Prediction of high on-treatment platelet reactivity in clopidogrel-treated patients with acute coronary syndromes.

BACKGROUND: About 40% of clopidogrel-treated patients display high platelet reactivity (HPR). Alternative treatments of HPR patients, identified by platelet function tests, failed to improve their clinical outcomes in large randomized clinical trials. A more appealing alternative would be to identify HPR patients a priori, based on the presence/absence of demographic, clinical and genetic factors that affect PR. Due to the complexity and multiplicity of these factors, traditional statistical methods (TSMs) fail to identify a priori HPR patients accurately. The objective was to test whether Artificial Neural Networks (ANNs) or other Machine Learning Systems (MLSs), which use algorithms to extract model-like 'structure' information from a given set of data, accurately predict platelet reactivity (PR) in clopidogrel-treated patients. METHODS: A complete set of fifty-nine demographic, clinical, genetic data was available of 603 patients with acute coronary syndromes enrolled in the prospective GEPRESS study, which showed that HPR after 1month of clopidogrel treatment independently predicted adverse cardiovascular events in patients with Syntax Score >14. Data were analysed by MLSs and TSMs. ANNs identified more variables associated PR at 1month, compared to TSMs. RESULTS: ANNs overall accuracy in predicting PR, although superior to other MLSs was 63% (95% CI 59-66). PR phenotype changed in both directions in 35% of patients across the 3 time points tested (before PCI, at hospital discharge and at 1month). CONCLUSIONS: Despite their ability to analyse very complex non-linear phenomena, ANNs or MLS were unable to predict PR accurately, likely because PR is a highly unstable phenotype.

Aortobronchial fistula after coarctation repair and blunt chest trauma.

A 34-year-old man had development of an aortobronchial fistula 17 years after patch aortoplasty for correction of aortic coarctation and 5 years after blunt chest trauma, an unusual combination of predisposing factors. The clinical presentation, characterized by dysphonia and recurrent hemoptysis, and the surgical findings suggested the posttraumatic origin of the fistula, which was successfully managed by aortic resection and graft interposition under simple aortic cross-clamping, associated with partial pulmonary lobectomy. When hemoptysis occurs in a patient with a history of an aortic thoracic procedure, the presence of an aortobronchial fistula should be suspected. Early diagnosis offers the only possibility of recovery through a lifesaving surgical procedure.

Valve-related complications in elderly patients with biological and mechanical aortic valves.

BACKGROUND: Controversy still exists about the choice of aortic prosthesis in elderly patients. This study investigates valve- and anticoagulant-related morbidity and mortality in elderly patients after aortic valve replacement (AVR) with a biologic (BP) or mechanical prosthesis (MP). METHODS: Between 1981 and 1995, 355 consecutive patients aged 70 years or older (mean, 74+/-4 years; range, 70 to 87 years) underwent isolated AVR. There were 222 (63%) replacements with an MP and 133 (37%) with a BP. Mean follow-up was 3.7+/-2.8 years (range, 3 months to 15 years), with a total follow-up of 1,214 patient-years. RESULTS: Hospital mortality was 7.6% (27 of 355), decreasing to 4.6% in the last 3 years. There were 55 late deaths, 33 in patients with MP and 22 in those with BP. At 10 years there was no significant difference between MP and BP recipients in the actuarial estimates of survival (51%+/-8% versus 33%+/-13%), freedom from valve-related death (82%+/-7% versus 72%+/-12%), and freedom from thromboembolism (84%+/-7% versus 94%+/-3%). In contrast, 10-year freedom from anticoagulant-related hemorrhages was 74%+/-8% for MP and 99%+/-1% for BP (p = 0.02). Only 1 structural deterioration occurred, in a patient with BP. CONCLUSIONS: Satisfactory early results can be obtained in elderly patients after AVR with both MP and BP. The comparable low late survival in the two groups was predominantly influenced by non-valve-related deaths. A higher incidence of anticoagulant-related hemorrhages limits the use of MP in elderly patients. Thus, in this population, BP should be preferred not just on the basis of their expected longer durability, but mainly to avoid the risk of anticoagulant-related hemorrhages.

Symptomatic improvement after transmyocardial laser revascularization: how long does it last?

BACKGROUND: The aim of this study was to determine whether short-term clinical improvement after isolated transmyocardial holmium laser revascularization (TMLR) in patients with coronary artery disease not amenable to traditional treatment is maintained through a longer follow-up. METHODS: Between November 1995 and June 1999 34 patients underwent TMLR (mean age, 67+/-7 years); previous revascularization procedures had been performed in 76%. Preoperatively, mean angina class was 3.6+/-0.5 in 12 patients with unstable angina; mean left ventricular ejection fraction was 47%+/-9%. RESULTS: There was 1 early death due to low cardiac output. Mean duration of TMLR and of the entire operation was 25+/-12 minutes and 125+/-43 minutes, respectively. There were no major postoperative complications; mean hospital stay was 8+/-4 days. There were 8 late deaths caused by stroke (2 patients), cardiac failure (1 patient), and myocardial infarction (5 patients). Follow-up of current survivors ranges from 4 to 48 months (mean, 32+/-12 months). At 1-year follow-up mean angina class was 1.8+/-0.8; but at a later follow-up (mean, 35+/-10 months) it significantly increased to 2.2+/-0.7 (p = 0.005). Three-year actuarial survival was 76%+/-8% and freedom from cardiac events 44%+/-10%. CONCLUSIONS: Our results show that after initial clinical improvement many patients experience return of angina or cardiac events; this questions the long-term symptomatic benefit of TMLR.

Dissection of atrial septum after mitral valve replacement.

We report a patient who presented with paraprosthetic leak complicated by dissection of the interatrial septum after mitral valve replacement. A review of the literature provides confirmation that only 3 cases have been previously reported of this potential, albeit extremely rare, complication of prosthetic mitral valve replacement. Prosthesis oversizing and improper mitral annular handling appeared to be the predisposing factors of this complication.

Performance of 21-mm size perimount aortic bioprosthesis in the elderly.

BACKGROUND: Aortic valve replacement in elderly patients with a small aortic annulus may pose difficult problems in terms of prosthesis selection. We have evaluated the hemodynamic performance of the 21-mm Carpentier-Edwards Perimount bioprosthesis implanted in elderly patients. METHODS: From July 1996 to June 1998, 19 patients (17 women and 2 men, mean age 76+/-4 years and mean body surface area 1.73+/-0.13 m2), had aortic valve replacement with a 21-mm Carpentier-Edwards Perimount bioprosthesis. The hemodynamic performance of the valve was evaluated in 16 patients, who completed at least a 6-month follow-up interval, with transthoracic color-Doppler echocardiography with particular reference to peak and mean transprosthetic gradients, effective orifice area index, and regression of left ventricular mass index. RESULTS: There were no late deaths and no major postoperative complications. At a mean follow-up of 12+/-7 months, compared to discharge, all patients showed clinical improvement with a significant reduction of peak gradient (from 23+/-4 to 21+/-6 mm Hg, p = 0.04) and left ventricular mass index (from 181+/-23 to 153+/-20 g/m2; p<0.001), whereas mean gradient (from 13+/-3 to 13+/-4 mm Hg, p = not significant) and effective orifice area index (from 1.12+/-0.34 to 1.13+/-0.28 cm2/m2, p = not significant) remained substantially unchanged. CONCLUSIONS: The use of a 21-mm Carpentier-Edwards Perimount bioprosthesis is associated with low transprosthetic gradients and significant reduction in left ventricular hypertrophy after aortic valve replacement. The results of our study suggest that a 21-m Carpentier-Edwards Perimount bioprosthesis should be considered a valid option in elderly patients with aortic valve disease and a small aortic annulus.

Early results of transmyocardial revascularization with a holmium laser.

BACKGROUND: Transmyocardial laser revascularization (TMLR), a surgical technique designed to improve perfusion in the ischemic myocardium by creating transmural channels, has been performed thus far using a carbon dioxide laser, with apparently gratifying early results. We have investigated clinically TMLR using a holmium laser as sole therapy for patients with coronary artery disease that is not amenable to traditional treatment such as coronary artery bypass grafting or percutaneous transluminal coronary angioplasty. METHODS: From November 1995 to December 1996, 16 patients underwent TMLR using a holmium laser. Their mean age was 68 +/- 6 years and 75% were men. Previous coronary artery bypass grafting or percutaneous transluminal coronary angioplasty had been performed in 81% and 31% of the patients, respectively. Before operation, their mean anginal class was 3.4 +/- 0.5 and their mean left ventricular ejection fraction was 0.49 +/- 0.06. Six patients had unstable angina. RESULTS: There were no operative deaths. The mean duration of TMLR was 27 +/- 13 minutes and the mean duration of the entire operation was 120 +/- 40 minutes. There were no major postoperative complications and the mean hospital stay was 8 +/- 4 days. There were 2 late deaths, 1 that occurred 40 days after TMLR as a result of stroke and 1 that occurred 4 months after TMLR as a result of myocardial infarction. Current survivors have been followed up for a mean of 10 +/- 4 months (range, 3 to 15 months), with 7 patients followed up for 1 year. At last follow-up, the mean anginal class had decreased to 1.8 +/- 0.7 (p = 0.001) and the patients had increased exercise tolerance and a reduced number of hospitalizations. However, no statistically significant changes in the percentage of segments with fixed or reversible ischemia and no statistically significant differences in the viability scores of lased and nonlased segments were observed. CONCLUSIONS: Transmyocardial laser revascularization using a holmium laser is a simple technique with low operative risk and low morbidity. Early results confirm that clinical improvement is obtained in most patients, although significant changes in myocardial perfusion are not evident in the short term.

Hemodynamic performance of stented and stentless aortic bioprostheses.

BACKGROUND: This study compares the hemodynamic performance of stented and stentless bioprostheses used for aortic valve replacement in patients with aortic stenosis and small aortic root. METHODS: Between 1995 and 1998, 37 patients with a 21-mm aortic annulus (group 1) underwent aortic valve replacement with either a 21-mm Edwards Perimount or a 23-mm St. Jude Toronto bioprosthesis whereas 47 patients with a 23-mm aortic annulus (group 2) received either a 23-mm Medtronic Mosaic or a 25-mm Edwards Prima bioprosthesis. In each group mean and peak gradients, effective orifice area index, and left ventricular mass index were compared during follow-up. RESULTS: Group 1 patients showed a significant reduction of mean (p < 0.001) and peak gradients (p = 0.001) during follow-up, more evident for St. Jude Toronto versus Edwards Perimount (p = 0.02 and p = 0.05, respectively). Group 2 patients showed a significant reduction of mean and peak gradients (p < 0.001), more evident for Edwards Prima versus Medtronic Mosaic (p < 0.001 and p = 0.07, respectively). Effective orifice area index significantly increased only in group 1 (p = 0.005). Left ventricular mass index significantly decreased in all patients regardless of the type of valve (p < 0.001). Patients with Edwards Prima showed a trend to a higher regression of left ventricular mass index versus Medtronic Mosaic recipients (p = 0.07). CONCLUSIONS: After aortic valve replacement, stented and stentless bioprostheses exhibited similar results with a more evident hemodynamic improvement during follow-up in the stentless valves. Stented bioprostheses of new generation, however, may parallel the hemodynamic performance of stentless valves and appear to be a valid alternative for aortic valve replacement in elderly patients with a small aortic annulus.

Hemodynamic assessment of the Medtronic Mosaic bioprosthesis in the aortic position.

BACKGROUND AND AIM OF THE STUDY: The Medtronic Mosaic bioprosthesis (MMB) is a newly developed tissue valve which incorporates several features such as a low-profile semi-flexible stent, zero-pressure tissue fixation, and anti-mineralization pretreatment with alpha-amino oleic acid aimed to improve hemodynamics and prevent structural deterioration. METHODS: Between November 1995 to June 1999, 62 patients underwent aortic valve replacement (AVR) with the MMB; 41 of these who reached the one-year follow up interval and who had isolated AVR without any concomitant procedure with size 23 mm and 25 mm MMB were evaluated by serial echocardiography after three, six and 12 months. RESULTS: For size 23 mm valves, mean and peak gradients were 12+/-3 and 21+/-6 mmHg at 3 months, 12+/-3 and 20+/-5 mmHg at 6 months, and 12+/-4 and 20+/-6 mmHg at 12 months. For size 25 mm valves, mean and peak gradients were 13+/-2 and 22+/-4 mmHg at 3 months, 12+/-3 and 21+/-5 mmHg at 6 months, and 12+/-4 and 22+/-6 mmHg at 12 months. In patients with 23 mm MMB, left ventricular mass index (LVMi) was reduced from 181+/-34 g/m2 before surgery to 158+/-32, 150+/-28 and 140+/-25 g/m2 at 3, 6 and 12 months after AVR (p <0.001); in patients with 25 mm MMB, LVMi was reduced from 182+/-28 g/m2 before surgery to 165+/-25, 156+/-24 and 146+/-19 g/m2 at 3, 6 and 12 months after AVR (p <0.001). CONCLUSION: Our results indicate that MMB is associated with low mean and peak gradients and significant reduction in LVMi throughout the postoperative period. Thus, the MMB appears to be an excellent cardiac valve substitute in elderly subjects who require AVR.

Mitral valve annuloplasty for degenerative disease: assessment of four different techniques.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair (MVR) is the treatment of choice in patients with degenerative valve disease. However, controversy persists as to whether mitral valve annuloplasty should always be included as part of the reconstructive procedure. METHODS: The records of 62 consecutive patients undergoing MVR for degenerative disease between January 1994 and December 1996 were reviewed. Four different annuloplasty techniques were associated with various MVR procedures: local posterior annuloplasty (group 1, n = 10), rigid Carpentier ring (group 2, n = 20), Duran ring (group 3, n = 17), and posterior annular plication with autologous pericardium (group 4, n = 15). The four patient groups were similar in terms of preoperative clinical and echocardiographic characteristics. Serial clinical and echocardiographic follow up was performed to assess functional status and stability of repair. RESULTS: There were no early or late deaths. Mean follow up in the entire patient series was 31 +/- 12 months. One patient in group 2 required reoperation 14 months after MVR. In all groups there was a significant improvement in NYHA functional class (from 2.7 +/- 0.6 to 0.9 +/- 0.5, p <0.001), with a reduction of left ventricular end-diastolic and end-systolic volumes (154 +/- 50 ml to 105 +/- 33 ml, p <0.001; and 64 +/- 23 ml to 52 +/- 22 ml, p <0.001). In patients of groups 2, 3 and 4, residual mitral incompetence at follow up (0.8 +/- 0.9 in group 2, 0.8 +/- 0.7 in group 3, and 0.2 +/- 0.6 in group 4) was not significantly different from discharge. However, in group 1, a higher degree of residual mitral regurgitation was present at discharge (0.9 +/- 0.6) with a trend to progress at follow up (1.6 +/- 0.5). CONCLUSION: In patients with degenerative mitral valve disease, MVR provides clinical and functional improvement. Techniques of stabilization of the entire posterior mitral annulus achieve better early and medium-term results, and should be always considered as part of MVR. Autologous pericardium appears to be an excellent annuloplasty material, though its apparent superiority over synthetic rings must be confirmed at longer follow up.

Ascending aorta dissection after aortic valve replacement.

BACKGROUND AND AIMS OF THE STUDY: The surgical management of patients with aortic valve disease associated with ascending aortic dilatation is a controversial issue. Structural abnormalities of the aortic wall predispose to further aortic enlargement and possibly to ascending aortic dissection (AAD). Indications to concomitant replacement of aortic valve and ascending aorta have not yet been clearly defined. METHODS: We reviewed eight consecutive patients (seven males and one female) among 2202 patients who underwent aortic valve replacement (AVR) between 1982 and 1996. These eight were subsequently reoperated on because of AAD, between November 1987 and November 1996. Indications for initial AVR were aortic regurgitation due to annular ectasia in five patients, combined aortic stenosis and regurgitation in two, and isolated aortic stenosis in one patient. RESULTS: The interval between AVR and AAD ranged from four months to 10.5 years. Five patients presented with acute AAD, and three with chronic AAD. Retrospectively, four patients showed progressive increase in ascending aortic diameter after AVR, with a mean diameter of 72+/-9 mm at reoperation. Histological examination showed cystic medial necrosis in three patients, atherosclerotic degeneration in one patient, and normal aortic wall structure in one. There was one operative death due to low cardiac output; the hospital mortality rate was 13%. There were no late deaths and no major adverse events during a mean follow up of 5+/-3 years (range: 8 months to 10 years). CONCLUSIONS: In patients with ascending aortic dilatation (> or = 55 mm diameter), AVR alone may not prevent progression of aortic root enlargement. In these patients, the ascending aorta should be concomitantly replaced. Following AVR, all patients with mildly or moderately dilated aortic root should be periodically controlled to detect signs of progression of aortic dilatation.

Cardiopulmonary exercise testing in patients with 21mm St. Jude Medical aortic prosthesis.

BACKGROUND AND AIM OF THE STUDY: Small-sized prostheses may be associated with high transprosthetic gradients, particularly in patients with a body surface area (BSA) >1.70m2, affecting left ventricular mass regression, symptom improvement and long-term survival. However, the influence of such gradients on exercise tolerance has not been clearly defined. The study aim was to verify the utility of cardiopulmonary exercise testing (CPX) in detecting patient-prosthesis mismatch, and to identify the clinical and echocardiographic data that predict exercise tolerance at CPX in patients with a 21mm St. Jude Medical (SJM) aortic prosthesis. METHODS: Twenty patients (one male, 19 females; mean age 66 +/- 9 years) with a 21 mm SJM prosthesis were evaluated by means of 2D echocardiography and CPX at 36 +/- 10 months after operation. Patients were divided into groups on the basis of a BSA of <1.70 m2 (group 1, n = 12) or > or =1.70 m2 (group 2, n = 8). RESULTS: At echocardiography, left ventricular mass reduction was 16 +/- 10% versus 9 +/- 6% in groups 1 and 2, respectively, mean gradient (MG) was 15 +/- 6 versus 17 +/- 4 mmHg (p = NS), effective orifice area index (EOAi) 0.86 +/- 0.10 versus 0.79 +/- 0.09 cm2/m2 (p = 0.05). At CPX, group 2 patients showed a significantly lower exercise duration (p = 0.02), maximum workload (p = 0.02), peak O2 uptake (p = 0.01), anaerobic threshold (AT) (p = 0.03), ventilatory equivalent for CO2 at AT (p = 0.007), and O2 cost of work (p = 0.03). Group 1 patients showed a ventilatory origin for their effort dyspnea, while group 2 patients showed a significant circulatory component. At multivariate analysis, BSA, age, EOAi and MG were independent predictors of CPX results. CONCLUSIONS: In patients with a 21 mm aortic SJM prosthesis and a BSA > or =1.70m2, CPX allows detection of patient-prosthesis mismatch, in terms of impaired exercise tolerance due to circulatory causes. CPX results can be anticipated on the basis of the patient's BSA, age, EOAi and MG. In these patients, technical solutions allowing implantation of a larger prosthesis should be considered whenever an active lifestyle is anticipated after aortic valve replacement.

Prospective evaluation of frequency and nature of transcranial high-intensity Doppler signals in prosthetic valve recipients.

BACKGROUND AND AIM OF THE STUDY: In asymptomatic prosthetic valve recipients, high-intensity transient signals (HITS) observed with transcranial Doppler (TCD) are a phenomenon of obscure clinical relevance which nature has not yet been elucidated convincingly. METHODS: Eighty-three patients without carotid disease, history of cerebrovascular accidents, and with negative preoperative TCD undergoing either valve replacement (mitral, n = 11; aortic, n = 56; mitral + aortic, n = 6; 40 mechanical prostheses, 29 biological prostheses, 10 homografts) or mitral repair (n = 10) were evaluated prospectively by means of TCD at discharge, three months and one year after surgery, to analyze the presence, incidence and characteristics of HITS. Furthermore, in 12 patients positive for HITS, TCD was repeated during a 30-min period of 100% O2 inhalation. RESULTS: Twenty-five patients (30%) were positive for HITS at all postoperative controls, although no neurological symptoms were observed. Mechanical prostheses showed a significantly higher incidence of HITS (85%) than biological prostheses (10%, p <0.001), repaired mitral valves (0%, p <0.001) and homografts (0%, p <0.001). At multivariate analysis the presence of a mechanical prosthesis was the only significant predictor of detection of HITS after valve replacement. During O2 inhalation, a significant decrease in the number of HITS per hour (55 +/- 79 versus 22 +/- 31, p = 0.002) occurred, which returned to initial values when room-air breathing was resumed. CONCLUSIONS: Prosthetic valve replacement, particularly when mechanical devices are used, is associated with the generation of HITS which persist throughout the follow up period, but remain clinically silent. The decrease of HITS during O2 inhalation strongly supports the hypothesis of the gaseous nature of such signals and confirms the validity of this method in helping to differentiate gaseous microemboli from solid microemboli in prosthetic valve recipients.

Transmyocardial holmium laser revascularization: feasibility of a thoracoscopic approach.

OBJECTIVE: Creation of transmyocardial channels from the epicardium to the left ventricular cavity with the use of a laser is a modern approach in the treatment of patients with chronic ischemic heart disease unsuitable for coronary angioplasty or bypass grafting. We present the results of transmyocardial laser revascularization (TMLR) with a holmium laser as sole therapy in 22 patients operated on between November 1995 and February 1997. METHODS: There were five females (23%) and 17 males (77%), with a mean age of 67+/-7 years (range 53-74 years). Previous myocardial revascularization had been performed in 77% of the patients. Pre-operatively, 12 patients (55%) were in angina class III and ten (45%) in class IV (mean 3.5+/-0.5); unstable angina was present in seven patients (32%). In 20 patients, TMLR was performed through a limited thoracotomy, while in two a thoracoscopic approach was used. Each patient received a mean of 33+/-8 channels in 27+/-13 min, while total operation lasted 130+/-28 min. RESULTS: There were no hospital deaths and no major post-operative complications. Mean hospital stay was 7+/-3 days; the two patients undergoing thoracoscopic TMLR were discharged after 4 and 5 days, respectively. Two deaths were observed after 40 days and 4 months after TMLR, due to stroke and myocardial infarction. Mean follow-up of current survivors is 10+/-6 months (range 3-15 months), with seven patients followed for over 12 months. At last follow-up, mean angina class is 1.9+/-0.6 (P < 0.001). A significant increase in exercise tolerance and a reduction of the number of hospitalizations for angina were also observed. However, no significant changes in myocardial perfusion were observed. CONCLUSIONS: The present study demonstrates that: (1) TMLR with a holmium laser yields clinical improvement in the majority of patients with severe angina unsuitable for conventional surgical treatment, (2) gratifying results in terms of improved anginal status and exercise tolerance are achieved, despite the lack of significant changes in myocardial perfusion at early follow-up and (3) TMLR through a thoracoscopic approach is a feasible procedure.

Ligament stability two to six years after anterior cruciate ligament reconstruction with autogenous patellar tendon graft and participation in accelerated rehabilitation program.

We studied patients who participated in our accelerated rehabilitation program after anterior cruciate ligament reconstructive surgery to determine if they showed signs of patellar tendon graft stretching. This program initiated in 1987 emphasizes early full hyperextension, early weightbearing as tolerated, and closed-chain functional activities with rapid return to sports when the patient has attained full range of motion, approximately 65% of strength, and has accomplished the running and agility drills prescribed. A total of 209 patients met the criteria of KT-1000 arthrometer followup at the time full range of motion (5 degrees/0 degrees/135 degrees) was attained and at 2 years or more after surgery. The KT-1000 arthrometer manual maximum difference between the reconstructed and normal knees was used as the indicator of change in the graft length. All patients completed postoperative subjective questionnaires. The mean KT-1000 arthrometer value was 2.06 mm (SD, +/- 2.2) at full range of motion and 2.10 mm (SD, +/- 1.9) at more than 2 years of followup (P = 0.7961). The patients' subjective stability scores averaged 19.6 with 97% reporting no instability episodes. Based on our findings, we conclude that an accelerated rehabilitation program after this type of reconstruction does not affect long-term stability as measured by the KT-1000 arthrometer.

Improving hemostasis during replacement of the ascending aorta and aortic valve with a composite graft.

The use of a composite graft is an established treatment for patients with aortic valve disease and ascending aortic aneurysms. Since bleeding from suture lines is a potential complication of this procedure, we modified the technique and evaluated the effect on hemostasis. From January 1994 through December 1998, 35 patients underwent composite aortic graft replacement for chronic aortic disease. In the first 16 patients (Group 1), we used the standard open technique, with excision of the aortic aneurysm and anastomosis of aortic buttons containing the coronary ostia to the vascular graft. In the next 19 patients (Group 2), we modified the technique by placing an additional suture at the proximal graft anastomosis and harvesting large coronary buttons that were then attached to the graft by an "endo-button" buttress method. There were no operative deaths; the actuarial survival rate at 36 months was 92% +/- 5%. Between groups 1 and 2, a significant difference was found in postoperative bleeding (1,052 + 433 mL vs 806 +/- 257 mL, respectively; p = 0.02) and in number of blood transfusions required (2.1 +/- 2.0 units vs 0.4 +/- 0.7 units, respectively; p = 0.002). Multivariate analysis showed that the surgical technique used in Group 1 was the only independent risk factor for postoperative bleeding of 1,000 mL or more (p = 0.01) and for transfusion requirements of 3 or more units of blood (p = 0.004). Composite aortic valve and root replacement can be accomplished with excellent results. Technical modifications may reduce bleeding complications and related morbidity significantly

The effects of the number and frequency of physical therapy treatments on selected outcomes of treatment in patients with anterior cruciate ligament reconstruction.

Health care reform will quite possibly change the delivery of physical therapy by demanding physical therapists to be more accountable for providing appropriate, yet cost-effective treatment. The purpose of this study was to retrospectively compare the results after anterior cruciate ligament (ACL) reconstruction between two groups of patients with different numbers and frequencies of physical therapy visits postoperatively. Two random samples of 100 patients from a total of 1,345 patients identified as undergoing ACL reconstruction from 1990 through 1993 were included. Group A patients attended physical therapy regularly and participated in a home exercise program, while patients in Group B attended limited physical therapy visits and also performed a prescribed home exercise program. Both groups followed the same postoperative rehabilitation program for early range of motion, early weight bearing, and muscle control. The outcome variables measured 1, 6, and 12 months postoperatively included the number of structured visits to physical therapy, range of motion, isokinetic strength testing, and subjective rating. Group A averaged 20 visits in the first 6 months while Group B averaged seven visits. The results revealed no significant difference for flexion, isokinetic strength, or subjective rating. There was a significant difference for hyperextension (Group A, 2 degrees; Group B, 6 degrees). The results of this investigation indicated that by following a structured physical therapy program postoperatively, it is possible for patients to achieve a successful outcome with a limited number of routine physical therapy visits.

Evaluation of ankle joint proprioception following injection of the anterior talofibular ligament*.

The purpose of this investigation was to measure ankle joint proprioception preceding and following injection of Xylocaine into the anterior talofibular ligament (ATFL). Previous investigators have indicated that the typical inversion ankle sprain causes decreased afferent input from the joint which results in a proprioceptive deficit at the ankle. It was hypothesized that anesthesia of the ATFL would simulate this proprioceptive deficit. Fourteen individuals were blindfolded and subjected to pre-test proprioceptive measurements on a multiaxial balance evaluator. Xylocaine was introduced into the ATFL and post-test measurements were taken. A significant increase in average time in balance was found following anesthesia of the ATFL. The unexpected results may indicate that multiple trials caused a learning effect. This supports the contention of other investigators that proprioceptive deficits can be improved with training. It is concluded that proprioceptive training should be included in the overall rehabilitation program following ankle sprains. J Orthop Sports Phys Ther 1986;8(2):70-76.

Rehabilitation program for both knees when the contralateral autogenous patellar tendon graft is used for primary anterior cruciate ligament reconstruction: a case study.

STUDY DESIGN: Case study of a basketball player who underwent an alternative surgical procedure for anterior (cruciate ligament (ACL) reconstruction and outline of the rehabilitation process designed for this procedure. OBJECTIVES: To describe the surgical procedure, detail the rehabilitation program, and report on this patient's clinical outcome. BACKGROUND: Anterior cruciate ligament injury, its treatment, and rehabilitation continue to be an area of interest to both clinicians and researchers. Surgical procedures have been refined and rehabilitation programs are constantly being evaluated and updated to allow the safest and most predictable return to activity. Currently, the autogenous bone-patellar tendon-bone graft is the graft of choice for ACL reconstruction. Typically the graft is taken from the ipsilateral knee. An alternative procedure is to take the graft from the contralateral, noninvolved knee, allowing 2 separate rehabilitation programs to take place. METHODS AND MEASURES: The patient was followed from the time of injury to 2 years postoperatively. Data collected included range of motion, isokinetic strength scores, ligament stability scores, subjective evaluation, and functional measures. RESULTS: At 3 weeks postoperative the patient had nearly full range of motion in both knees, normal gait, and was beginning sport-specific drills. He was shooting the basketball and jumping by 5 weeks and returned to competitive sports 6 weeks after surgery. He was able to play in all 32 games of the season, starting in 23 of them. CONCLUSIONS: Using the contralateral patellar tendon graft may be appropriate for primary ACL reconstruction of patients, particularly those desiring an early expedient return to athletic competition.

Rehabilitation and use of protective devices in hand and wrist injuries.

Hand and wrist injuries are common among athletes. Although the hand does not often bear weight and these injuries do not always sideline an athlete, careful attention must be paid when treating injuries of the hand and wrist. Rehabilitation is given for common injuries of the hand and wrist, including exercises and protective splints and braces. Details on how to fabricate a playing cast for athletes are also discussed.