George R. Daicoff

Unstable angina pectoris: National cooperative study group to compare surgical and medical therapy: II. In-Hospital experience and initial follow-up results in patients with one, two and three vessel disease

Abstract A prospective randomized study comparing intensive medical therapy with urgent coronary bypass surgery for the acute management of patients with unstable angina pectoris was carried out by nine cooperating medical centers under the auspices of the National Heart, Lung, and Blood Institute. Between 1972 and 1976, a total of 288 patients were entered into the study. All patients had transient S-T or T wave changes, or both, in the electrocardiogram during pain; 90 percent had pain at rest in the hospital, and 76 percent had multivessel coronary disease. The medically and surgically treated patients were comparable with respect to clinical, electrocardiographic and angiographic characteristics and left ventricular function. During the total study period, the hospital mortality rate was 5 percent in the surgical group and 3 percent in the medical group (difference not significant). The rate of in-hospital myocardial infarction was 17 and 8 percent in the respective groups (P In the 1st year after hospital discharge class III or IV angina (New York Heart Association criteria) was more common in medically than in surgically treated patients with one vessel disease (22 percent versus 3 percent, P The results indicate that patients with unstable angina pectoris can be managed acutely with intensive medical therapy, including the administration of propranolol and long-acting nitrates in pharmacologic doses, with adequate control of pain in most patients and no increase in early mortality or myocardial infarction rates. Later, elective surgery can be performed with a low risk and good clinical results if the patients angina fails to respond to intensive medical therapy.

Unstable angina pectoris: National cooperative study group to compare medical and surgical therapy

A preliminary report is presented of a prospective randomized trial conducted by eight cooperative institutions under the auspices of the National Heart and Lung Institute to compare the effectiveness of medical and surgical therapy in the management of the acute stages of unstable angina pectoris. To date 150 patients have been included in the randomized trial, 80 assigned to medical and 70 to surgical therapy; the clinical presentation, coronary arterial anatomy and left ventricular function in the two groups are similar. Some physicians have been reluctant to prescribe medical or surgical therapy by a random process, and the eithical basis of the trial has been questioned. Since there are no hard data regarding the natural history and outcome of therapy for unstable angina pectoris, randomization appears to provide a rational way of selecting therapy. Furthermore, subsets of patients at high risk may emerge during the process of randomization. The design of this randomized trial is compared with that of another reported trial. Thus far, the study has shown that it is possible to conduct a randomized trial in patients with unstable angina pectoris, and that the medical and surgical groups have been similar in relation to the variables examined. The group as a whole presented with severe angina pectoris, either as a crescendo pattern or as new onset of angina at rest, and 84 percent had recurrence of pain while in the coronary care unit and receiving vigorous medical therapy. It is anticipated that sufficient patients will have been entered into the trial within the next 12 months to determine whether medical or surgical therapy is superior in the acute stages of unstable angina pectoris.Abstract A preliminary report is presented of a prospective randomized trial conducted by eight cooperative institutions under the auspices of the National Heart and Lung Institute to compare the effectiveness of medical and surgical therapy in the management of the acute stages of unstable angina pectoris. To date 150 patients have been included in the randomized trial, 80 assigned to medical and 70 to surgical therapy; the clinical presentation, coronary arterial anatomy and left ventricular function in the two groups are similar. Some physicians have been reluctant to prescribe medical or surgical therapy by a random process, and the ethical basis of the trial has been questioned. Since there are no hard data regarding the natural history and outcome of therapy for unstable angina pectoris, randomization appears to provide a rational way of selecting therapy. Furthermore, subsets of patients at high risk may emerge during the process of randomization. The design of this randomized trial is compared with that of another reported trial. Thus far, the study has shown that it is possible to conduct a randomized trial in patients with unstable angina pectoris, and that the medical and surgical groups have been similar in relation to the variables examined. The group as a whole presented with severe angina pectoris, either as a crescendo pattern or as new onset of angina at rest, and 84 percent had recurrence of pain while in the coronary care unit and receiving vigorous medical therapy. It is anticipated that sufficient patients will have been entered into the trial within the next 12 months to determine whether medical or surgical therapy is superior in the acute stages of unstable angina pectoris.

Unstable angina pectoris: National cooperative study group to compare surgical and medical therapy: III. Results in patients with S-T segment elevation during pain

Abstract A prospective randomized study comparing intensive medical therapy with urgent coronary bypass surgery for the acute management of patients with unstable angina pectoris was carried out by nine cooperating medical centers under the auspices of the National Heart, Lung, and Blood Institute. Between 1972 and 1976, a total of 288 patients were entered into the study; 79 of these (27 percent of the total study group) with 70 percent or more fixed obstruction in one or more coronary arteries had episodes of pain at rest associated with transient S-T segment elevation. Forty-two were randomized to medical and 37 to surgical therapy. The hospital mortality rate was 4.8 percent for the medical and 5.4 percent for the surgical group (difference not significant). The rate Of in-hospital myocardial infarction was 12 percent in the medical and 14 percent in the surgical group (difference not significant). During the 1st and 2nd years of follow-up, 25 percent in the medical and 15 percent in the surgical group complained of New York Heart Association class III or IV angina (difference not significant). During an average follow-up period of 42 months 45 percent of the medically treated patients later underwent surgery to relieve unacceptable angina. In the medical group 65 percent were working full- or part-time at the end of 1 year and 61 percent at the end of 2 years of follow-up; comparable figures for the surgically treated group were 63 and 68 percent. The results indicate that patients with unstable angina pectoris with transient S-T segment elevation during pain at rest with fixed obstruction of 70 percent or more in one or more coronary arteries do not differ significantly from patients with pain at rest associated with transient S-T segment depression or T wave inversion. The condition of such patients can be stabilized, and they can be managed with a maximal medical program including propranolol and long-acting nitrates in pharmacologic doses with good control of pain in most and no increase in rate of early mortality or myocardial infarction. Later, elective surgery can be performed with a lower risk and good clinical results if the patients angina fails to respond to intensive medical therapy.

Intraoperative Evaluation of Surgical Systemic-to-Pulmonary Artery Shunts

Abstract At the time of operation it is difficult to ascertain the patency, inadequacy, or excessiveness of surgical systemic-to-pulmonary artery shunts performed for various types of cyanotic heart disease. An intraoperative test based on the decrease in mean aortic pressure upon opening the newly created shunt was made in 36 patients undergoing operation for creation of a subclavian-to-pulmonary artery or aorta-to-pulmonary artery anastomosis. The subsequent postoperative course of these patients was compared to the percentage of decrease in mean aortic pressure. A failure of the pressure to fall always indicated an occluded shunt (3 patients), a pressure drop of less than 9% always indicated an inadequate shunt for sustained palliation (4 patients), a pressure drop greater than 20% could indicate an excessively large shunt (1 of 3 patients), and a pressure drop between 9 and 20% usually indicated an adequate shunt for sustained palliation (29 of 32 patients). The exceptions are noted and discussed. This intraoperative test accurately predicts occluded, patent, or excessive shunts so that immediate revision may be undertaken.

Congestive Heart Failure in Infancy Treated by Early Repair of Ventricular Septal Defect

Six patients, ages 6, 10, 11, 15, 22, and 33 months, in severe congestive heart failure unresponsive to intensive medical therapy underwent operative closure of large ventricular septal defects successfully. The intraoperative management and the postoperative care are presented in detail. Our early results are gratifying and justify early closure of life-threatening ventricular septal defects in infants.

Intraoperative Doppler Coronary Artery Finder

Time-consuming difficulty is occasionally encountered in finding coronary arteries or previously placed vascular grafts during coronary revascularization procedures. A catheter-tipped, continuous-wave Doppler ultrasonic probe with simple audio output has been shown to be capable of expediting the search for these vessels.

Ascending Aorta-to-Pulmonary Artery Anastomosis for Cyanotic Congenital Heart Disease

Abstract A total of 101 infants and children with cyanotic congenital heart disease and inadequate pulmonary blood flow underwent an ascending aorta-to-pulmonary artery anastomosis at the University of Florida from January, 1964, to December, 1972. The operative mortality was 37%. The 64 surviving patients have experienced improved oxygenation of the blood and disappearance of hypoxic episodes for up to 8 years postoperatively. Two of 4 late deaths were related to inadequate pulmonary blood flow. Cardiac catheterization was performed in 16 patients 1 week to 6 years after the operation. Eight patients later underwent complete cardiac repair and discontinuance of the shunt.

Correction of Ventricular Septal Defect in Childhood

Abstract One hundred and two consecutive patients underwent operative repair of ventricular septal defect with 9 operative deaths. Preoperative cardiac catheterization was performed in 100 patients. Severe pulmonary hypertension was present preoperatively in 8 of the 9 patients who died. Two patients had permanent heart block. Postoperative cardiac catheterization was performed in three-quarters of the surviving patients. Two patients had significant residual ventricular septal defect. The 92 surviving patients have been followed up to eleven years postoperatively and are asymptomatic.