamic evaluation of the 19 mm Björk-Shiley aortic valve prosthesis.

Between November, 1973, and March, 1980, 43 patients underwent isolated aortic valve replacement with 19 mm Björk-Shiley prostheses at the Johns Hopkins Hospital. There were 4 male and 39 female patients ranging from 12 to 75 years old (mean, 54.5 years). Average weight was 62 +/- 2 kg and average body surface area, 1.64 +/- 0.3 m2. Five patients died within thirty days of operation; however, since 1975, hospital mortality has been 5.9%. The 38 survivors have been followed up for as long as 85 months (mean, 40 months). There were 4 late deaths, and actuarial survival in patients discharged from the hospital was 81% at five years. All long-term survivors were in New York Heart Association Functional Class I (29 patients) or Class II (5 patients). Preoperative and postoperative echocardiograms in 17 patients demonstrated significant decreases in mean left ventricular wall thickness (12.9 +/- 1.8 mm vs 10.3 +/- 1.4 mm; p less than 0.001) and in left ventricular mass (262 +/- 95 gm vs 188 +/- 50 gm; p less than 0.02). Postoperative cardiac catheterization data were obtained from an additional 24 patients undergoing aortic valve replacement with the 19 mm Björk-Shiley prosthesis at the National Heart Institute. Average peak systolic gradient at rest was 16 mm Hg (range, 0 to 45 mm Hg) and was found to be directly related to body surface area (r = 0.60, p less than 0.002). Average effective valve orifice area was 1.06 cm2 (range, 0.63 to 2.02 cm2). For patients with small aortic roots, aortic valve replacement with the 19 mm Björk-Shiley valve is a satisfactory and, perhaps, preferable alternative to aortic annuloplasty to accommodate larger sized prostheses.

Actuarial Analysis↗
PubMed1980

Improved exposure of the mitral valve in patients with a small left atrium.

A modification of the usual approach to the mitral valve is described and illustrated. This technique employs right atriotomy and interatrial septotomy, which can be easily performed when standard left atriotomy does not provide satisfactory mitral valve exposure. While this modification is not often necessary, it can be helpful in patients with a small left atrium, especially those with a small left atrium and associated left ventricular hypertrophy.

Heart Atria↗
PubMed1980

Unstable angina pectoris. Factors influencing operative risk.

Experience was reviewed with 471 consecutive patients who had coronary artery bypass (CAB) operation alone. The hospital mortality rate was 2% in 341 patients operated on for treatment of stable angina pectoris. There were ten deaths (7.7%) in the 130 patients who underwent CAB for treatment of unstable angina. In this series, age greater than 70 years, poor left ventricular function, distal coronary arteries unfavorable for grafting and the presence of main left coronary artery disease were factors associated with increased operative mortality. In 78 patients with unstable angina who had none of these increased risk factors, the mortality rate was 1.3%. Hospital mortality was 33% in patients older than 70 years and 29% in patients with poor left ventricular function and/or distal vessels unfavorable for grafting. In 23 of the 130 patients, the only increased risk factor present was severe stenosis of the main left coronary artery and one of them (4.3%) died. Thus, when elderly patients and patients with poor left ventricular function or poor distal vessels were excluded, the hospital mortality rate associated with CAB in patients with unstable angina was low (2.0%, 2/101 patients) and equal to that for operation in patients with stable angina pectoris.

Adult↗
PubMed1980

Traumatic pseudoaneurysm of the thoracic aorta in close proximity to the anterior spinal artery: a therapeutic dilemma.

Operative therapy is generally advocated for the management of chronic traumatic pseudoaneurysms of the aorta. A potential complication of both thoracic and abdominal aortic aneurysmectomies is paraplegia secondary to infarction or ischemia of the spinal cord. The present report describes a patient with a traumatic aneurysm of the lower thoracic aorta immediately adjacent to the origin of the anterior spinal artery, both delineated angiographically. In this particular situation, it was elected to follow the patient because the aneurysm was asymptomatic, small, and chronic, and because the risk of spinal cord injury associated with aneurysmectomy was estimated to be high. Serial computerized tomography (CT) scanning was used as a means of measuring the exact aneurysm size. Operation will be recommended if the aneurysm produces symptoms or enlarges, as demonstrated by CT scans.

Adult↗
PubMed1980

The influence of cardiac geometry on the results of ventricular aneurysm repair.

Operative repair of ventricular aneurysms should improve left ventricular function. Despite its theoretic advantage, the mortality following this operation is high, and many patients have severe postoperative hypotension. The cardiac findings were studied in 18 patients who died after repair of ventricular aneurysms. All hearts were examined at autopsy after postmortem coronary arteriography and fixation in a distended state. Five patients in Group I had intractable fatal postoperative hypotension, 7 in Group II initially had severe hypotension that improved, and 6 in Group III did not have postoperative hypotension. Curvature thickness indexes (CTIs) of the ventricular segments, which correlate with their pressure-producing activity, were determined in the 18 hearts. CTIs for the left ventricular free wall and septum were lower in Group I and Group II patients with hypotension than those in Group III without. The reduced CTIs in patients with postoperative shock appear to arise as a result of ventricular reconstruction that reduces ventricular wall curvature. The authors suggest that left ventricular function after aneurysm resection would be improved by inverting, rather than everting, the edges of the ventriculotomy, thereby increasing wall curvature and the CTI. Noninvasive determinations of the CTI may prove of value in guiding topographic reconstruction of ventricles with aneurysms.

Adolescent↗
PubMed1979

Routine use of autotransfusion following cardiac surgery: experience in 700 patients.

An autotransfusion technique has been developed for collection and reinfusion of shed mediastinal blood. This system has been routinely applied in the postoperative management of 592 consecutive adult and 108 pediatric cardiac surgical patients. Two hundred seventy-one adult patients (46%) and thirty-six pediatric patients (33%) actually received autologous blood. Autotransfusion volume ranged from 50 to 21,350 ml per patient. In 1976 at our institution, homologous transfusion requirements averaged 8.4 +/- 0.7 units per adult patient. During 1978, with the routine use of postoperative autotransfusion, bank blood transfusions were lowered to 4.2 +/- 0.3 units per patient (p less than 0.001). In contrast to perioperative autotransfusion techniques, collection and reinfusion of shed mediastinal blood is particularly useful for intravascular volume replacement in patients with serious postoperative bleeding.

Adult↗
PubMed1979

Current management of atrial myxoma with emphasis on a new diagnostic technique.

Sixteen patients aged 22-64 years have undergone removal of atrial myxoma at the Johns Hopkins Hospital. The first two patients had myxomas removed by closed surgical approach, and both died. Fourteen consecutive patients have undergone operation with the aid of cardiopulmonary bypass, and all survived. There has been one late death unrelated to myxoma. Current surgical approach is excision of the tumor and its stalk or base and resection of the portion of intra-atrial septum to ensure complete removal. Recently a new diagnostic technique of two-dimensional phased array real time echocardiography has been used in four patients, including a pregnant woman, to confirm the clinical diagnosis of atrial myxoma. This technique provides a two-dimensional view of both atria and ventricles in cross section or sagittal view. This noninvasive method is painless, is independent of cardiac function and carries no risk or radiation hazard. The two-dimensional echocardiogram is superior to the standard one-dimensional or M-mode echocardiogram for diagnosis of myxoma in that it can evaluate simultaneously both right and left atria, can detect smaller space-occupying lesions because of better resolution and can more readily determine the size of the lesion and its stalk, can evaluate the mobility of the tumor and can determine more accurately the extent of tumor obstruction. Because of these qualities, we have relied on two-dimensional echocardiography as the definitive diagnostic procedure for detection of atrial myxoma. Currently operation for atrial myxoma is performed without cardiac catheterization or angiocardiography.

Adult↗
PubMed1978

Improved myocardial performance in postoperative cardiac surgical patients with sodium nitroprusside.

Myocardial performance in the immediate postoperative period was studied 49 cardiac surgical patients treated with nitroprusside alone. With a thermodilution catheter positioned in the pulmonary artery, cardiac output was calculated and cardiac index, systemic vascular resistance index, and stroke work index were derived before after treatment with nitroprusside. The drug was a administered to all patients because of elevated systemic vascular resistance index. Based on their mean arterial pressure and cardiac index before treatment, the patients fell into two groups. Group I patients (N = 25) had elevated mean arterial pressure and normal cardiac index. Group II patients (N = 24) had normal mean arterial pressure and subnormal cardiac index. Nitroprusside administration resulted in a significant reduction of systemic vascular resistance index in all patients. In Group I the mean arterial pressure was lowered significantly while cardiac index increased only slightly. In Group II there was no change in arterial pressure, but cardiac index improved significantly. The results not only confirm that nitroprusside is effective in managing postoperative hypertension, but also demonstrate that in patients with postoperative left ventricular failure, the drug can improve cardiac output by reducing systemic vascular resistance without significantly lowering arterial blood pressure.

Adult↗