Carl C. Gill

Influence of the Internal-Mammary-Artery Graft on 10-Year Survival and Other Cardiac Events

We compared patients who received an internal-mammary-artery graft to the anterior descending coronary artery alone or combined with one or more saphenous-vein grafts (n = 2306) with patients who had only saphenous-vein bypass grafts (n = 3625). The 10-year actuarial survival rate among the group receiving the internal-mammary-artery graft, as compared with the group who received the vein grafts (exclusive of hospital deaths), was 93.4 percent versus 88.0 percent (P = 0.05) for those with one-vessel disease; 90.0 percent versus 79.5 percent (P less than 0.0001) for those with two-vessel disease; and 82.6 percent versus 71.0 percent (P less than 0.0001) for those with three-vessel disease. After an adjustment for demographic and clinical differences by Cox multivariate analysis, we found that patients who had only vein grafts had a 1.61 times greater risk of death throughout the 10 years, as compared with those who received an internal-mammary-artery graft. In addition, patients who received only vein grafts had 1.41 times the risk of late myocardial infarction (P less than 0.0001), 1.25 times the risk of hospitalization for cardiac events (P less than 0.0001), 2.00 times the risk of cardiac reoperation (P less than 0.0001), and 1.27 times the risk of all late cardiac events (P less than 0.0001), as compared with patients who received internal-mammary-artery grafts. Internal-mammary-artery grafting for lesions of the anterior descending coronary artery is preferable whenever indicated and technically feasible.

Determinants of Blood Utilization during Myocardial Revascularization

Blood transfusion during cardiac surgical procedures has steadily decreased, but little information is available regarding the factors that determine its necessity or amount. To determine the predictors of blood utilization during myocardial revascularization, 441 consecutive patients undergoing primary myocardial revascularization were studied. Forty-four patients (10%) received blood during hospitalization with a mean transfusion of 0.3 +/- 1.4 units per patient. Age, sex, weight, body surface area, preoperative hematocrit, blood volume, and red blood cell volume were examined univariately for trends. All demonstrated a statistically significant trend for both need and amount of transfusion (p less than 0.001). Neither number of grafts nor duration of cardiopulmonary bypass demonstrated statistically significant trends. All univariately significant factors were evaluated by multivariate logistic regression analysis. Red cell volume was the best predictor of the need for transfusion (p less than 0.001), followed by age. No other factors improved predictive capabilities. We conclude that preoperative red cell mass and age are the principal determinants of the need for and quantity of blood transfused during myocardial revascularization. Use of this information may greatly improve the efficiency of ordering blood before operation.

Marfan's syndrome: natural history and long-term follow-up of cardiovascular involvement

A retrospective analysis was undertaken to define the natural history and long-term follow-up of a group of patients with Marfans syndrome. Eighty-four patients were diagnosed between January 1959 and June 1987 as having Marfans syndrome; 68% were male; their ages ranged from 2 to 67 years (mean 26.6). Sixteen patients constituted the early surgical group (those who underwent surgery before 1979; mean age 36.1 years). Nineteen patients constituted the late surgical group (surgery in 1979 or later; mean age 33.3 years). The nonsurgical group comprised 49 patients (mean age 19.3 years). Fifty-seven percent of the patients had a diastolic murmur and 38% had cardiomegaly at presentation. Fifty-seven percent underwent cardiac catheterization, which revealed aortic root dilation (85%), aortic regurgitation (73%), aortic dissection (33%) and mitral regurgitation (36%). Thirteen of the 19 patients in the late surgical group received a composite graft repair of the ascending aorta as compared with only 2 of the 16 in the early surgical group. Follow-up information was obtained on 81 (96%) of 84 patients; the follow-up time was 2 to 332 months (mean 99). Thirty-one of the 81 patients died at age 3 to 63 years (mean age 35 years); 87% of the known causes of death were related to the cardiovascular system. Sixty-one percent of deaths were the result of aortic dissection or rupture or sudden cardiac death. Of the 50 survivors, 98%, including all patients in the late surgical group, were in functional class I or II. Overall survival at 5, 10 and 15 years after operation was 78.4%, 57.1% and 49.5%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Anomalous origin of the left coronary artery from the pulmonary artery (Bland-White-Garland syndrome) in adult patients: Long-term follow-up after surgery

Congenital anomalous origin of the left coronary artery arising from the pulmonary artery, or the Bland-White-Garland syndrome (BWGS), is an uncommon but frequently lethal lesion of both children and adults.’ Although approximately 80 % to 90% of patients develop congestive heart failure and die in infancy, some patients may present as adolescents or adults.*z3 Although often asymptomatic, many adults with BWGS demonstrate evidence of previous myocardial infarction and frequently exhibit ischemic patterns when evaluated with stress electrocardiography or stress thallium-201 myocardial imaging.4-6 Several reports of recurrent arrhythmias7 or sudden death2s8 in such patients have been published. Most clinicians recognize the need for surgical intervention. Surgical approaches have included reimplantation of the anomalous left coronary artery from the pulmonary artery to the aorta,g ligation of the anomalous left coronary artery from inside the pulmonary artery,‘O or ligation of the left coronary artery combined with saphenous vein grafting to the anterior descending coronary artery.” No data are currently available which demonstrate the superiority of one surgical approach over another in adult patients. This report describes the presentation, evaluation, and long-term follow-up in 10 adult patients with BWGS following various methods of surgical repair.

Long-term function of the morphologic right ventricle in adult patients with corrected transposition of the great arteries

Because of the concern about the ability of the morphologic right ventricle (MRV) to function over a long term as a systemic ventricle, adult patients with congenitally corrected transposition of the great arteries (CCTGA) were evaluated to determine the long-term function of the MRV. Morphologic right ventricular function was assessed by functional clinical classification and angiographic ejection fraction in 18 adult patients with congenitally corrected transposition of the great arteries. These patients had a mean age of 30.2 +/- 14.5 years (range 10 to 67 years). All but one had hemodynamically significant lesions, the most common being left atrioventricular valve regurgitation (11 patients), ventricular septal defect (seven patients), atrial septal defect (four patients), and pulmonic stenosis (three patients). The mean MRV ejection fraction at presentation was 55% +/- 11.5% (range 24% to 74%). Twelve of the 18 patients (67%) were followed clinically, with a mean follow-up time of 9.9 +/- 7.1 years (range 1 to 22 years). Eight were reassessed angiographically, with a mean MRV ejection fraction of 51.3% +/- 10.7% (range 30% to 67%). The other four were followed up clinically and evaluated by two-dimensional echocardiography, with normal MRV function in two patients. Eight of 12 patients (67%) were in functional class I at follow-up, one was in functional class II, one was in functional class III, and two had died. Our data suggest that the morphologic right ventricle can function appropriately over a long term in adult patients with congenitally corrected transposition of the great arteries.(ABSTRACT TRUNCATED AT 250 WORDS)

Reoperations for Valve Surgery: Perioperative Mortality and Determinants of Risk for 1,000 Patients, 1958–1984

One thousand consecutive cardiac reoperations for valve surgery in 897 patients were reviewed to determine in-hospital mortality and indicators of risk. Subgroups based on the number of previous cardiac procedures and the valve or valves replaced or repaired at reoperation (aortic valve, mitral valve, tricuspid valve, or multiple valves and mortality [deaths/number of procedures (% mortality)]) for those subgroups are as follows: (Table: see text) Predictors of increased risk for a first aortic valve reoperation were advanced age (p = .0002), endocarditis (p = .0018), female sex (p = .014), impaired left ventricular function (p = .039), and number of coronary vessels obstructed by 70% or more (p = .055). For a first mitral valve reoperation, the predictors were advanced age (p less than .0001), preoperative shock or cardiac arrest (p = .01), previous aortic or tricuspid valve operations (p = .02), type of mitral valve procedure (risk for repair of periprosthetic leak was greater than mitral valve replacement which was greater than mitral valve-conserving operation [p = .05]), and impaired left ventricular function (p = .059). For a first multiple valve reoperation, the predictors were diabetes (p = .04) and ascites (p = .02), whereas patients undergoing mitral valve replacement and tricuspid valve operations were at decreased risk (p = .01). Comparison of second reoperations with first reoperations indicates risk increases for multiple operations (p = .01) but not for aortic or mitral valve procedures. Rereplacement of a prosthesis (p = .007), coronary bypass grafting at reoperation (p = .006), and advanced age (p = .06) increased the risk for second reoperations. Age is the most consistent predictor of risk for patients undergoing valve reoperations.

Replacement of aortic valve combined with myocardial revascularization: determinants of early and late risk for 500 patients, 1967-1981.

Five hundred consecutive patients underwent aortic valve replacement and coronary revascularization in the years from 1967 to 1981, with 29 (5.9%) in-hospital deaths. Current operative mortality (1978-1981) is 3.4%. Univariate and multivariate analyses were used to identify determinants of early and late risk. Female sex, aortic insufficiency, and advanced age increased in-hospital mortality, whereas use of cardioplegia decreased it. At follow-up of 471 patients who survived hospitalization for 1 to 135 months (mean 41) after surgery, 96 late deaths were documented. Survival rates were 87%, 80%, and 55%, and event-free survival rates were 80%, 65%, and 39% at 2, 5, and 10 years after surgery, respectively. The late survival rate was unfavorably influenced by the presence of moderately or severely impaired left ventricular function and double-vessel coronary disease; the rate was enhanced for patients in age group from 50 to 59 years old and was not influenced by the method of myocardial protection. The event-free survival rate decreased with the presence of moderately or severely impaired left ventricular function and was enhanced for patients with New York Heart Association class I or II symptoms before surgery. Patients with bioprostheses who did not receive anticoagulants had higher survival and event-free survival rates than did either patients with bioprostheses who received anticoagulants or patients with mechanical valves, whether they received anticoagulants or not.

Trends in Selection and Results of Coronary Artery Reoperations

The first 1,000 patients undergoing isolated coronary artery reoperation were divided into four cohorts of 250 patients each: 1969 to 1976; 1976 to 1979; 1979 to 1981; and 1981 into 1982. Graft failure as an indication for reoperation rose from 26% in Group 1 to 40% in Group 4, and the interval lengthened from 17 to 61 months, presumably a result of late closures 5 to 10 years postoperatively. Progressive atherosclerosis in previously ungrafted vessels has decreased from 62% in Group 1 to 23% in Group 4, a decline attributed to more complete revascularization initially. The frequency of three-vessel disease, stenosis of the left main coronary artery, and left ventricular impairment continues to rise in candidates for reoperation. Yet, operative mortality has declined from 5% to 2%, and most other forms of perioperative morbidity have decreased significantly when the early years are compared with the later experience. The number of grafts per patient has increased from 1.4 to 2.3, and complete revascularization in reoperations has increased from 65% to 76%. After a mean of 29 months, graft patency was 81% overall in 154 patients restudied after reoperation. Patency was similar for grafts to arteries previously involved with graft failure and to arteries not previously grafted. Five-year actuarial survival for patients in the first three cohorts (mean, 57 months) was 89%.(ABSTRACT TRUNCATED AT 250 WORDS)

Determinants of 10-year survival after primary myocardial revascularization.

The first 1000 patients undergoing primary isolated myocardial revascularization each year from 1971 to 1978 were analyzed to elucidate the determinants of long-term survival. Five-year survival was 93.2%, and 10-year survival was 79.3%. Five-year survivals were 96.1%, 94.2%, 92.1%, and 90.8%, respectively, for single, double, triple, and left main disease. Ten-year survivals for the same subsets were 88.6%, 83.0%, 74.9%, and 70.9%. Five-year survivals were 95.3%, 92.4%, 88.0%, and 81.3% for patients with normal, mild, moderate, and severe impairment of the left ventricle. Ten-year survivals for the same subsets were 84.1%, 76.5%, 65.8% and 53.6%. Patients receiving internal mammary artery grafts had 95.6% and 85.8% 5- and 10-year survivals that were superior to 92.0% and 76.2% in patients with only vein grafts. Patients completely revascularized had 95.0% and 82.5% 5- and 10-year survivals, while incompletely revascularized patients had lower (90.5% and 75.2%) 5- and 10-year survivals. Advancing age was the most important factor influencing late survival. Other risk factors in descending order of significance were impaired left ventricular function, no mammary artery graft, smoking, abnormal EKG, three vessel or left main disease, left ventricular end diastolic pressure (LVEDP) greater than 24, hypertension, 1971 to 1974 surgical era, cholesterol greater than 300, incomplete revascularization, and two vessel disease.

Patent ductus arteriosus in adults-long-term follow-up: Nonsurgical versus surgical treatment

The long-term prognosis of adult patients with patent ductus arteriosus treated medically or surgically has not been demonstrated. One hundred seventeen adult patients ranging in age from 18 to 81 years (mean 36) were followed up for 1 to 37 years (mean 18). Forty-five patients were treated nonsurgically and 72 had surgical closure. The nonsurgical group experienced significantly more cyanosis (p = 0.002) and had fewer diastolic murmurs (p greater than 0.001) than did the surgical group. In the nonsurgical group, patients with cardiomegaly before treatment were more likely to die (p greater than 0.001) than were patients who did not have cardiomegaly. In the surgical group, patients with cardiomegaly before treatment had a worse prognosis (p = 0.09) than that of patients with normal heart size. Seven patients, five in the nonsurgical and two in the surgical group, presented with a pulmonary artery systolic pressure greater than 100 mm Hg. Five of these patients are alive and well at a mean follow-up time of 18 years. The two nonsurvivors were in the nonsurgical group and died at 4 and 19 years of follow-up, respectively. Adult patients with patent ductus arteriosus should be treated surgically, especially if cardiomegaly is seen at initial presentation.