Biomedical subjects

Willis H Williams

Publications and source records attributed to Willis H Williams.

8 recordsLinked to original sources

PubMed2005

Pulmonary outcomes of off-pump vs on-pump coronary artery bypass surgery in a randomized trial.

STUDY OBJECTIVES: Comparison of pulmonary outcomes after off-pump coronary artery bypass (OPCAB) vs on-pump coronary artery grafting with cardiopulmonary bypass (CABG/CPB). STUDY DESIGN: We examined preoperative and postoperative respiratory compliance, fluid balance, hemodynamics, arterial blood gases, chest radiographs, spirometry, pulmonary complications, and time to extubation in a prospective trial of 200 patients randomized to OPCAB vs CABG/CPB performed by one surgeon. RESULTS: One CABG/CPB patient and two OPCAB patients required mitral valve repair or replacement and were withdrawn. After three crossovers from CABG/CBP to OPCAB and one crossover from OPCAB to CABG, 97 CABG/CPB patients and 100 OPCAB patients remained. There were no significant preoperative demographic differences between groups. Postoperative compliance was reduced more after OPCAB than after CABG/CPB (- 15.4 +/- 10.7 mL/cm H(2)O vs - 11.2 +/- 10.1 mL/cm H(2)O [mean +/- SD]; p = 0.007), associated with rotation of the heart into the right chest to perform posterolateral bypasses (p < 0.001) and the concomitant increased fluid requirements necessary to maintain hemodynamic stability during rotation of the heart. In addition to higher intraoperative fluid intake (4,541 +/- 1,311 mL vs 3,585 +/- 1,033 mL, p < 0.0001), OPCAB patients had higher intraoperative fluid balance (3,903 +/- 1,315 mL vs 1,772 +/- 1,373 mL, p < 0.0001), and higher postoperative pulmonary arterial diastolic pressure (15.0 +/- 5.5 mm Hg vs 11.8 +/- 5.2 mm Hg, p < 0.0001) and central venous pressure (10.4 +/- 4.5 mm Hg vs 8.4 +/- 4.7 mm Hg, p < 0.0001). Despite lower compliance, immediate postoperative Pao(2) on fraction of inspired oxygen of 1.0 (275 +/- 97 torr vs 221 +/- 92 torr, p = 0.001) was higher after OPCAB and extubation was earlier (p = 0.001). Postoperative chest radiographs, spirometry, mortality, reintubation, or readmission for pulmonary complications were not different between groups. CONCLUSIONS: Compared to CABG/CPB, OPCAB was associated with a greater reduction in postoperative respiratory compliance associated with increased fluid administration and rotation of the heart into the right chest to perform posterolateral grafts. OPCAB yielded better gas exchange and earlier extubation but no difference in chest radiographs, spirometry, or rates of death, pneumonia, pleural effusion, or pulmonary edema.

Cardiopulmonary Bypass↗

PubMed2004

Off-pump vs conventional coronary artery bypass grafting: early and 1-year graft patency, cost, and quality-of-life outcomes: a randomized trial.

CONTEXT: Previous trials of off-pump coronary artery bypass (OPCAB) have enrolled selected patients and have not rigorously evaluated long-term graft patency. A preliminary report showed OPCAB achieved improved inhospital outcomes, similar completeness of revascularization, and shorter lengths of stay compared with conventional coronary artery bypass grafting (CABG). OBJECTIVE: To assess graft patency, clinical and quality-of-life outcomes, and cost among patients while in the hospital and at 1-year follow-up. DESIGN, SETTING, AND PATIENTS: Randomized controlled trial of patients unselected for coronary anatomy, ventricular function, or comorbidities between March 10, 2000, and August 20, 2001, at a US academic center. A total of 200 patients were enrolled; 3 patients were withdrawn after randomization for mitral valve repair or replacement. Follow-up was complete for 197 patients at 30 days; 185 at 1 year. INTERVENTIONS: One surgical session consisting of elective OPCAB or CABG with cardiopulmonary bypass. The surgeon had extensive experience performing off-pump surgery; patients were subsequently managed by blinded protocols. MAIN OUTCOME MEASURES: Coronary angiography documented graft patency prior to hospital discharge and at 1 year; health-related quality of life; and cost of the index and subsequent hospitalization(s). RESULTS: Graft patency was similar for OPCAB and conventional CABG with cardiopulmonary bypass at 30 days (absolute difference, 1.3%; 95% confidence interval [CI], -0.66% to 3.31%; P =.19) and at 1 year (absolute difference, -2.2%; 95% CI, -6.1% to 1.7%; P =.27). Rates of death, stroke, myocardial infarction, angina, and reintervention were similar at 30 days and 1 year. There were no significant differences in health-related quality of life. Mean total hospitalization cost per patient at hospital discharge was 2272 dollars (95% CI, 755 dollars-3732 dollars) less for OPCAB (P =.002) and 1955 dollars (95% CI, -766 dollars to 4727 dollars) less at 1 year (P =.08). CONCLUSIONS: In this randomized single-surgeon trial among unselected patients with angiographic follow-up, OPCAB achieved similar graft patency in the hospital and at 1 year. Cardiac outcomes and health-related quality of life at 30 days and 1 year were similar and patients incurred a lower cost. OPCAB may provide complete revascularization that is durable and cost-effective.

Aged↗

PubMed2003

Outcomes and long-term survival for patients undergoing mitral valve repair versus replacement: effect of age and concomitant coronary artery bypass grafting.

BACKGROUND: A paucity of literature is available on the effects of age and coronary artery bypass grafting (CABG) on the outcomes of patients undergoing mitral valve (MV) repair versus replacement. METHODS AND RESULTS: A matched study was performed using prospectively collected data from the Emory cardiovascular database from 1984 to 1997 comparing 625 MV repair patients with 625 MV replacement patients. Mean age was significantly higher in the replacement group (56+/-14 versus 55+/-14 years). Preoperative demographics and postoperative outcomes were similar between groups. Length of stay (LOS) was significantly less in the repair group (9.5+/-9.4 versus 12.3+/-13.1 days). In-hospital mortality was significantly less in the repair group (4.3% versus 6.9%), and overall 10-year survival was significantly higher in the repair group (62% versus 46%). Ten-year survival of patients <60 years of age was significantly higher in repair patients (81% versus 55%) but similar in patients > or =60 years of age (33% versus 36%, respectively). Ten-year survival of MV repair without CABG was significantly higher compared with MV replacement patients (74% versus 51%) but similar to patients with concomitant CABG (28% versus 34%, respectively). Independent predictors of long-term mortality included increasing age, urgent/emergent status, female sex, diabetes mellitus, increasing weight, heart failure, decreasing ejection fraction, concomitant CABG, and MV replacement. CONCLUSIONS: Mitral valve repair has reduced LOS and improved in-hospital and 10-year survival. However, in the present series, MV repair does not provide significant long-term survival benefit over MV replacement in patients older than 60 years of age or those requiring concomitant CABG.

Adult↗

PubMed2003

Mitral valve replacement in children.

BACKGROUND AND AIMS OF THE STUDY: Although repair of the mitral valve in children with or without concomitant congenital heart defects has improved significantly, it is not always achievable. The study aim was to review a 20-year experience of mitral valve replacement (MVR) in children. METHODS: Since 1980, 90 patients (37 males, 53 females; mean age 8.1 years; range: 3 weeks to 18 years) have undergone a total of 102 MVR operations (12 redo-MVR, nine multiple valves, and three with common atrioventricular valve replacement). Tissue valves were used in 13 patients (14%). The etiology for valve disease was congenital in 72 patients (80%), and 34 patients had atrioventricular septal defect (AVSD). Other etiologies included rheumatic heart disease (n = 8), myxomatous disease (n = 4), endocarditis (n = 3), and Kawasaki disease, left atrial myxoma and idiopathic hypertropic subaortic stenosis (each n = 1). In total, 36 patients (40%) had a previous mitral valve repair, and 34 (38%) had concomitant repair of associated lesions. RESULTS: Hospital mortality was significantly higher in children aged < 2 years (52%, 15 of 29) compared with older children (3%, 2 of 61) (p < 0.001). Fourteen hospital deaths were associated with failed repair of complex congenital heart defects, mainly AVSD under age 2 years, followed by MVR. Mean follow up was 9.3 years (range: 7 months to 21.5 years). There were four late deaths; major events included thromboemboli (n = 6), bleeding (n = 9), endocarditis (n = 1) and cardiomyopathy with orthotopic heart transplantation (n = 7). CONCLUSION: MVR is a good surgical option for a nonrepairable mitral valve in children aged over 2 years. MVR following failed AVSD repair carries a high incidence of morbidity and mortality.

Adolescent↗

PubMed2003

Is routine use of temporary epicardial pacing wires necessary after either OPCAB or conventional CABG/CPB?

OBJECTIVES: Placement of temporary epicardial pacing wires (PWs) after coronary artery bypass graft (CABG) is routine procedure in many centers, despite infrequent but significant complications, including hemorrhage, tamponade, and death. The resurgence of off-pump CAB (OPCAB) prompted a reexamination of this practice. METHODS: Two hundred unselected coronary patients were prospectively randomized to undergo either OPCAB or conventional CABG on cardiopulmonary bypass (CAB G /CPB). Three patients were excluded after randomization. Management, including placement or avoidance of PWs, followed unbiased, criteria-driven protocols. Patients requiring pacing immediately prior to chest closure (bradycardia with cardiac ou t put < 2.2 L/min per m2, nodal or junctional arrhythmias, atrioventricular block) received PWs. In all other patients use of PWs was avoided. Duration of pacing and complications related to PW placement or avoidance were recorded. RESULTS: PWs were placed in 33 of 197 (17%) of patients, 23 of whom were paced after arrival in the intensive care unit and 10 of whom were never paced. Twelve OPCAB versus 21 CABG/CPB patients had PWs (P =.08). Patients with PWs were older, more commonly female, had more chronic obstructive pulmonary disease, and had longer hospital stays than those not requiring PWs. Preoperative beta blocker use, coronary anatomy, and number of grafts performed were not correlated with need for PWs. No patient without PWs required postoperative pacing by any means nor suffered any complication attributable to avoidance of PWs. CONCLUSIONS: Need for pacing immediately prior to chest closure accurately and safely identifies coronary patients who will require postoperative pacing after OPCAB or CABG/ CPB. Routine use of PWs is unnecessary. OPCAB may be associated with a reduced requirement for PWs.

Aged↗

PubMed2002

One hundred pulmonary valve replacements in children after relief of right ventricular outflow tract obstruction.

BACKGROUND: Surgical repair of obstructive lesions of the right ventricular outflow tract (RVOT) in children commonly creates pulmonary valve incompetence that may eventually require pulmonary valve replacement (PVR). We reviewed our experience with PVR late after RVOT reconstruction. METHODS: We performed 100 PVRs in 93 children 1.1 months to 22.4 years (median 8) after RVOT reconstruction. Children with right ventricular to pulmonary artery conduits and primary PVRs were excluded. Age at PVR was 4.5 months to 27.9 years (median 9.5 years). Initial diagnosis was tetralogy of Fallot and variants, 62; critical pulmonary stenosis, 15; pulmonary atresia with intact ventricular septum, 7; and others, 9. Eleven patients had a redo PVR. A total of 62 PVRs were homografts; 38 were porcine valves. RESULTS: There was one early death. On follow-up of 5 months to 12.4 years (mean 4.9 years) there were no late deaths although 1 child underwent cardiac transplantation. Actuarial freedom from redo PVR at 8 years was 100% for porcine valves but 70% for homograft valves (p = 0.17). For children younger than 3 years at PVR, freedom from reoperation was 76% at 1 year and 39% at 8 years compared with freedom from redo PVR at 8 years of 100% for children older than 3 years. On latest echocardiogram 97% of porcine valves had mild or no pulmonary regurgitation compared with 72% of homograft valves. CONCLUSIONS: PVR after RVOT reconstruction can be performed with low risk. Porcine valves may be superior to homograft valves although this advantage may be due to older age at time of PVR.

Adolescent↗

PubMed2002

Konno aortoventriculoplasty in children and adolescents: from prosthetic valves to the Ross operation.

BACKGROUND: In children with complex multilevel left ventricular outflow tract obstruction (LVOTO), the Konno aortoventriculoplasty is used to enlarge the aortic root and increase the size of the aortic valve implanted. We present our experience with the evolution of this surgical approach from prosthetic valves to the Ross operation. METHODS: Between March 1982 and July 2000, 60 patients (36 males and 24 females) had 72 Konno aortoventriculoplasties (prosthetic valve and Konno group [57 patients; redo, 12] and Ross-Konno group [15 patients]). The patients' ages ranged from 5 days to 18 years (mean, 8.2 years). The underlying anatomic diagnoses were congenital aortic stenosis and LVOTO in 51 patients, coarctation of the aorta with bicuspid aortic valve in 13, severe aortic insufficiency associated with a ventricular septal defect in 8, interrupted aortic arch in 6, mitral stenosis in 6, atrioventricular septal defect in 5, and endocarditis in 3. There was no statistical difference in age or diagnosis between the two groups. The prosthetic valve group included 42 mechanical valves, 9 homografts, and 6 xenografts. RESULTS: Follow-up ranged from 10 months to 18.5 years (mean, 9.7 years) in the prosthetic valve and Konno group compared with 5 months to 3.7 years (mean, 2.1 years) in the Ross-Konno group (p < 0.05). There were 10 early deaths and four late deaths in the prosthetic valve and Konno group as compared with one early death and two late deaths in the Ross-Konno group (p = not significant). Reoperations for LVOTO and aortic valve replacement were significantly higher in the prosthetic valve and Konno group as opposed to the Ross-Konno group (16 vs 0, p < 0.05) mainly because of the biological valve and Konno subgroup. There were no statistical differences in reexploration for bleeding, pacemaker insertion, and reoperations for indications other than LVOTO and aortic valve replacement between the two groups. CONCLUSIONS: The Konno aortoventriculoplasty is a good surgical option for complex LVOTO. Patients with a prosthetic valve and Konno carry a high rate of reoperation. Early operative results with the Ross-Konno operation seem promising.

Adolescent↗

PubMed2002

Valve replacement in patients on chronic renal dialysis: implications for valve prosthesis selection.

BACKGROUND: Reports are sparse describing heart valve replacement in patients with end-stage renal disease. This review assesses a 15-year experience and outcomes after valve replacement in patients on chronic preoperative renal dialysis. METHODS: A computerized database, hospital records, and telephone contact provided outcome data for patients on chronic dialysis undergoing valve replacement between March 22, 1985, and October 13, 2000, in two hospitals. RESULTS: Seventy-two patients underwent 95 valve procedures (74 operations). Ages ranged from 23 years to 84 years (mean, 57 years). Fifty-five aortic, 30 mitral, and 3 tricuspid valve replacements and 7 valvuloplasties were performed. Six of the 74 procedures were reoperative valve replacements. In the 46 patients with reliable long-term (greater than 30 days) follow-up data, significant bleeding or stroke was documented in 17 of 34 patients with a mechanical valve and 1 of 12 patients with a bioprosthetic valve. Overall survival (including two operative deaths) was 72.8% at 3 months, 65.4% at 6 months, 60.5% at 1 year, 39.8% at 2 years, 28.5% at 3 years, and 15.9% at 6 years (Kaplan-Meier). Type of valve implanted did not influence early and late survival. CONCLUSIONS: In this series of patients on chronic dialysis, survival appears to justify valve replacement. However, the sixfold higher incidence of late bleeding or stroke in patients on dialysis with a mechanical valve requiring warfarin suggests that bioprosthetic valves are the valve substitute of choice in patients on chronic dialysis.

Adult↗