Analogical reasoning and postoperative outcome. Predictions for patients scheduled for open heart surgery.

We investigated whether postoperative outcome of open heart surgery is related to preoperative cognitive dysfunction. Patients ill enough to require open heart surgery frequently have gravely compromised circulation and, hence, possible brain damage. The Conceptual Level Analogy Test (CLAT), a new, rigorously constructed analogy test, was used to measure cognitive dysfunction. The results indicated that the CLAT, aministered preoperatively to open heart surgery patients, differentiated between patients having different types of postoperative outcome. A significant relationship between type of surgical procedure and poor postoperative outcome was also found; cardiac valvular surgery patients had significantly worse outcome than coronary bypass surgery patients. The incidence of good outcome (survival with no psychiatric complications) was 28% for cardiac valvular surgery patients with extremely poor preoperative CLAT scores, but 74% for valvular surgery patients with higher preoperative CLAT scores.

Analogy tests and psychopathology at follow-up after open heart surgery.

A study of 100 coronary bypass and cardiac valvular surgery patients investigated whether preoperative brain damage, as measured by the Conceptual Level Analogy Test (CLAT), is a major risk factor for postoperative psychiatric symptoms and mortality. Three cognitive psychological tests, including the CLAT, and psychatric interviews were given preoperatively, postoperatively, and at 18-month follow-up. Surgical outcome was specified as: Catastrophic Outcome (death or severe stroke), Psychiatric Complications, or Good Outcome (survival with no psychiatric complications). Inhospital outcome related significantly to analogy test scores, as did both surgical procedure and diagnosis of rheumatic heart disease. However, long-term outcome was unrelated to medical diagnosis and only weakly related to surgical procedure, but highly significantly related to preoperative analogy scores. The CLAT was a more consistent predictor of both short- and long-term outcome than any of the other ten variables considered (medical and surgical variables, inhospital outcome, demographic measures, other psychological tests).

Results of aortocoronary bypass grafting in patients with subendocardial infarction: late follow-up.

Twenty-eight patients with subendocardial infarction (Group A) were compared with 28 patients with unstable angina (Group B) and 28 with stable angina (Group C) matched for age and sex. The three groups did not differ in prevalence of diabetes, hypertension, old infarction or duration of disease. There were no significant differences in number of diseased vessels, coronary score, abnormal left ventricular wall motion or left ventricular end-diastolic pressure. Angiograms performed 2 weeks postoperatively revealed closure of 3 of 31 grafts (16 patients) in Group A, closure of 3 of 34 grafts (17 patients) in Group B and closure of 6 of 50 grafts (22 patients) in Group C (differences not significant). Postoperative angiograms showed improved wall motion in 37 percent of Group A, 53 percent of Group B and 36 percent of Group C (differences not significant). Postoperative new Q waves appeared in one hospital in Group A and in two patients in Groups B and C. There were no hospital or late deaths. In a mean follow-up period of 29 months, 68 percent of patients in Group A, 61 percent in Group B and 54 percent in Group C were asymptomatic. Thus, bypass grafting was performed with similarly low mortality and morbidity in patients with subendocardial infarction and in those with angina; more than one third of postoperative angiograms in the three groups showed improved wall motion; and late follow-up studies demonstrated functional improvement in the majority of patients in all three groups.

Risk of coronary surgery. Two hundred consecutive patients with no hospital deaths.

Revascularization surgery must carry a low morbidity and mortality rate to be a valid alternative treatment of obstructive coronary disease. A consecutive series of 200 patients underwent coronary bypasses at LIJ-HMC. The average age was 53.9 years (33 to 77) with 81.5 per cent of the patients men. Clinical presentation was as follows: 28 per cent were in New York Heart Association Class III and 72 per cent in Class IV (or unstable). Previous infarctions were documented in 37 per cent. Sixteen patients (8 per cent) had disease of the main left coronary artery. Single bypasses were placed in 37.5 per cent, double in 40.5 per cent, and triple or quadruple in 22 per cent. The rate of vein graft patency was 95.3 per cent (245 of 257 studied grafts). There were no hospital deaths in this consecutive group of 200 patients. There have been two late deaths after an average follow-up period of 16 months.

Patent ductus arteriosus with hypoplastic lung.

A median sternotomy approach was used for closure of patent ductus arteriosus associated with a hypoplastic right lung. The anterior approach to the left ductus is indicated if left thoracotomy is contraindicated.

Medical-surgical aspects of left main coronary artery disease.

Disease of the left main coronary artery compromises circulation to the major part of the left ventricle and thus threatens massive myocardial infarction and sudden death. Cardiac catheterization and coronary bypass surgery, in previous reports, have been associated with high mortality and morbidity rates. We report 50 patients with over 50 per cent narrowing of the left main coronary artery. The clinical pattern in these patients was variable and a left main coronary artery lesion could not be predicted before coronary angiography. There was only one death during cardiac catheterization. One patient died while waiting for elective surgery. Coronary bypass surgery was performed in 42 patients; one died during surgery. Forty-one patients are alive at 2 to 39 months follow-up (mean, 19 months). Thirty-six patients are asymptomatic or have minimal symptoms. Compared to the prognosis in patients with left main coronary artery stenosis treated medically, coronary bypass surgery performed on urgent basis offers a much better prognosis. Both coronary angiography and bypass surgery can be performed in these patients with a very low risk.

Survival after coronary surgery.

A 4.4 year follow-up study has been done on a previously reported group of 200 consecutive patients who underwnet coronary bypass. The yearly mortality rate has been 1% (8/200 in 4 years). Our total group of 1,038 surgically treated patients has had an operative mortality rate of 1.3%, and an early graft patency rate of 89.6% has been recorded in the 60% of patients consenting to restudy. These results are compared to natural history studies with and without angiography. Comparison with recent prospective randomized studies of patients with chronic stable angina and those with unstable angina suggests that a low operative mortality rate and optimal technical performance are necessary to improve the survival rate of patiens with symptomatic obstructive coronary disease.

Combined valve and coronary artery surgery.

From 1970 to 1978, 79 patients (Group 1) underwent combined valve replacement and coronary bypass operation. They were compared with 79 consecutive subsequent patients (Group 2) undergoing similar valve replacement. In Group 1, 73% were men compared with 48% in Group 2. The average age in Group 1 was 60 years (range, 42 to 84 years) and in Group 2, 57 years (range, 29 to 74 years). When the patients were first seen, angina was present in 49% in Group 1 and only 24% in Group 2. More than 95% of the patients in both groups were in New York Heart Association Functional Class III or IV. Areas of abnormal contraction were twice as frequent in the angiograms of patients in Group 1 (43%). Thirty-three mitral, 44 aortic, and 2 aortic plus mitral valve replacements were performed in each group. One to 4 grafts were placed in each patient group. One to 4 grafts were placed in each patient in Group 1, and most had single or double grafts. Early morbidity was more frequent in Group 1. Early mortality was 5 to 6% in each group. Late mortality (average, 3.5 years after operation) was 16 to 17% in each group. The working status and Functional Classification at follow-up were similar for patients in both groups. Combined valve and coronary operation carried a similar operation risk and had similar late results as valve replacement alone.

Should the pericardium be closed after an open-heart operation?

A controlled clinical study was carried out to decide whether the pericardium should be left open or closed after open-heart operations. One hundred patients had the pericardium closed with interrupted silk, another 100 had the pericardium left open. Complications were alike except for the more frequent occurrence of a pericardial rub in the closed group (14 vs 3 patients), though the incidence of post-pericardiotomy syndrome was equal. There was no late tamponade. Two early reexplorations for bleeding were done in the open group, none in the closed. There were no postoperative deaths. In the patients who consented to postoperative angiography following revascularization procedures, the incidence of graft failure was equal in both groups. The pericardium should be closed after an open-heart operation. Morbidity and mortality are unchanged, and repeat cardiac exploration is safer.

Late coronary bypass graft flow: quantitative assessment by roentgendensitometry.

Quantitative assessment of the flow in 45 saphenous vein aortocoronary bypass grafts in 30 patients was performed by a roentgendensitometric technique. Detalis of the technique are given. Mean graft flow for all grafts measured in the early postoperative period (two weeks) and again in the late postoperative period (six months to 3 years; average, 1.5 years) significantly decreased (72.6 +/- 34.7 to 57.4 +/- 28.6 ml/min; p less than 0.01). Mean graft diameter also significantly decreased over the same period (3.5 +/- 0.6 to 3.0 +/- 0.6 mm; p less than 0.01). Differences could not be related to graft site or to the time interval between early and late recatheterization. Changes in diameter did not correlate with changes in flow. During a 3-year follow-up, saphenous vein grafts significantly decreased in diameter and flow but still functioned adequately; and vein grafts generally remained larger than the recipient arteries. The determinant of adequacy of flow is the native coronary bed.

Pulmonary sequestration causing congestive heart failure in infancy: a report of two cases and review of the literature.

Congestive heart failure as a presenting symptom in infants with pulmonary sequestration is rare, and the cases of only 3 such patients have been reported. The clinical features, hemodynamics, and management of two additional patients are described. Both were seen in severe congestive heart failure in the absence of any associated cardiac anomalies. The physical findings, plain roentgenograms, electrocardiograms, and echocardiograms may provide some diagnostic clues, but cardiac catheterization is the essential diagnostic investigation. In 1 patient, pneumonectomy was performed because of extensive changes throughout the affected lung. In the other, ligation of the anomalous systemic artery to the sequestered lobe was the only surgical procedure. Both patients are doing well 15 months and 18 months after operation. Success with the latter surgical approach has not been reported previously.