Symmetry aortic connector system.
Explore the source record for details and available documents.
Anastomosis, Surgical↗
Biomedical subjects
R L Quigley
Publications and source records attributed to R L Quigley.
Thrombelastographic changes in OPCAB surgical patients.
The purpose of this study was to determine whether thrombelastography could detect hypercoagulability in the off-pump coronary artery bypass (OPCAB) patient. Seventeen OPCAB and six cardiopulmonary bypass (CPB) patients were studied pre- and postprocedure, as well as on each of the first three postoperative days (POD). In the OPCAB patients, there was a small reduction in the postprocedure coagulation index (CI). This was followed by an increase in the CI on each of the next three POD, reaching a level exceeding the mean preprocedure CI by 2.32 units, indicative of a state of relative hypercoagulability. The mean CI for the CPB patients decreased significantly in the postprocedure sample. Over the next 72 h, the CI increased to a level that nearly equaled the preprocedure 'baseline'. We concluded that our study identified a state of relative hypercoagulability in the OPCAB patient 72 h after surgery. The mechanism of this hypercoagulation, as well as the clinical significance of this finding, is yet to be determined.
Aged↗
Creative arterial bypass grafting can be performed on the beating heart.
BACKGROUND: To demonstrate that compromise is unnecessary in either the design or performance of beating heart surgery, we report our experience, over 1 year, of total arterial revascularization where composite or creative grafting was utilized. METHODS: We performed 321 off-pump coronary artery bypass operations, of which, 290 (90%) were done with only arterial conduits. The mean number of distal anastomoses was 2.48, with a range of 1 to 5. There were no aortic anastomoses. One hundred eighty-nine patients (65%) were male, and 101 (35%) were female, with a mean age of 67 years. Comorbidities included chronic renal failure (CRF), 21 (7%); diabetes, 92 (32%); obesity, 68 (23%); hypertension, 212 (73%); chronic obstructive pulmonary disease, 189 (65%); cerebral vascular accident (CVA), 39 (13%); smoking, 164 (56%); and hypercholesterolemia, 151 (52%). The mean ejection fraction was 56%, with a range of 21% to 71%. All procedures were performed with external stabilizers with or without vacuum assist. The complete arterial revascularizations included a T-graft (internal thoracic [ITA]/radial arteries [RA]), 130 (45%); a sequential graft (ITA +/- RA), 118 (41%); a U-graft (coronary-coronary graft perfused by the ITA or right gastroepiploic artery), 5 (2%); an I-graft (ITA/RA), 4 (1%); an X-graft (ITA/RA), 2 (12); and a Y-graft (ITA/RA), 31 (10%). RESULTS: The postoperative incidence of atrial fibrillation was 80 of 290 (27%); CVA, 5 of 290 (2%); bleeding resulting in take-back, 5 of 290 (2%); CRF, 8 of 290 (3%); deep sternal infection, 4 of 290 (1%); and readmission (30-day) for angina, 4 of 290 (1%). The observed perioperative (30-day) mortality was 9 of 290 (3.1%), with the STS predicted rate of 3.82%. CONCLUSIONS: Our experience indicates that once the operating surgeon has learned to safely expose the lateral and inferior walls of the heart, the type of conduit and the method of revascularization should be no different than that used with cardiopulmonary bypass. However, we still recommend conventional methods of revascularization (on-pump with saphenous vein conduits) for the ischemic patient.
Aged↗
Anatomic lung resections using minimally invasive thoracic surgery (MITS).
We have designed a minimally invasive thoracic surgery (MITS), which, in this report, we compare to the conventional muscle-sparing thoracotomy (MST). We retrospectively compared 70 consecutive MITS patients (mean age, 65 years) and 70 consecutive MST patients (mean age, 60 years) who underwent thoracotomies for similar pathologies between 1995 and 1997. All comparisons between the MITS and MST groups were made using the Student's t-test. Extubation times, intensive care unit (ICU) stays, analgesia requirements, morbidities/mortalities, hospital lengths of stay (LOS), and cost analyses were all compared. Nine of the 70 planned MITS procedures were converted intraoperatively to MST. All nine of these patients were admitted to the ICU. All of the MST patients spent a minimum of 24 hours in the ICU. The mean LOS in the MITS group was 2.87 days with a mean hospital cost of 6,480.00 dollars, while in the MST group it was 8.28 days (P = 0.003) and 11,490.00 dollars (P = 0.006). There were no deaths and 6 complications in the MITS series. There were two mortalities and 15 complications in the MST patients. Our MITS procedure not only may be performed with low morbidity and cost, it also allows early ambulation and early hospital discharge.
Journal Article↗
Coronary artery bypass with "snake" grafts: fifteen-year follow-up.
BACKGROUND: Since 1970 we have used the "snake" graft in more than 8000 cases of coronary artery bypass grafting (CABG). We followed, for over 15 years, 214 patients who underwent CABG in 1981 with only a "snake" graft by one surgeon (William H. Sewell, M.D.). METHODS: Eighty-four percent (180/214) were male and 16% (34/214) were female with an average age of 58 and 66 years, respectively. The average left ventricular ejection fraction (LVEF) was > 55% in 63% (135/214) of the patients and < 55% in 37% (79/214); 15% (33/214) had diabetes and 77% (164/214) were smokers. The mean preoperative New York Heart Association (NYHA) functional class was 3.1+/-0.6 (range I-IV). Diagnostic arteriography demonstrated two vessel disease in 5% (9/214), three vessel disease in 89% (191/214), and left main disease in 6% (14/214). The average number of distal grafts per patient was 3.4. Coronary arteriography was performed 8-weeks postoperatively. Annual follow-up with a questionnaire determined incidence of redo procedures and survival. RESULTS: The perioperative 30-day mortality was 1% (2/214). At 8 weeks there was a graft patency rate end-to-side of 85%, side-to-side 97%, and the proximal segment of 95%. Four percent (9/214) had redo surgery while 6% (13/214) underwent angioplasty during the 15 years. Sixty-seven percent (144/214) were alive at 15 years with a significantly improved mean NYHA functional class of 1.2+/-0.9 (p < 0.001). Twenty-four percent of those 166 live patients (35/144) had an average LVEF of 50% by echocardiography. There were 34 (16%) noncardiac deaths, 32 (15%) cardiac deaths, and 2 (1%) unknown causes. CONCLUSIONS: The results of this study suggest that survival using the "snake" graft conduit is competitive with that observed using the internal mammary artery.
Aged↗
Regulation of integrin-mediated adhesion by muscarinic acetylcholine receptors and protein kinase C in small cell lung carcinoma.
STUDY OBJECTIVES: Improved understanding of the phenotypic characteristics of small cell lung cancer (SCLC) cells may facilitate the development of new therapies for this bronchogenic malignancy with early metastases. Herein we investigate whether activation of the M3 subtype of muscarinic acetylcholine receptor (mAChR) expressed on SCLC cells affects beta1-integrin-mediated adhesion of these cells. DESIGN: Adhesion of the SCLC cell lines SCC-9 and NCI-H345 to extracellular matrix (ECM) proteins was investigated. Cell adhesion was quantified by labeling the cells with either toluidine blue dye and measuring optical density or 3H-thymidine and measuring beta-activity. Fluorescence-activated cell sorting was used to quantify the SCLC cell surface expression of beta1-integrins. SETTING: Experiments were conducted in the Molecular Pharmacology Laboratory, Guthrie Research Institute. MEASUREMENTS AND RESULTS: Activation of mAChR with the agonist carbachol (10 microM, 1.5 h) significantly increases adhesion of the SCC-9 SCLC cell line to the ECM proteins laminin and collagen types I and IV. In contrast, mAChR activation does not alter the adhesion of SCC-9 cells to vitronectin, fibronectin, poly-L-lysine, or bovine serum albumin. Carbachol also does not alter the adhesion of NCI-H345 SCLC cells that lack functional mAChR. Preincubation of SCC-9 cells with the AIIB2 blocking antibody to beta1-integrin inhibits mAChR-induced adhesion to ECM proteins. Immunofluorescence analysis indicates that mAChR activation does not alter the surface expression of beta1-integrins by SCC-9 cells. Direct stimulation of protein kinase C (PKC) by treatment with phorbol 12-myristate 13-acetate (PMA) (10 nM, 1.5 h) increases the adhesion of both the SCC-9 and NCI-H345 cell lines to ECM proteins. These results indicate that direct activation of PKC or stimulation of M3 mAChR (which results in increased PKC activity) increases the binding activity of beta1-integrins, resulting in increased adhesion of SCLC cells to ECM proteins. CONCLUSIONS: The ability of mAChR to regulate SCLC proliferation and adhesion suggests that activation of these receptors may be used to alter SCLC tumorigenesis and metastasis.
Atropine↗
A coronary artery bypass "fast-track" protocol is practical and realistic in a rural environment.
BACKGROUND: In this study we determine retrospectively whether assignment of all patients undergoing coronary artery bypass grafting to a "fast-track" protocol (FT) is practical and realistic in our rural institution. METHODS: We compared the outcome of 266 consecutive patients undergoing coronary artery bypass grafting who were fast-tracked in 1996 with that of 266 consecutive patients who were managed conventionally (NFT) in 1994. The surgical techniques were comparable in both groups; however, FT anesthesia used inhalational agents and short-acting narcotics. All comparisons were performed using the Student's t test or the chi 2 test. RESULTS: Postoperatively 95% of the FT group were extubated by 24 hours compared with 0% in the NFT group (p < 0.0001). The mean intensive care unit length of stay in the FT group was 1.7 +/- 0.8 days, whereas it was 2.6 +/- 0.6 days in the NFT group (p < 0.001). The mean postoperative length of stay was 6.4 +/- 1.2 days in the FT group compared with 7.5 +/- 0.9 days in the NFT group (p < 0.001). There were no significant differences in 30-day morbidity/mortality. There was a substantial cost savings in the FT group. CONCLUSIONS: The fast-track protocol can be successful without any compromise of patient care. Early discharge from the hospital, however, is not always feasible.
Adjuvants, Anesthesia↗
Platelet-rich plasma harvest in redo CABG.
Explore the source record for details and available documents.
Blood Loss, Surgical↗
Passive retrograde cerebral perfusion during routine cardiac valve surgery reverses middle cerebral artery blood flow and reduces the risk of stroke.
BACKGROUND AND AIMS OF THE STUDY: Cerebral complications constitute a major source of morbidity and disability after cardiac valve surgery. These may be the result of macroembolization (air/debris) or inadequate perfusion pressure. In an attempt to reduce the incidence of cerebral vascular accident (CVA)/transient ischemic attack (TIA), we have routinely performed three minutes of passive retrograde cerebral perfusion (PRCP) on all valve cases. Here, we retrospectively determined our perioperative (0-30 day) incidence of CVA/TIA. METHODS: In all cases, the extracorporeal circuit consisted of an ascending aortic cannula and either one two-stage or two single-stage venous cannulae. Three minutes of PRCP was instituted in all cases upon discontinuation of anterograde cardiopulmonary bypass (CPB) via a shunt distal to the heart/lung machine between the arterial and venous cannulae. Mean systemic blood pressure was maintained at 60 mmHg with Neo-Synephrine. Central venous pressure never exceeded 25 mmHg. In 10 cases, transcranial Doppler ultrasonography (TCD) was used to assess middle cerebral artery (MCA) blood flow. In total, 209 consecutive valve procedures with PRCP (group A) were compared with 164 consecutive valve procedures with no PRCP (group B). All data were compared using Fisher's exact probability test. The incidence of CVA/TIA was also compared with published retrospective and prospective data. RESULTS: TCD demonstrated blood flow reversal in the MCA after a minimum of 30 s. The incidence of CVA/TIA was 0% (0/209) in group A, and 2.4% (4/165) in group B (p = 0.0386). The incidence of CVA/TIA in published retrospective data is 0.7-3.8% and 4.8-5.2% in prospective data. CONCLUSIONS: We have demonstrated in 209 consecutive valve cases that, upon discontinuation of CPB, routine three-minute PRCP not only reversed MCA blood flow, but also reduced the incidence of neurologic events.
Cerebrovascular Circulation↗
The effect of leukocytes on adhesion molecules. An explanation of blood transfusion enhancement of tumor growth.
OBJECTIVE: To determine the mechanism of the adverse relationship between perioperative blood transfusion and lung cancer recurrence, by focusing on endothelial cell adhesion molecules (CAMs), which are thought to play a role in distant tumor cell implantation. DESIGN AND OUTCOME MEASURES: Murine endothelial cells were cocultured with allogeneic leukocytes, syngeneic leukocytes, and syngeneic lung carcinoma cells for 60 hours. The percentage of endothelial cells expressing vascular CAMs (VCAMs) and intercellular CAMs (ICAMs) was quantified during this time using indirect immunofluorescence and flow cytometry. Tumor cell adhesion to the endothelium was quantified for 6 hours using cells labeled with sulfur 35 and a scintillation counter. SETTING: Laboratory. MATERIALS: C57/BL and Balb/C mice. RESULTS: Vascular CAM was not expressed on the endothelium, but ICAM was preferentially expressed without stimulation. Tumor-cell adhesion and endothelial ICAM expression were inversely related. After 15 hours of coculture, tumor cell adhesion was four-fold greater in the experimental group than in the control, and coincident endothelial ICAM expression was fourfold lower. CONCLUSION: Endothelial cell ICAM expression is negatively correlated with metastatic potential.
Animals↗
Immediate hemodynamic effects of thrombolytic therapy on the ischemic myocardium.
Thrombolytic agents are used to restore coronary artery perfusion and limit the size of a myocardial infarction. The systemic effects of these drugs, streptokinase (SK), urokinase (UK), and recombinant tissue plasminogen activator (rtPA), have been studied extensively. Although their effects on rheology and late myocardial performance have been well-documented to date, there have not been any studies evaluating the acute hemodynamic consequences of thrombolytics immediately after administration. In this report we use an isolated Langendorf rodent heart preparation to evaluate the acute hemodynamic effects of thrombolytic therapy on both the normal and the ischemic myocardium. We quantified performance by documenting cardiac output, coronary blood flow, and blood pressure. Although each thrombolytic agent significantly transiently impairs cardiac performance, differences in effect between the agents were statistically insignificant. This was also the case with both the normal as well as the ischemic myocardium. The results of this study would not support favoring the use of one of these agents over the other with regards to primary myocardial performance.
Animals↗
Acute dilutional anemia and critical left anterior descending coronary artery stenosis impairs end organ oxygen delivery.
OBJECTIVE: Limited cardiac reserve, secondary to coronary disease, may be associated with end organ morbidity. In this study, we investigate the significance of anemia in the pathogenesis of this phenomenon. DESIGN: Nonrandomized controlled animal trial. SETTINGS: Animal laboratory in a university hospital. SUBJECT: Anesthetized dogs. INTERVENTIONS/MEASUREMENTS: Fourteen anesthetized dogs underwent isovolemic hemodilution with 6% hetastarch from a baseline hematocrit of 40 to 20%. Radioactive microspheres were used to evaluate regional blood flow and cardiac index. Systemic oxygen delivery, consumption, serum lactate, and systemic vascular resistance were recorded during each experiment. Arterial venous oxygen difference was determined from arterial and mixed venous blood. Seven dogs had an iatrogenic critical stenosis of their left anterior descending coronary artery (experimental group); seven dogs did not (control). MAIN RESULTS: Only in the control animals, the cardiac index increased by 35% with hemodilution to 20%. Systemic oxygen delivery decreased in both the control and the experimental animals. Systemic oxygen consumption and lactate levels were unchanged in both groups. In the renal cortex, spleen, distal colon, ileum, gallbladder, and stomach body, regional O2 delivery was significantly decreased with hemodilution to 20% in both groups. This finding was also observed in the left ventricle and cervical spinal cord in the experimental group. In addition, regional O2 delivery was reduced in the spleen, distal colon, and gallbladder with hemodilution to only 30%. Regional blood flow in the stomach body, gallbladder, ileum, renal cortex, and distal colon, in both groups, and the spleen in the control group was unchanged from baseline with hemodilution to 20%. However, regional blood flow under all other circumstances (control or experimental) was significantly increased with hemodilution to 20% with the exception of the spleen, which showed significant regional blood flow decrease in the experimental group only. CONCLUSIONS: These data suggest that with limited cardiac reserve, anemia may compromise aerobic splanchnic circulation. These observations may further our understanding of the pathogenesis of cholecystitis, gastric stress ulcers, ileal endotoxin translocation, and ischemic colitis in critically ill patients with coronary artery disease.
Anemia↗
Migration of an automatic implantable cardioverter-defibrillator patch causing massive hemothorax.
The automatic implantable cardioverter-defibrillator is composed of shocking electrodes (patches or coils), sensing electrodes, and a generator implanted in the abdominal wall. A number of complications with defibrillators have been reported, including migration of the various components. We describe a patient in whom one of the patches, originally sutured extrapericardially, migrated in the right hemithorax and eroded into the ipsilateral lung. The resultant massive hemothorax necessitated urgent thoracotomy, patch removal, and hematoma evacuation. A hybrid implantable cardioverter-defibrillator system was created as a replacement to minimize surgery while protecting the patient from sudden death.
Defibrillators, Implantable↗
A technique of positive-pressure single-lung ventilation via a silicone T-Y stent.
Airway control and protection, in any operation, is the first priority. The presence of a T-Y stent in the proximal airway can complicate this fundamental principle. Here we describe an effective and safe technique for positive-pressure single-lung ventilation via a T-Y stent for a lung lobectomy.
Airway Obstruction↗
Modulation of alloreactivity in transplant recipients by phenotypic manipulation of donor endothelium.
Phenotypic manipulation of allograft endothelium to reduce immunogenicity would have a significant impact on transplantation. In this study we have demonstrated that random seeding of a heart allograft with endothelium, of host origin, not only promotes long-term survival, but reduces the requirement for pharmacologic immunosuppression. We propose that this simple technology could easily be extrapolated to the clinical arena where hypothermia and preservation solutions have allowed allografts to remain ex vivo for extended periods.
Animals↗
Cardiopulmonary bypass with adequate flow and perfusion pressures prevents endotoxaemia and pathologic cytokine production.
Endotoxin and cytokine inflammatory mediators comprise the afferent and efferent limbs of the 'acute phase response'. During cardiopulmonary bypass (CPB) there may be gut translocation of endotoxin and contact activation of lymphocytes. It has been hypothesized that the haemodynamic instability encountered following CPB is caused by the 'acute phase response'. In this study we attempted to quantify the acute phase response in patients undergoing open-heart surgery and determine the influence of these cytokines on perioperative morbidity. Four perioperative blood samples were drawn from 20 consecutive patients undergoing coronary artery bypass grafting (CABG). These samples were assayed for endotoxin and four cytokines. In all cases the cardiac index was maintained > 2.4 l/min/m2 during nonpulsatile normothermic bypass (37 degrees C) and > 1.8 l/min/m2 during nonpulsatile hypothermic bypass (28 degrees C), and the perfusion pressure > 60 mmHg. Endotoxin was not detected in any of the test samples despite positive nonpatient controls. Interleukin 6 (IL-6) and tumour necrosis factor (TNF) were not detected despite an assay sensitivity of 80 and 10 pg/ml, respectively. TNF was detectable with an assay sensitivity of 0.5 pg/ml although there were no significant differences within the group. Interleukin 1 (IL-1) was detected (range = 0.98 - 9.09 ng/ml) in patients and again there were no trends within the group. The platelet activating factor (PAF) values peaked at crossclamp release (1.3 ng/ml versus a baseline of 0.2 ng/ml); however, there was no significant difference within the study.
Analysis of Variance↗
The haemostatic effectiveness of autologous platelet rich plasma sequestered after heparin administration and institution of cardiopulmonary bypass.
Preoperative harvesting and postoperative reinfusion of autologous platelet rich plasma (PRP) has been reported to decrease blood loss as well as the requirement for homologous blood transfusion following cardiopulmonary bypass (CPB). We have developed a technique of intraoperative PRP sequestration which occurs during the initial period of CPB after the patient's circulation is supported and heparin has been given (PRP+). This process does not require any additional hardware, personnel or expense and it is performed without difficulty or complication. To evaluate the effect of PRP+ sequestration and reinfusion on blood loss and homologous blood requirement after CPB, we randomly assigned 126 consecutive patients undergoing elective open heart surgery into the experimental group 1 (PRP+) (n = 64) or the control (no platelet pheresis) group 2 (n = 52). A third group (n = 10) were not included in the randomization. Patients in group 3 had PRP prepared by conventional techniques (PRPc) prior to heparin administration and given to the patient after protamine infusion. Aggregation and activation studies were performed on the PRP+, PRPc, and blood bank platelets (BBP). Per cent aggregation of PRP in response to ADP was superior to that of BBP. There were no significant differences in ADP induced aggregation between PRP+ and PEPc. There was no significant difference in platelet activation (CD62) or number between the three groups. Patients infused with PRP+ showed significantly increased aggregation to ADP when compared with untreated patients 120 minutes after return to the ICW. Furthermore, more homologous haemostatic components (platelets/fresh frozen plasma) were required in the control group. We have demonstrated that collection of autologous PRP+ after administration of heparin does not interfere with its haemostatic effectiveness compared with PRPc prepared before the initiation of bypass. Moreover, this can be performed universally in haemodynamically unstable patients without any additional costs.
Aged↗
Thoracentesis and chest tube drainage.
Thoracentesis can be used as both a diagnostic and a therapeutic tool. Tube thoracostomy can be life saving. Each technique requires familiarity with the principles of pulmonary and pleural anatomy and physiology. It is mandatory that all pulmonary and critical care practitioners be familiar with the indications, benefits, and risks of these interventions to prevent devastating complications.
Chest Tubes↗