Donald C. Mullen

Results of Intraaortic Balloon Pumping after Cardiac Surgery: Experience with the Percor Balloon Catheter

One hundred thirty-eight patients undergoing an open-heart procedure required an intraaortic balloon pump (IAPB) postoperatively. In Group I (N = 45), the AVCO femoral conduit surgical technique was used; in Group II (N = 93), the Percor balloon was inserted either in the operating room after groin cutdown (open insertion) or percutaneously in the intensive care unit (percutaneous insertion). IABP usage increased in Group II (3% versus 1.6%; p less than 0.001). Immediate mortality was 40% (55/138). Use of the Percor balloon in Group II resulted in lower immediate mortality (32/93 or 34% versus 23/45 or 51%; p less than 0.06). Delayed mortality from multiorgan failure was 11.6% (16/138). Immediate percutaneous insertion at the bedside rather than a return to the operating room for open insertion yielded lower mortality (2/8 or 25% versus 6/7 or 86%; p less than 0.05). Open insertion of the Percor balloon decreases the failure rate of insertion compared with both the AVCO femoral conduit technique (7/85 or 8.2% versus 5/45 or 11%) and percutaneous insertion. It has more complications than the AVCO femoral conduit technique (7/85 or 8.2% versus 2/45 or 4.4%) and less than percutaneous insertion.

Long-Term Follow-up of the Björk-Shiley Prosthetic Valve Used in the Mitral Position

Abstract This study analyzes 547 patients who had mitral valve replacement with a Bjork-Shiley prosthesis over a 9-year period (mean follow-up, 46.5 months). Operative mortality was 7.3%, and 5-year survival was 76.9%. Serious anticoagulation problems occurred in 1.8% (10 patients) and serious thromboembolic episodes in 5.3% (28 patients) (1.3 per 1,000 patient-months). The study includes 257 patients with isolated mitral valve replacement (Group 1) and 290 who had associated procedures (Groups 2 through 5). Hospital mortality in Group 1 was 2.7% compared with 11.7% in Groups 2 through 5 ( p p In the patients in Group 1 with pure mitral insufficiency (MI), 5-year survival was 70.9%, significantly lower ( p Significantly lower ( p

Prognostic Considerations in the Management of Left Ventricular Aneurysms

This report summarizes a four-year experience with 60 patients who had left ventricular aneurysm (LVA) resection and bypass of all significantly diseased coronary arteries, with an operative and late mortality of 3.3 and 8.3%, respectively. Their cardiac catheterizations were reviewed, and the only values that seemed to reflect prognosis were preoperative cardiac index and the presence of absence of septal motion. The lower the cardiac index, the less likely the patient was to do well postoperatively. There were now survivors who had lacked septal motion by left anterior oblique ventriculogram. Patients without septal motion are therefore no longer considered surgical candidates. If septal motion is present, resection of LVA carries no more risk than myocardial revascularization without LVA.

An Alternative Approach to Isolated Circumflex Coronary Bypass Reoperations

Abstract A method for secondary and tertiary revascularization of circumflex marginal coronary arteries with descending aorta–coronary saphenous vein bypass grafts using an arterial occluder is described.

Ten-Year Follow-up in Aortic Valve Replacement Using the Björk-Shiley Prosthesis

An in-depth statistical analysis of early and late results of aortic valve replacement using the Björk-Shiley tilting-disc prosthesis is presented. Our experience with this prosthesis indicates that replacement carries a low surgical risk, a low incidence of complications (embolization, infection, or hemorrhage due to long-term use of anticoagulants), and good long-term survival. Coexisting coronary artery disease increases surgical mortality significantly, and simultaneous, complete revascularization is essential. Patients undergoing isolated aortic valve replacement did significantly better than those requiring other simultaneous procedures or those who had had previous operations. Earlier operation is imperative since progress of aortic valve disease is unpredictable by duration of symptoms, and patients in New York Heart Association Functional Class II have a low surgical risk and a greatly increased survival. It would appear from this study that additional criteria, such as increasing ventricular dilatation and hypertrophy determined by echocardiographic studies and gated nuclear studies showing deterioration of ejection fraction on exercise, should be used to help determine time of surgical intervention rather than symptomatology alone.

Late Evaluation of Patients Undergoing Valve Replacement with the Björk-Shiley Prosthesis

This study analyzes 484 patients who survived mitral, aortic, or mitral and aortic valve replacement using the Björk-Shiley prosthesis from January, 1970, through December 31, 1974. Long-term follow-up of 1 1/2 to 6 1/2 years (mean, 3.67 yr) was done on 435 patients (98.2%). Eighty to 85% of the patients have improved noticeably. Thromboembolic problems occurred in 6.9%, representing 1.5 emboli per 1,000 patient-months. Anticoagulant bleeding problems occurred in 6.4% of the patients; late mortality was 15%. Actuarial survival curves showed patients at risk to 6 years having a 79% chance of survival. The same analysis according to preoperative New York Heart Association Functional Classification showed a striking reduction in survival in class IV patients. The Björk-Shiley prosthesis is a good choice for valve replacement today. Earlier diagnosis and treatment are needed to obtain better long-term survival.

Survival and “Event-free” Analysis of 785 Patients with Björk-Shiley Spherical-Disc Valves at 10 to 16 Years

Seven hundred eighty-five patients underwent Björk-Shiley spherical-disc valve replacement from 1970 to 1976. There were 268 mitral valve replacements (MVR), 227 aortic valve replacements (AVR), 65 double-valve replacements, and 225 combined procedures. A 97.2% follow-up (mean, 12 years) was achieved. With an operative mortality of 4.1% for MVR, 8.4% for AVR, 15.4% for double-valve replacement, and 12.4% for combined procedures, the 12-year survival was most closely related to age at valve replacement: age less than 50 years, 70%; age 50 through 59 years, 52%; and age 60 years or more, 38%. Twenty-four patients (3.1%) (6 who had MVR, 5 who had AVR, 1 who had double-valve replacement, and 12 who had combined procedures) had a thrombosed valve 1 to 134 months postoperatively; this is equal to 0.36 thrombosed valve per 100 patient-years. One hundred eighteen embolic episodes occurred in 94 (13%) of the operative survivors or 1.8 emboli per 100 patient-years. There were major bleeding complications in 0.5% of patients and minor bleeding complications, in 4.0%. Endocarditis appeared in 30 patients (4.2%) or 0.4 episode per 100 patient-years and paravalvular leaks, in 20 patients (2.8%). The event-free survival by age group and valve site at 5, 10, and 12 years is presented. Events included death, thrombosed valves, strokes, bleeding, emboli, paravalvular leaks, and endocarditis. There were 5.3 events per 100 patient-years excluding operative deaths.

Improved Early Results After Aortic Valve Replacement: Analysis by Surgical Time Frame

Primary aortic valve replacement was performed in 430 patients. It was an isolated procedure in 339 and was combined with coronary artery bypass grafting in 91. Of these patients, 282 underwent operation from 1970 through 1976 (time frame 1) and 148 from 1980 through 1985 (time frame 2). They were divided into subgroups by age, New York Heart Association functional class, combined coronary artery bypass graft, and valvular lesion. Overall hospital mortality was 7.7% (time frame 1 = 10.6% versus time frame 2 = 2.0%; p less than 0.01). Overall, functional class III or IV was the strongest predictor of hospital mortality (p less than 0.001). Association of coronary artery bypass graft was the next strongest predictor of hospital mortality (p less than 0.01), and it retained its predictive value in time frame 2. Overall, hospital mortality was higher in patients older than 55 years (10.5% versus 3.5%; p less than 0.05). There were no hospital deaths in patients younger than 55 years in time frame 2. Type of valvular lesion was not a predictor of hospital mortality. Hospital mortality in patients receiving cardioplegia was 2%. Cardioplegia use has lessened the effect of age and functional class as predictors of hospital mortality after primary aortic valve replacement. Earlier operation in time frame 2 played a substantial role in the overall improvement of early results.

Life-threatening Chylothorax after Left Internal Mammary Artery Dissection: Therapeutic Considerations

Persistent chylothorax developed in a 53-year-old man after left internal mammary artery (LIMA) takedown and required surgical intervention. After an unsuccessful supraclavicular approach, left-sided standard thoracotomy showed thick adhesions around the LIMA takeoff with a diffuse oozing rather than an identifiable discrete leak. A possible leaking point was stitched, the area was sealed with fibrin adhesive, and complete remission ensued. Operation for chylothorax after LIMA takedown is challenging. A left-sided standard thoracotomy with minimal dissection and use of fibrin adhesive rather than blind stitching are recommended.

A Comparative Synchronous Coronary Surgery Survival Study

Utilizing patient criteria published by the Veterans Administration Cooperative (VAC) Study, a cohort of 229 surgically treated patients was retrieved from the Milwaukee Cardiovascular Data Registry. These patients were all operated on by one surgeon during 1972 to 1974. Four-year survival of this group was compared with that of the medically treated cohort of 310 patients from the VAC Study. Operative mortality was included in all surgical groups. The cumulative 4-year survival of both groups revealed a 95 to 85% advantage for surgical therapy. In patients with three-vessel disease, the cumulative survival favored surgical therapy--94% compared with 80% in the medically terated cohort--and in patients with triple-vessel disease and a normal left ventricle, surgical therapy again showed better results: 100% compared with 88%. Patients with two-vessel disease and a normal left ventricle who underwent surgical intervention had slightly better 4-year survival than those who had medical treatment--100% versus 95%--and those with two-vessel disease and an abnormal left ventricle had a 93% survival after surgical treatment compared with 84% for those with medical treatment. For patients with single-vessel disease, there was no difference in survival between the surgical and medical cohorts.