Long-term follow-up of cloth-covered Starr-Edwards prostheses.

One hundred patients in whom cloth-covered Starr-Edwards prostheses were implanted have now been followed for 3 to 7 years. The hospital mortality rate was 5 per cent, and survival at five years was 70 per cent. Complications related to valve design occurred in 8 per cent (4 per cent fatal). The majority of late deaths and poor results were related to progressive cardiac disease rather than valve-related complications. The results indicate that cloth-covered prostheses have significantly lowered the incidence of thromboembolism and eliminated poppet dysfunction. The problem of strut cloth wear was clinically observed only twice in 500 patient-years of follow-up.

Quality of life after myocardial revascularization. Effect of increasing age.

The effect of increasing age on quality of life, survival, and risk of reoperation was studied in 2479 patients followed up prospectively 2 to 20 years after myocardial revascularization. Quality of life was determined from annual questionnaires, which we used to calculate a health status index from the patient's symptomatic status and subjective response to the operation, which was graded between zero and 1.00 (asymptomatic). Four age groups were studied: age 49 years or less (AG40), 50 to 59 years (AG50), 60 to 69 years (AG60), and 70 years or older (AG70). Associated problems (left ventricular aneurysm, valve disease, acute myocardial infarction) necessitating treatment were present in 17% (61/361) of AG40 patients, 19% (165 of 859) of AG50 patients, 23% (213/927) of AG60 patients, and 31% (102/332) of AG70 patients. The hospital mortality rate was higher in older patients undergoing combined procedures but not in patients undergoing coronary bypass grafts only. Probability of survival and health status indexes were calculated excluding patients with valve disease and cardiogenic shock. Probability of survival was significantly better (p less than 0.001 by the Wilcoxon test) in patients less than age 60 than in those 60 years or older, but in patients with an ejection fraction greater than or equal to 0.40, probability of survival at 12 years was 0.64 (age less than 60) versus 0.62 (age greater than or equal to 60). The actuarial risk of reoperation, calculated as the difference between probability of survival and probability of survival without reoperation, progressively increased in younger patients but not in patients aged 60 years or older. At 15 years, the reoperation rates were 26% (AG40), 14% (AG50), 5% (AG60), and 7% (AG70). Mean health status index for years 1 to 5 was 0.85 in AG40 patients, 0.84 in AG50 patients, 0.89 in AG60 patients, and 0.90 in AG70 patients; for years 6 to 10, 0.81, 0.80, 0.86, and 0.89; and for years 11 to 15, 0.77, 0.78, 0.84, and 0.84, respectively. Thus quality of life after myocardial revascularization is better, improvement lasts longer, and reoperation rate is less in patients aged 60 years or older.

Repair of lesions of the descending thoracic aorta with the TDMAC-heparin shunt.

Utilizing a heparinized tridodecylmethylammonium chloride (TDMAC) shunt makes it possible to treat various surgical diseases of the descending thoracic aorta without cardiopulmonary bypass. Since the initial report by Gott and associates on the use of the heparinized shunt, few subsequent clinical trials have appeared in the literature. Six patients with Type III dissecting thoracic aneurysm, acquired and congenital coarctation of the aorta, saccular arteriosclerotic aneurysm, and transection of the descending thoracic aorta were operated upon by means of this technique. Only one patient had more than 500 ml. of chest tube drainage in the first 8 hours postoperatively. There were no instances of paraplegia, renal failure, or death. This technique is also recommended for repair of innominate artery aneurysms, endarterectomy of the innominate or subclavian artery, arch aneurysm, penetrating injuries of the thoracic aorta, and proximal abdominal aneurysms. Surgical indications, operative management, and postoperative follow-up are discussed.

Oxygen dissociation after transfusion of blood stored in ACD or CPD solution.

In 20 patients undergoing open-heart surgery, 2,3-diphosphoglycerate (2,3-DPG) concentrations, oxygen affinity of hemoglobin (Po2 at half saturation of hemoglobin with oxygen [P50]), hemoglobin concentration, and pH were measured repeatedly. Measurements were made before and at various times after open-heart surgery and replacement of blood loss with blood stored in acid-citrate-dextrose (ACD) or citrate-phosphate-dextrose (CPD) solutions for less than 72 hours (10 cases per group). Infusion of ACD blood caused P50 and 2,3-DPG concentration to decrease significantly after the operation. The infusion of blood stored in CPD did not significantly increase the oxygen affinity. No significant changes in hemoglobin concentration or pH were observed immediately after the operation in either group. To compensate for the increased oxygen affinity, there must be a rise in cardiac output or more likely a decrease in venous Po2. The transfusion of CPD blood, therefore, is more favorable in terms of oxygen supply, particularly in patients who have had cardiac surgery.

Early valve replacement in active infective endocarditis. Results and late survival.

In the past 14 years, 42 patients with active infective endocarditis underwent early valve replacement for severe congestive heart failure, major prosthetic dehiscence, intramyocardial abscesses, sepsis, or major embolization. Blood cultures were positive in 40 patients and the valve tissues were positive in two others. All patients received antimicrobials for from 1 to 4 weeks. Drug addiction was noted in 24%, urinary tract manipulation in 7%, dental work in 5%, contaminated prosthesis in 2%, and unknown cause in 62%. Organisms were predominantly staphylococcal (43%) and streptococcal (41%); the remainder were gram-negative (9%) or fungal (7%). The aortic valve was involved in 72%, mitral in 14%, tricuspid in 7%, and both aortic and mitral in 7%. By the New York Heart Association (NYHA) functional classification, 90% (38/42) were in Class III or IV. Operative mortality was 10% (4/42) and all four patients had preexisting renal failure necessitating dialysis. No predominant organism correlated with early deaths. In aortic valve replacement (30 patients), operative mortality was 7%. Postoperatively, 95% (35/37) were Class I or II with one lost to follow-up. Subsequent reoperation was required in five patients (13%) for recurrent endocarditis, with an operative mortality of 20% (1/5). Late death occurred in 45% (17/38). Overall probability of survival was 0.53 at 5 years. For isolated aortic valve involvement, the 5 year survival was 0.58. Survival for native valve involvement was 0.58 and for prosthetic endocarditis, 0.55. This study shows that after at least 1 week of antibiotics, early operation in patients with active endocarditis has an acceptable operative mortality. Clinical improvement is excellent in 95% and more than half survived 5 years or longer.

Hemodynamic effect of myocardial revascularization in the impaired ventricle.

The hemodynamic effect of myocardial revascularization with saphenous vein grafts (mean 3.3 per patient) was analyzed 1 year after operation in 111 patients. Operations were performed using one continuous period of aortic cross-clamping with hyperkalemic cardioplegia for distal anastomoses in 84% of patients; 16% had arrest with topical and systemic hypothermia for myocardial protection. Group I (N = 18) had normal ventricles (ejection fraction [EF] greater than 50%; left ventricular end-diastolic pressure [LVEDP] less than or equal to 12 torr); Group II (N = 64) had ischemic ventricles (EF greater than 50%, LVEDP greater than 13 torr); and Group III (N = 30) had abnormal ventricles (EF less than 50%, LVEDP greater than 13 torr). Hemodynamic measurements were obtained before and 1 year after operation. Fifteen of 18 patients (83%) in Group I did not show significant hemodynamic changes, but in three EF decreased by greater than or equal to 10% and LVEDP increased by greater than 10% over preoperative levels. In Group II, EF was unchanged or slightly better in 89% (57/64) and worse in seven patients. Improvement in cardiac index (p less than 0.01) and LVEDP (p less than 0.001) was significant. Worsening of EF in 10 of 82 patients in Groups I and II was attributed to graft closure and/or poor myocardial protection. In Group III, significant improvement in cardiac index (p less than 0.001), EF (p less than 0.001), and LVEDP (p less than 0.01) was also noted. A subset of nine patients with EF less than or equal to 35% showed postoperative improvement in 56%. Of the remaining 20 patients with an EF of greater than 35% to less than 50%, half had greater than or equal to 20% improvement in postoperative EF. Operative mortality was 3.3% (1/30) for Group III. Late mortality was 1.5% (1/64) for Group II and 10% (3/29) for Group III. Significant improvement was noted postoperatively in 67% (57/85) of all patients who had preoperative treadmill tests (p less than 0.001). This study shows that myocardial revascularization significantly improved left ventricular performance in most patients with ischemic and abnormal ventricles. Previous studies that fail to show improvement may be related to incomplete revascularization and/or poor myocardial preservation. These data, therefore, justify the need for revascularization of the impaired ventricle.

Subjective multivariable analysis bu computer for evaluation of coronary artery bypass.

Subjective multivariable analysis by computer was utilized to evaluate the results in a series of 659 patients undergoing coronary artery saphenous vein bypass surgery. A video terminal gave access to a remote computer. The postoperative subjective response was evaluated by questionnaires sent to patients at 6- to 12-month intervals, and was augmented by treadmill testing and postoperative coronary arteriography. Operative risk and subjective response are related only to the degree of ventricular function lost prior to surgery. Long-term results were best in patients in whom complete revascularization was possible. Current operative risk is less than 1%; a five-year survival rate of 90% to 95% is predicted. More than 90% of patients were asymptomatic or "greatly improved." Postoperative treadmill tests were negative in 88% of patients in these groups. In patients who were only "slightly improved" or "not improved," repeat catherization showed a graft patency rate of 84%, suggesting that recurrent symptoms were related to the extent of preoperative disease or to the progression of disease in nongrafted vessels, rather than to graft occlusion.

Carcinoma of the esophagus.

Carcinoma of the esophagus continues to have a low 5-year cure rate despite advances in radical surgery and super-voltage radiation. Neither patient education nor newer diagnostic techniques have improved survival. The reported operative mortality is 4 to 30% for esophagogastrostomy and 10 to 44% for colon interposition. Average survival time with surgery is 11 to 28 months and 5 to 11 months with irradiation. Local recurrence is high (33 to 76%) with irradiation. The reported 5-year survival rate with preoperative irradiation followed by surgery is higher (14 to 25%). Recent reports have concentrated on improving functional rehabilitation rather than improving cure rates. Palliative surgery is more acceptable because of lowered operative morbidity and mortality and the high complication rate with radiation therapy for far advanced disease. New approaches of interest include fundoplication added to esophagogastrostomy, substernal gastric bypass with anastomosis in the neck, reversed gastric tube (Heimlich operation), the addition of postoperative rather than preoperative irradiation in patients with potentially curable lesions, the use of preoperative hyperalimentation, and the potential application of immunotherapy.

Retrograde aortic dissection during cardiopulmonary bypass: "nonoperative" management.

Seven patients are reported in whom retrograde aortic dissection occurred, 2 during valve replacement and 5 during coronary artery bypass, among 770 patients perfused through the common femoral artery. Successful management included : (1) immediate cessation of cardiopulmonary bypass; (2) removal of the arterial cannula and its replacement in the ascending aorta, usually through both lumens of the dissection; (3) completion of the operation by suturing the proximal ends of saphenous vein grafts to both lumens of the dissection in the ascending aorta; and (4) no treatment of the dissection itself. One patient died of other causes 30 days postoperatively. Follow-up from 2 to 3 1/2 years in 6 long-term survivors has revealed no complications related to the dissection. Saphenous vein graft function is apparently satisfactory.

Health status after myocardial revascularization: inferior results in women.

We followed up 1,335 patients (287 female, 1,048 male) for 2 to 18 years (mean, 4.3 years) after they had undergone coronary artery bypass grafting. A health status index was calculated on the basis of their responses to annual questionnaires. The female patients were older (64.1 +/- 0.3 versus 60.4 +/- 0.3 years) and had a higher incidence of diabetes (28.6% versus 16.1%). The risk profile of women was otherwise similar to that of men. The hospital mortality was significantly higher in the women, particularly in those younger than age 60. The probability of survival (Kaplan-Meier) at 5, 10, and 15 years was lower in female patients at each interval. The mean health status index was also lower in women at 5, 10, and 15 years, and also lower in all subsets. In nondiabetic patients, the hospital mortality and probability of survival at 10 years did not differ between the female and male patients. In the diabetic patients, the hospital mortality was 11.0% (women) and 3.6% (men); the survival at 10 years was 0.42 (women) and 0.56 (men) (p < 0.001). Thus, the health status in women is less satisfactory than that of men after myocardial revascularization, and the probability of survival is lower. The excess mortality in female patients may be due to the higher incidence of diabetes in this group.

Postoperative treadmill performance and graft patency after myocardial revascularization.

In a prospective study, a random selection of 122 patients who had coronary artery bypass grafting were studied angiographically and given treadmill tests preoperatively and one year after operation, regardless of their symptoms. A total of 397 grafts were performed (average, 3.3 grafts per patient) on all primary and secondary coronary vessels deemed graftable. Complete coronary revascularization (grafts to vessels 1.5 mm or more in diameter with 50% or greater stenosis) was achieved in 104 patients (85%); 18 patients (15%) were considered incompletely revascularized. One hundred sixteen of the 397 grafts (29%) were to the left anterior descending (LAD) coronary artery, 99 (25%) to the right coronary artery, 126 (32%) to the obtuse marginal branch, 52 (13%) to the diagonal branch of the LAD coronary artery, and 4 (1%) to the septal coronary arteries. Overall results showed that patients with positive postoperative treadmill tests had a graft patency of 64%, compared with 86% for patients with negative treadmill tests (p less than 0.001). Completely revascularized patients with all grafts patent had a 4.8% (3/62) incidence of positive treadmill performance, compared with 60% (6/10) for incompletely revascularized patients with all grafts patent (p less than 0.001). Completely revascularized patients with positive treadmill tests had a graft patency of 58% (45/78), while those with negative treadmill evaluations had a graft patency of 86% (227/264) (p less than 0.001). The patency rate for incompletely revascularized patients with positive treadmill performance was 78% (25/32) and 87% (20/23) for those with negative treadmill performance. This difference was not statistically significant. This study shows that postoperative treadmill performance is highly dependent on completeness of revascularization and graft patency. It therefore supports the prognostic importance of regular treadmill exercise testing to monitor continued graft patency.

Impact of gender on coronary bypass operative mortality.

BACKGROUND: In spite of many reports investigating the influence of gender on coronary artery operations, it is still uncertain whether gender is an independent risk factor for operative mortality. A major problem of previous reports has centered around the fact that men and women constitute quite different populations, thereby making direct comparisons difficult. METHODS: The Society of Thoracic Surgeons National Cardiac Surgery Database was used to retrospectively examine 344,913 patients undergoing coronary artery bypass graft operations from 1994 through the most recent data harvest. The operative mortality of male and female patients was compared for a variety of single risk factors and combinations of risk factors. A logistic risk model was used to account for all important patient parameters so that individuals could be stratified into comparable categories allowing for direct comparisons of risk-matched male and female patients. RESULTS: The univariate analysis showed that the 97,153 women carried a significantly higher mortality for each of the risk factors examined. The multivariate analysis and the risk model stratification showed that women had significantly higher mortality as compared to equally matched men in the low- and medium-risk part of the spectrum, but in high-risk patients, there was no difference between male and female mortality. CONCLUSIONS: Gender is an independent predictor of operative mortality except for patients in very high-risk categories.

Factors influencing patency of saphenous vein grafts.

To determine factors affecting saphenous vein graft patency, 218 grafts in 66 unselected patients were studied angiographically 1 year after operation. Fourteen variables were extracted from the angiograms, electrocardiograms, and intraoperative flow measurements to assess their predictive value. Preoperative coronary vessel diameter and degree of proximal stenosis measured angiographically correlated significantly with graft patency. Graft patency for vessels greater than 1.5 mm in diameter with greater than 70% stenosis was 93% (98 out of 105). Vessel size at operation and the presence of reactive hyperemia greater than 20 ml per minute also correlated significantly with graft patency. Reactive hyperemia increased significantly as the severity of the vessel stenosis proximal to the graft increased, thus suggesting a mechanism for the improved patency rate of grafts to more stenotic vessels. The patency rate of the end-to-side component of a continuity graft (left anterior descending coronary artery and diagonal or marginal artery in 1 graft) was 100% and of the side-to-side component, 77%. This study shows that the patency rate for saphenous vein grafts compares favorably with the reported patency for internal mammary grafts when critical factors such as vessel size (greater than 1.5 mm) and degree of stenosis (greater than 70%) are considered in bypass selection.

Transfusion therapy in cardiac surgery: impact of the Paul Gann Blood Safety Act in California.

The Paul Gann Blood Safety Act became law in California on January 1, 1990, mandating that patients be informed of the risks and alternatives of blood transfusions. To evaluate the impact of this legislation, the authors compared transfusion therapy in patients undergoing cardiac surgery during 1990 to previous years (1986 to 1987 and 1989). Surgical techniques were unchanged. Homologous component usage was 8.7 +/- 0.6 (mean +/- SE) units/patient in 1986 to 1987 (n = 373), 8.2 +/- 0.9 in 1989 (n = 219) and 4.3 +/- 0.6 in 1990 (n = 222), P less than .001 by ANOVA. Erythrocyte transfusions were 3.5 +/- 0.2, 3.2 +/- 0.2, and 2.2 +/- 0.2 units/patient (P less than .001); platelet/plasma usage was 5.2 +/- 0.5, 4.9 +/- 0.7 and 2.1 +/- 0.4 units/patient (P less than .001). The number of patients not requiring transfusions increased from 28 per cent in 1989 (61 of 219) to 47 per cent in 1990 (104 of 222). A slight but significant decrease in cardiopulmonary bypass time and perioperative blood loss occurred. The authors conclude that this legislation stimulated the surgical team to control blood loss during surgery and to avoid the anticipatory use of component transfusions.

Myocardial rupture in expanded infarcts: repair using pericardial patch.

Myocardial rupture is found in approximately 20% of fatal infarctions, but the diagnosis is rarely made before death. Rupture occurs in "expanding" transmural infarctions. The diagnosis should be considered in any patient who develops recurrent chest pain and cardiovascular instability within the first week after infarction. Echocardiographic evidence of a dilated infarct with pericardial effusion is confirmatory. Three cases are described, and previous reports are reviewed. Because most patients have multivessel disease, we recommend pericardiocentesis and rapid cardiac catheterization. Infarctectomy may be appropriate when the edges of the lesion are obvious, but the more typical diffuse, serpiginous defects should be closed with dacron-bolstered sutures covered with a wide autologous pericardial patch. Myocardial rupture is a treatable condition, and a high index of suspicion is necessary in order to recognize it more frequently.