Late results of combined mitral valve replacement and coronary bypass surgery.

The incremental risk of coronary bypass surgery was analyzed in 718 patients undergoing mitral valve replacement between 1971 and 1983. Ninety-eight patients (14%) had significant coronary artery disease requiring coronary bypass surgery. In 70 of these patients, the origin of the mitral valve disease was nonischemic, whereas 28 patients had ischemic mitral regurgitation unsuitable for conservative valve surgery. There were six operative deaths (9%) and four perioperative myocardial infarctions (6%) after mitral valve replacement and coronary bypass surgery for nonischemic mitral valve disease. Operative mortality was related to low output cardiac failure before operation or perioperative myocardial infarction. Actuarial curves predict survival (+/- standard error) of 55 +/- 7% at 5 years and 43 +/- 8% at 10 years. Preoperative functional class was the only significant predictor of long-term survival in this group (p less than 0.05). The actuarial survival of the 620 patients without coronary artery disease who underwent mitral valve replacement alone was 63 +/- 3% at 10 years. This was significantly better than that of the 70 patients who underwent mitral valve replacement and coronary bypass surgery for nonischemic mitral valve disease (p less than 0.001). Conversely, 5 year survival of the 28 patients with ischemic mitral regurgitation was 43 +/- 10%. This confirms the negative detrimental effect of an ischemic origin of mitral valve disease on survival after mitral valve replacement and coronary bypass surgery (p less than 0.0001).

Aortic valve replacement with coronary bypass grafting. Significant determinants of ten-year survival.

Concomitant aortic valve replacement (AVR) and myocardial revascularization were performed on 197 patients between 1969 and 1981. Operative mortality during the period 1969 to 1975 was 15.6% compared to 5.0% for the years 1976 to 1981 (p less than 0.02). The incidence of perioperative myocardial infarction (PMI) declined over the same period from 14.2% to 2.0% (p less than .01). Functional class and left ventricular end-diastolic pressure significantly influenced mortality, whereas age, sex, duration of symptoms, cardiac index, wall motion abnormality, type of valve lesion, and completeness of revascularization did not. Type of myocardial preservation did not significantly affect operative mortality, although a trend favoring either cardioplegia or continuous perfusion of both coronary ostia and grafts was observed. Life-table analysis shows a survival rate during the 10 year follow-up period equal to that of patients undergoing isolated AVR. Cornary bypass grafting (CABG) returns patients with combined aortic valve (AVD) and coronary artery disease (CAD) to a prognostic curve determined by their valvular disease alone.

Mitral repair in complete atrioventricular canal. Ease of correction in early infancy.

During the past 5 years all patients with complete atrioventricular (AV) were subjected to surgical correction regardless of age. Thus we were able to assess the ease and reliability of mitral repair in early infancy. Key features of operation include division of bridging leaflets when indicated, selection of a patch sufficiently small to prevent postoperative annular dilation, attachment of the leaflets to the patch with continuous nonpledget-supported sutures at a level determined by the chordal structure, and, based on the size of the mural leaflet, construction of a bicuspid or tricuspid mitral valve. Operative mortality and postoperative morbidity were no greater in patients under 6 months of age than in older patients. Reoperation for mitral regurgitation was required in three patients. In all of them, the primary reason for the failure of repair was that the mitral valve had been left tricuspid; in two of them, the mitral anulus was dilated, as well. Repair was uniformly accomplished by bicuspidization, combined in two instances with a Wooler-type annuloplasty and shortening of the free margin of the aortic leaflet. The absence of secondary scarring of the leaflets in the patients under 6 months of age facilitated repair in this age group. Early repair is possible, and preferable, provided that meticulous attention is paid to the technical features of the repair and a proper decision is made with regard to treatment of the mitral "cleft."

Coronary bypass operation following acute complicated myocardial infarction.

The indications for operation to correct acute mechanical defects after myocardial infarction are clearly established. Less clear is the use of surgical procedures for nonmechanical complications such as persistent ischemia or circulatory collapse. Between 1974 and 1981, 80 patients underwent coronary artery bypass grafting (CABG) within 2 weeks of infarction. Continued pain was the indication in 83% and cardiogenic shock in 17%. Seventeen patients were operated upon within 24 hours of infarction, 35 from 1 to 7 days, and 28 from 8 to 14 days. Eighty-one percent were men; mean age was 58 years. In 39% of patients the infarction was the premier symptom of coronary artery disease. Sixty-two percent had impaired left ventricular function as judged by left ventricular end-diastolic pressure greater than 15 mm Hg or abnormal wall motion seen on ventriculogram. Overall operative mortality was 5.0%; early mortality by indication was 3.0% for pain and 14.3% for shock. Operation for pain carried a 7.7% mortality if done within 48 hours of infarction and was 0% for those patients operated upon after that time. The status of 90% of all patients was known as of December, 1981, with a mean follow-up of 2.9 years. Life-table analysis demonstrates a 5 year survival rate of 85% +/- 6% in the group operated upon for pain. CABG in the immediate postinfarction period can be done safely with a 5 year survival in patients without hemodynamic compromise comparable to that of patients with chronic angina undergoing elective operation. These results should encourage the application of early postinfarction CABG in other high-risk subgroups of patients.

The evolution of reparative techniques for the mitral valve.

Forty-eight adult patients underwent mitral valve repair for nonischemic valvular incompetence between 1963 and 1981. Early in our experience, 21 individuals received wedge leaflet resection or leaflet plication with posteromedial commissural annuloplasty. More recently, midleaflet annuloplasty has been employed in 13 patients and is now our preferred technique. Operative mortality was 6.3%, and all deaths occurred prior to 1973. Eventually valve replacement was necessary in 10 patients; all replacements were done prior to 1977. Technical errors and progression of rheumatic disease each accounted for half of these replacements. Five-year survival by the life table method was 74 +/- 9% for the entire group. Survival at 5 years for patients with prolapsing leaflets was significantly better (87 +/- 7%) than for those with normal leaflet motion (46 +/- 14%). A residual postoperative murmur of mitral insufficiency correlated with the likelihood of subsequent valve replacement. Important technical aspects of valve repair are described, and criteria for optimal patient selection are discussed. The evolution of reparative methods has led to a better understanding and broader application of mitral valve reconstruction.

Papillary muscle rupture complicating acute myocardial infarction. Treatment with mitral valve replacement and coronary bypass surgery.

Six cases of complete or partial rupture of the papillary muscle after acute myocardial infarction are presented. All cases were treated by mitral valve replacement and concomitant coronary bypass surgery. An average delay of 3 days between rupture and operation occurred in the four patients with rupture of the main muscle trunk. The operative mortality rate was 50 percent. Such patients present with acute, florid left ventricular failure secondary to the severe mechanical burden imposed on the newly infarcted heart. The resulting valvular incompetence must be corrected by urgent mitral valve replacement if survival is to be lengthened. Patients with partial or apical head ruptures have a lesser degree of regurgitation and symptoms are largely dependent on intrinsic ventricular function. Both of our patients with partial muscle rupture presented with severe heart failure 2 to 4 months later, and both did well postoperatively. We believe that prompt operation without prolonged attempts at medical stabilization is the key to decreasing operative mortality, especially in instances of complete muscle rupture. Since ischemic heart disease remains the leading cause of death in such patients, coronary artery bypass surgery should be performed in conjunction with valve replacement.

Hand infections in hospitalized patients.

Two hundred hospital admissions for hand infections are reviewed with regard to the causes of infection, modes of effective therapy and causes of residual impairment. Patients with human bite injuries and those who delayed seeking treatment most frequently had severe injuries. Appropriate antibiotics and prompt surgical therapy of hand abscesses are essential.

Multiple simultaneous and sequential estrogen receptor values in patients with breast cancer.

Fifty-nine women had multiple estrogen receptor assays done, either simultaneously or sequentially. Eighty-six percent of the patients who had multiple synchronous estrogen receptor assays from various metastatic sites showed no significant discrepancy in estrogen receptor values. When estrogen receptor assays were done sequentially without intervening therapy, 83.5 percent of the patients maintained their initial positivity or negativity. However, when the second estrogen receptor determination was preceded by either chemotherapy or hormonal therapy, 33 percent of the patients had a significant discrepancy in estrogen receptor values. The most common discrepancy was estrogen receptor-positive tumors becoming estrogen receptor-negative, although a small number of patients were found whose receptor values became more positive after hormonal ablation.

Endocarditis. Changing trends in epidemiology, clinical and microbiologic spectrum.

Infective endocarditis refers to infection of the endocardium or heart valves by microbes, resulting in tissue destruction. Clinical presentation is quite variable, and a high level of suspicion is essential for recognition. Diagnosis is dependent on identification of the causative agent in blood cultures. Cultures that are persistently negative indicate the presence of culture-negative endocarditis, and diagnosis is one of exclusion. Treatment of endocarditis consists of high doses of antibiotics active against the infecting organism. Individualized therapy is the key to management.

Human sequelae of severe carbamate poisoning.

Carbofuran is a carbamate that functions as a cholinesterase inhibitor. Accidental or intentional ingestion can produce a life-threatening syndrome that requires prompt diagnosis and treatment. We describe a case of intentional carbofuran ingestion that resulted in coma, respiratory failure from acute respiratory distress syndrome (ARDS), and cortical blindness.