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PubMedDate not supplied

Limits of arterial myocardial revascularization.

A prospective study of myocardial blood perfusion after coronary artery bypass graft (CABG) was conducted in two groups of patients. In group 1, a two-year assessment by exercise thallium myocardial scintigraphy without medical treatment was performed in 122 patients who consecutively underwent CABG with exclusive use of both internal mammary arteries (IMA) and gastroepiploic artery (GEA). In group 2, myocardial function and perfusion were determined by radionuclide investigations performed before and one year after CABG in 100 patients with preoperative LV dysfunction (defined as LV ejection fraction (LVEF) less than 0.40), comparing results of myocardial revascularization performed with either exclusive arterial grafts (arterial group, 54 patients) or one arterial graft (IMA) associated with a sequential vein graft (vein group, 46 patients). In group 1, 21% of patients presented silent residual electric ischemia during exercise stress testing and 26% had reversible scintigraphic ischemic defect despite complete revascularization, 18% of those in the inferior wall bypassed with GEA and 8% in the anterior wall bypassed with the right IMA. In group 2, the significant preoperative ischemia significantly decreased in both the vein group and the arterial group. LV function was significantly improved in the vein group; in contrast there was no modification of LV function in the arterial group. A multivariate analysis showed that the surgical technique used and the preoperative LVEF were independent prognostic factors of the postoperative myocardial outcome, with a positive impact of the vein use on the postoperative myocardial function recovery. It is important to recognize that arterial grafts have some limitations in the ability to supply blood flow for coronary circulation that may induce postoperatively silent residual myocardial ischemia and a lack of LV function recovery.

Coronary Artery Bypass↗

PubMed2006

Postoperative physical training following colorectal surgery: a randomised, placebo-controlled study.

BACKGROUND AND AIMS: Major surgery is often followed by fatigue and reduced physical function. We wished to study if postoperative physical training reduced fatigue and improved physical function. MATERIAL AND METHODS: Randomised, placebo-controlled, single-blinded study. Participants were unselected patients > or = 60 years undergoing elective colorectal surgery without disseminated cancer or inflammatory bowel disease. Group A trained muscular strength and work capacity. Group B performed relaxation exercises and received hot wrappings and massage. Main outcome measures were: fatigue (visual analogue scale), muscular strength, walking speed, physical performance test, and physical function questions (SF-36). RESULTS: Preoperatively the two groups were similar except that A was more fatigued than B. By postoperative day seven fatigue had increased compared to preoperatively, more in B than A, but by day 30 and 90 there were no significant differences between groups. All indices of physical function decreased postoperative day seven and were at the preoperative level day 90 with no significant differences between groups in change in function. Day seven the change in knee extension strength tended to be lower in B than A but by day 30 changes were similar in both groups. CONCLUSION: Postoperative training did not improve physical function, but reduced fatigue in hospital.

Aged↗

PubMed2004

The failing Fontan circulation: successful conversion of atriopulmonary connections.

OBJECTIVES: Symptoms from low cardiac output or refractory atrial arrhythmias are complicating atriopulmonary (classical) Fontan connections. We present our experience of converting such patients to total cavopulmonary connections with and without arrhythmia surgery. METHODS: Between 1997 and 2002, 15 patients (mean age, 19.7 +/- 7.0 years) underwent conversion operations 12.7 +/- 3.5 years after atriopulmonary Fontan operations. Preoperative New York Heart Association functional class was I in 2 patients, II in 2 patients, III in 6 patients, and IV in 5 patients. Four patients underwent intracardiac lateral tunnel conversion alone, and 11 received extracardiac total cavopulmonary connection, right atrial reduction, and cryoablation. RESULTS: No mortality occurred. One patient had conduit obstruction in the immediate postoperative period requiring replacement, and another required a redo operation for endocarditis. Average hospitalization was 17.9 +/- 9.38 days; chest drains were removed on median day 4 (range, 1-29; mean, 7.4 +/- 7.58 days). At follow-up (mean, 42.6 +/- 22.1 months), late atrial arrhythmias had recurred in 3 of 4 patients with intracardiac total cavopulmonary connections (without ablation) and 1 of 11 patients with extracardiac total cavopulmonary connections with ablation. All patients are in New York Heart Association class I or II. Exercise ability (Bruce protocol) improved 69% from a mean of 6.18 +/- 4.01 minutes to 10.45 +/- 2.11 minutes (P <.05). Need for antiarrhythmic agents decreased postoperatively (patients receiving < or =1 antiarrhythmic: 9 preoperatively vs 15 at long-term follow-up, P <.05). No patient has required transplantation. Protein-losing enteropathy, which was present in 1 patient, improved transiently with conversion. There was 1 late death from gastrointestinal hemorrhage. CONCLUSIONS: Fontan conversion can be achieved with low mortality and improvement in New York Heart Association class and exercise ability. Concomitant arrhythmia surgery reduces the incidence of late arrhythmias.

Adolescent↗

PubMed2002

Safety of dobutamine stress echocardiography in patients with unruptured intracranial aneurysms.

Dobutamine stress echocardiography has been increasingly used for the preoperative assessment of patients who undergo major vascular surgery. The safety of this modality has been well documented in various patient subgroups, including patients with aneurysms of the aorta. No previous reports, however, have addressed the safety of this form of stress testing in patients with unruptured intracranial aneurysms. After reviewing the experience of 2 institutions, we identified 40 patients who underwent dobutamine stress echocardiography while harboring at least 1 unruptured intracranial aneurysm, and found no evidence of aneurysm instability in relation to the dobutamine infusion. Although vasodilator stress modalities should intuitively be the non-exercise stress technique of choice in these patients, stress echocardiography with the use of dobutamine appears to be safe and represents an acceptable option when used for diagnostic purposes or preoperative risk stratification in this patient population.

Aged↗

PubMed1997

Radionuclide imaging in the evaluation of heart disease.

Myocardial perfusion imaging with stress testing by exercise or pharmacologic methods and functional evaluation of the left ventricle are useful in many patients. Uses include determination of diagnosis and prognosis of patients with coronary artery disease, preoperative evaluation, management and risk stratification following cardiac events, evaluation of therapy and assessment of left ventricular status in many situations, including postmyocardial infarction and chemotherapy with cardiotoxic drugs. Many recent advances in imaging techniques, stress methods and radiopharmaceuticals make this a complex area of clinical diagnosis. It requires a coordinated effort of primary care, cardiology and nuclear medicine specialists to provide optimal patient care.

Algorithms↗

PubMed1994

Early and intermediate results of the Fontan procedure at moderately high altitude.

At higher elevations, alveolar hypoxia increases pulmonary vascular resistance and may limit the cardiac output of individuals without a subpulmonary ventricle. Thus, we reviewed the outcome of definitive palliation for tricuspid atresia and other forms of single ventricle in 60 consecutive Fontan patients living at a mean elevation of 1,370 m (range, 910 to 2,130 m). There were four early deaths (6.7%; 70% confidence limits, 4.1% to 10.7%) and six late deaths. Kaplan-Meier actuarial survival (+/- standard error) is 79.6% +/- 8.2% at 5 years. Survival was significantly decreased in patients with a preoperative mean pulmonary arterial pressure greater than or equal to 15 mm Hg unless the Fontan procedure was performed with a residual fenestration. Exercise tolerance was significantly worse at higher elevations in a subgroup of patients who have traveled to altitudes of 1,680 to 3,350 m. We conclude that the early and intermediate results of the Fontan procedure at moderately high altitude are similar to results reported at sea level. However, exercise tolerance may be impaired at higher elevations in many patients.

Adolescent↗

PubMed1993

Left atrial plication and mitral valve replacement for giant left atrium accompanying mitral lesion.

Between January 1982 and November 1992, 38 patients received simultaneous mitral valve replacement (MVR) and left atrial plication (LAP) because of giant left atrium accompanying mitral lesion. Their ages ranged from 33 to 70 years, and the mitral lesion was caused by rheumatic heart disease in all patients. MVR was performed with a St. Jude Medical prosthesis for all patients and the left atrial wall was plicated with running 3-0 Nespolene to reduce the width to 3 to 5 cm. Respiration requiring mechanical ventilation more than 48 hours after operation occurred in four patients (10.5%) and postoperative low cardiac output requiring a high dose of dopamine HCl or intraaortic balloon pumping in nine patients (23.7%). The left atrial diameter measured by echocardiogram was a mean of 7.3 +/- 1.0 cm before operation and 5.8 +/- 1.0 cm postoperatively. The cardiothoracic ratio on the chest roentgenogram registered a preoperative mean of 73.3% +/- 9.8% and was 65.7% +/- 8.4% after operation. The pre- and postoperative values were significantly different (p < 0.01). The postoperative exercise level was a mean of 5.3 metabolic units for 24 patients and the postoperative New York Heart Association functional classification indicated Class I or II for 37 patients with no evidence of left atrial thrombus except in the case of one early death. LAP with MVR for patients with giant left atrium due to mitral lesion appeared to result in improvement in respiratory and circulatory functions.

Adult↗

PubMed1996

Bilateral lung volume reduction surgery for advanced emphysema. A comparison of median sternotomy and thoracoscopic approaches.

STUDY OBJECTIVES: To compare short-term outcomes following bilateral lung volume reduction surgery performed by median sternotomy (MS) and video-assisted thoracoscopic surgery (VATS). METHODS: Bilateral lung volume reduction surgery was performed by MS in 80 patients and by VATS in 40. All patients underwent preoperative assessment with pulmonary function testing, arterial blood gas determination, and 6-min walk test (6MWT). Pulmonary function testing and 6MWT were repeated at 3 to 6 months postoperatively. RESULTS: The mean age of the VATS group was lower than that of the MS group (59.3 +/- 9.4 vs 62.4 +/- 6.9 years; p = 0.001), but there were no differences in baseline functional parameters of disease severity (FEV1, FVC, residual volume [RV], arterial PCO2, or 6MWT). All patients in both groups were extubated at the completion of surgery, but 17.5% of patients in the MS group and 2.5% in the VATS group (p = 0.02) subsequently required reintubation at some point during the postoperative course. Thirty-day operative mortality was 4.2% for the MS group and 2.5% for the VATS group (p = not significant). However, total in-hospital mortality was 13.8% for the MS group, while it remained 2.5% for the VATS group (p = 0.05). Mortality was largely confined to patients 65 years of age or older. There was no significant difference in duration of air leaks or length of hospital stay between the two groups. Functional outcomes achieved with the two techniques were similar. Specifically, there was no difference between the two groups in mean postoperative FEV1, FVC, RV, or 6MWT, or in the magnitude of change in these parameters over preoperative values. CONCLUSIONS: Bilateral lung volume reduction surgery performed by either MS and VATS approaches leads to similar improvements in pulmonary function and exercise tolerance. VATS is associated with a significantly lower incidence of respiratory failure and a trend toward decreased in-hospital mortality and may be the preferred technique, particularly for high-risk patients.

Carbon Dioxide↗

PubMed1992

The role of ambulatory monitoring in assessing cardiac risk in peripheral vascular surgery.

Patients undergoing vascular surgery have a uniformly higher risk for postoperative cardiac events, and this risk has traditionally been difficult to quantify. Research has focused on the addition of noninvasive testing to the preoperative assessment of patients at moderate risk by clinical criteria. Current data suggest that preoperative ambulatory monitoring successfully identifies risk for cardiac events in patients undergoing vascular surgery and represents a practical alternative, particularly when patients cannot exercise. Postoperative monitoring appears to be particularly useful in heralding cardiac events in high-risk patients with enough lead time to make prophylactic and preemptive intervention feasible.

Electrocardiography, Ambulatory↗

PubMed1993

[Vagal paraganglioma].

Vagal paragangliomas are rare tumors of neural crest origin. This neoplasm is generally located at various points along the peripheral distribution of the vagus nerve, in the region of the jugular and nodose ganglia, just beneath the perineurium of the nerve, but may arise anywhere along the course of the vagus nerve. Histologically, vagal paragangliomas are similar to carotid body tumors, and occasionally can undergo malignant transformation and metastasize (10-19%) or infiltrate the base of the skull. Selective arteriography can distinguish vagal paraganglioma from carotid body tumor, because the first lies above carotid bifurcation without widening of the vessels. CT scanning and MR are useful for preoperative evaluation of the jugular foramen for neoplastic involvement. Surgical resection is the treatment of choice, but usually it isn't possible to exercise these lesions without sacrifice of the vagus nerve. A careful follow-up examination for the development of metastases and multicentric paragangliomas is necessary. Two cases of vagal paragangliomas one of them with cervical node metastases, are reported. Diagnostic and surgical features of these rare neoplasms are outlined.

Adult↗

PubMed1996

[Surgical treatment of aorto-iliac occlusive disease].

Recently, various endovascular techniques were applied to the short segmental stenosis of aorto-iliac artery. However, bypass operation is the most reliable treatment for multiple stenotic or occlusive lesion. Preoperative systemic evaluation is important for the adequate selection of the patients and the operations. Dipyridamole-thallium scintigraphy is more useful than exercise stress testing to assess cardiac risks of patients with peripheral arterial diseases. Anatomical bypass is the standard operation resulting in favorable patency. Despite of relatively inferior long term patency, extra-anatomical bypass operations are useful alternatives for the patients having high systemic risks or severe sclerosis of aorto-iliac arteries. The improved medical care of the elderly patients with severe systemic diseases results in the increase of extra-anatomical bypass and extended operation combined with infrainguinal revascularization.

Aorta↗

PubMed2003

Respiratory failure after lung transplantation.

STUDY OBJECTIVES: To characterize patients who acquired postoperative respiratory failure after lung transplantation (LT), and to identify risks associated with postoperative respiratory failure and poor surgical outcome. STUDY DESIGN: Retrospective clinical analysis in a tertiary care transplantation center. METHODS: We reviewed the records of 80 consecutive patients who underwent LT from April 1994 to May 1999, analyzing their records for a number of preoperative and perioperative variables and complications. RESULTS: Forty-four patients (55%) acquired postoperative respiratory failure and had a mortality rate of 45%. No difference was noted between patients with respiratory failure and those without in terms of age (mean +/- SD, 56 +/- 9 years vs 53 +/- 11 years), gender, baseline pretransplant arterial blood gas analysis (PaCO(2), 46 +/- 9 mm Hg vs 44 +/- 10 mm Hg), and cardiopulmonary exercise testing (maximum oxygen uptake, 0.76 +/- 0.44 L/min/m(2) vs 0.82 +/- 0.20 L/min/m(2)). Ischemic reperfusion lung injury (IRLI) [55%] and perioperative cardiovascular/hemorrhagic events (36%) were the major contributors to the development of respiratory failure. Preoperative pulmonary hypertension, right ventricular (RV) dysfunction, ischemic times, and need for bilateral LT and cardiopulmonary bypass (CPB) were higher in patients with respiratory failure (p < 0.05) compared to recipients without respiratory failure. However, the presence of preoperative moderate-to-severe RV dysfunction was the only independent factor (odds ratio, 21.9; 95% confidence interval, 1.6 to 309.0). CONCLUSION: Respiratory failure after LT is common and is associated with high morbidity and mortality. Respiratory failure often occurred in patients with operative technical complications, cardiovascular events, and postoperative IRLI, which were observed most in patients requiring CPB because of RV dysfunction.

Female↗

PubMed1978

[Aorto-coronary by-pass: pre and post-operative ergometric evaluation of 95 patients (author's transl)].

95 angina patients surgically treated by aortocoronary saphenous vein by-pass, have been studied by comparing the factors limiting the exercise (i.e. muscular exhaustion, angina, electrocardiographic changes), the total work performed, the O2 consumption and the heart rate-arterial pression product. After surgery the incidence of positive effort tests (effort angina and/or ecg evidence of myocardial ischemia) decreased from 79% to 27,4% (p less than 0,001), and the average amount of work performed increased from 2718 to 3504 Kgm (p less than 0,01), the MVO2 from 13,9 to 15,6 cc/min/Kg. (p less than 0,01) and the heart rate-arterial pression product from 206 to 243 (p less than 0,001). The patients who preoperatively were more invalidated (that is able to performe a lasser amount of physical work) presented a more pronounced improvement in comparison with those who had a greater tolerance to exercise. It seems therefore that for these latter patients the bypass grafting surgery should be justified only if a significant increase of life expectancy and reduction of myocardial infarction incidence could be definitely proved. The exercise performance improvement after surgery was statistically significant only in the patients with post infarction or with unstable angina not in those with chronic angina. The perioperative infarction (present in 8,4% of cases) did not show any unfavorable correlation with the result of the late postoperative effort test.

Adult↗

PubMed2004

Manipulation and arthroscopy under general anesthesia and early rehabilitative treatment for frozen shoulders.

OBJECTIVE: To evaluate the efficacy of manipulation followed by arthroscopic release of the glenohumeral joint in conjunction with an immediate and intensive rehabilitation program. DESIGN: Retrospective, descriptive study. SETTING: A free-standing, university-affiliated orthopedics and rehabilitation hospital. PARTICIPANTS: Forty patients with a clinical diagnosis of adhesive capsulitis resistant to pharmacologic and physical therapy (PT). INTERVENTIONS: Patients underwent manipulation and arthroscopic release of the capsular joint and were given an intensive PT program on the first postoperative day. MAIN OUTCOME MEASURES: All patients were evaluated pre- and postoperatively at follow-up at an average of 42 months by using the Simple Shoulder Test (SST), the Constant-Murley system score, and passive (PROM) and active (AROM) range of motion. RESULTS: The SST, which showed a mean preoperative score of 2.2+/-0.7, was 10.8+/-0.7 (P<.001) after surgery. Preoperatively, the mean Constant-Murley score was 33.2%+/-1.9%; postoperatively, the mean score was 91.7%+/-2.9% (P<.001). PROM increased from 90 degrees to 165 degrees for anterior elevation, from 85 degrees to 160 degrees for abduction, from 20 degrees to 60 degrees for external rotation, and from 10 degrees to 40 degrees for internal rotation. AROM improved for anterior elevation from 82 degrees to 155 degrees; for abduction from 77 degrees to 143 degrees, and for external rotation, with the arm along the patient's side, from 5 degrees to 50 degrees. CONCLUSIONS: Results support the efficacy of manipulation follow by arthroscopic release and rehabilitative treatment for patients with resistant adhesive capsulitis of the shoulder.

Adult↗

PubMed1990

[Evaluation of late surgical results in coronary disease supported by exercise stress test, noninvasive examination and work resumption].

The aim of the study was to assess effectiveness of surgery in management of coronary artery disease (CAD) during long-term follow-up in bearings of physical efficiency and work resumption. 21 males observed during 3-7 years after coronary artery by-pass grafting (CABG) underwent the study. Patients age ranged from 37 to 60 years (mean 51.7) at the beginning of the follow-up. 10 patients had hypertension and 12 suffered from myocardial infarction before CABG. Number of by-pass grafts ranged from 2 to 4. Postsurgical rehabilitation was performed in the cardiological health resort hospital. Assessment was based on anamnesis and physical, ECG, noninvasive as well as ECG bicycle exercise stress examinations. Long-term follow-up proved significant postoperative increase of exercise tolerance expressed by prolongation of ECG exercise test duration as well as augmentation of maximal load and performed work. Left ventricular contractility improvement measured by LVET/PEP and LVETI parameters was also stated. The best results were observed up to 6 years after surgery in patients with grafted left anterior descending artery. Preoperative myocardial infarction did not effect on longterm results of surgery. 75% of patients resumed a work after myocardial revascularization.

Adult↗

PubMed2001

The influence of patient strength, aerobic capacity and body composition upon outcomes after coronary artery bypass grafting.

BACKGROUND: Physical activity, physical fitness and body habitus of patients may be important predictors of outcomes after cardiac surgery. This study sought to quantify physical fitness and determine whether components of fitness enhance the prediction of outcomes in a group of patients undergoing coronary artery bypass grafting. METHODS: A group of 200 patients were evaluated prior to coronary artery bypass surgery. A Veterans Specific Activity Questionnaire (VSAQ) measured aerobic capacity. A grip dynamometer assessed strength. Skin-fold thickness was used to calculate percent body fat and lean body mass index. Patients were divided into low risk (0-2.5%) and high risk (>2.5%) groups based on the STS National Cardiac Surgery Database prediction of operative mortality. RESULTS: Patients with both a high percent body fat and a low VSAQ were at higher risk for at least one serious complication (p<0.05) and a longer postoperative length of stay (p<0.05). CONCLUSION: This study suggests: 1) An index of physical fitness can be obtained preoperatively in cardiac surgical patients; 2) This information aids in the prediction of operative risk.

Aged↗

PubMed1992

Usefulness of dipyridamole-thallium scanning for preoperative evaluation of cardiac risk for nonvascular surgery.

The ability to stratify cardiac risk before nonvascular surgery using clinical markers and dipyridamole-thallium scanning (DTS) was assessed for patients with known or suspected coronary artery disease unable to exercise. Of 100 consecutively studied patients who proceeded to nonvascular surgery, 9 (9%) experienced greater than or equal to 1 perioperative cardiac ischemic event, including death in 2 patients (2%) and nonfatal myocardial infarction in 2 (2%). Logistic regression identified 2 clinical predictors (age greater than 70 years and history of heart failure), and 1 DTS (thallium redistribution) predictor of events. Of 45 patients with neither clinical variable, none (0%; 95% confidence intervals [CI] 0 to 8%) had events. Of 55 patients with greater than or equal to 1 clinical marker, 9 (16.4%; 95% CI 7 to 26%) had events. Within this subgroup, 1 of 31 patients (3.2%; 95% CI 0 to 16%) without thallium redistribution had events compared with 8 of 24 (33.3%; 95% CI 14 to 52%) with redistribution. An algorithm combining 5 independent clinical and 2 DTS predictors, derived previously in vascular surgery patients, was validated in the 100 nonvascular surgery patients. It is concluded that preoperative planar DTS is most useful to stratify selected nonvascular surgery patients at intermediate or high risk by clinical assessment. However, for almost half of those patients with known or suspected coronary artery disease, DTS may be unnecessary because of sufficiently low predictive value based on simple clinical descriptors.

Aged↗

PubMed1997

Transmyocardial laser revascularisation combined with coronary artery bypass grafting without cardiopulmonary bypass.

OBJECTIVE: To achieve complete myocardial revascularisation in patients with diffuse coronary artery disease, patients with inordinately high risk of cardiopulmonary bypass (CPB) like severe systemic disease or diffuse atherosclerosis of the aorta. METHODS: We have adopted the technique of combining coronary artery bypass grafting (CABG) with transmyocardial laser revascularisation (TMLR) using 1000 W CO2 laser machine. TMLR is done to areas supplied by ungraftable arteries, while CABG without cardiopulmonary bypass is done to the left anterior descending artery (LAD) and/or right coronary artery (RCA). TMLR + CABG on beating heart without CPB has been performed on 56 patients. Age ranged from 37 to 81 years with a mean of 56.17. Four patients were in renal failure, two were redo CABG. Preoperatively 39.28% patients had angina class III and 10.71% had angina class IV. Four patients were on preoperative IABP support. RESULTS: The mean number of grafts was 1.09. Internal thoracic artery (ITA) was used in 96.4% of the patients. Five patients showed elevation of CPK-MB, while three patients had an increase in Troponin T. Mortality was 1.8% (one patient died of intractable ventricular arrhythmia). The mean follow-up is 9.2 months. Myocardial perfusion scanning showed a stepwise improvement in reversible ischemia increasing from 52% at baseline to 91% at 12 months; 90.9% of the patients were angina free at 12 months. Metabolic stress test demonstrated an average increase in exercise tolerance from 5.2 min at baseline to 9.4 min at 12 months. Metabolic equivalents (METs) increased from 4.5 at baseline to 9.4 at 12 months. The average 44% Karnofsky score preoperative also increased to 86% at 12 months. CONCLUSIONS: Our results indicate that the technique is surgically feasible and safe, with excellent short term results.

Adult↗