Javier Fernandez

Coronary Artery Bypass Grafting in Patients with Chronic Congestive Heart Failure: A 10‐Year Experience with 203 Patients

Abstract From 1983 to 1992, 203 patients with chronic congestive heart failure and no angina underwent primary coronary artery bypass. This represented 3% of patients undergoing coronary artery bypass grafting. Ninety‐two percent of the patients were in New York Heart Association (NYHA) functional class III or IV prior to undergoing coronary artery bypass grafting. Thallium perfusion imaging was performed in 21% of the patients, with a reversible defect present in 88%. An internal mammary artery graft was used in 70% of the patients. The hospital mortality was 6.0% and the actuarial survival at 5 years was 59%. An improvement in NYHA functional class occurred in 75% of the surviving patients with a mean improvement of 1.6 ± 0.6 functional classes. Univariate analysis identifed risk factors for hospital death as emergency operation, recent myocardial infarction (< 30 days), and the need for an intra‐aortic balloon pump. A trend emerged for nonuse of an internal mammary artery to predict hospital death. A positive thallium perfusion scan was not a predictor of early or late survival, nor did it influence NYHA functional class. The use of the internal mammary artery signifcantly enhanced late survival (p = 0.01), however, did not affect the functional class of survivors. We conclude that coronary artery bypass grafting is effective in ameliorating symptoms of chronic congestive heart failure in patients suffering from chronic ischemic cardiomyopathy and can be performed with acceptabie early and late mortality.

Perioperative risk factors affecting hospital stay and hospital costs in open heart surgery for patients≥65 years old

OBJECTIVEnDemographic changes, associated with increased demands for open heart surgery in the elderly, place increased burden on financial resources. To evaluate perioperative risk factors affecting incidence of hospital events and estimation of hospital charges, 2577 patients > or = 65 years (range 65-91), operated on from January 1991 to December 1994, were compared with a concurrent cohort of 2642 younger patients.nnnMETHODSnStatistical analysis, by surgical procedure, focused on hospital mortality, key postoperative complications affecting length of hospital stay and hospital charges.nnnRESULTSnOverall hospital mortality was 4.7%, 3.5% in younger patients versus 6.1% in the older group (P << 0.01). Mortality was significantly lower in patients less than 65 years undergoing coronary artery bypass grafting (3% versus 5%, P < 0.01) and valve replacement (4% versus 9%, P = 0.01). Significant risk factors for hospital death in the elderly: diabetes (P < 0.01), hypertension (P < 0.01), myocardial infarction (P < 0.01) and congestive heart failure (P < 0.01). Significant postoperative events, more common in older patients, included prolonged ventilation (P << 0.01), congestive heart failure (P << 0.01), infection (P << 0.01), cerebrovascular accident (P < 0.01), and intra aortic balloon pump (P < 0.01). Incremental risk factors for morbidity in the elderly were: higher New York Heart Association class, congestive heart failure, emergent operation, and female gender. Mean length of hospital stay for the < 65 group was 15.3 versus > 19.5 days for the > 65 group (P << 0.01). Length of stay over 18 days positively correlated with increased morbidity in both age groups. For patients > or = 65 years of age, the average hospital charge for open heart surgery was 172% higher for patients with a length of stay greater than 18 days compared with 165% for patients less than 65 years of age.nnnCONCLUSIONSnHigher operative mortality and longer length of stay in elderly patients, resulting in increased health care costs, was associated with more co-morbidities. These results suggest interventions designed to reduce congestive heart failure and other co-morbidities may improve patients recovery and reduce costs.

Perioperative events in patients with failed mechanical and bioprosthetic valves

From 1963 through 1991, 1037 patients underwent reoperative valvular procedures. The 478 patients having reoperations for either failed bioprosthetic (n = 212) or mechanical (n = 266) valves were evaluated. There were 210 male (44%) and 268 female (56%) patients. The mean age at reoperation of the patients in the bioprosthesis group was 59.7 years and and that in the mechanical valve group was 56.1 years (p = 0.0006). The mean interval to the time of reoperation was 84.7 months in the mechanical valve group and 74 months in the bioprosthesis group. There was no difference between the two groups in the functional class at reoperation. More severe mitral valve stenosis and incompetence, more severe aortic valve stenosis, and higher right ventricular and pulmonary arterial pressures were noted in the bioprosthesis group than in the mechanical valve group. Hemolysis (p = 0.05) was more prevalent in the patients with mechanical valves than in the ones with bioprostheses. A longer aortic occlusion time (p = 0.0001) and longer cardiopulmonary bypass time (p = 0.0001) were required for the reoperations in the bioprosthesis group. The operative mortality was 13.2% for the bioprosthesis patients and 12.4% for the mechanical valve patients. The risk factors for hospital death included the cross-clamp time (p = 0.0001), the functional class (p = 0.00001), the presence of ascites (p = 0.02), hepatomegaly (p = 0.002), and decreasing ejection fraction (p = 0.05). We conclude that mechanical valve failures do not produce catastrophic events resulting in poor reoperative results.

Actuarial survival and other events following valve surgery in octogenarians : comparison with an age-, sex-, and race-matched population

From January 1973 to December 1989, 54 patients over 80 years of age underwent an intracardiac repair which included a cardiac valve operation. There were 21 males and 33 females. Mean age at operation was 82 years, range 80-89 years. Fifty-two patients (96%) were in New York Heart Association functional class III or IV preoperatively. Six patients had undergone previous valve surgery (11%). There were eight hospital deaths (14.8%). Risk factors for hospital death included older age at repair (p = 0.008), increased total cardiopulmonary bypass time (p = 0.06), and, possibly, smaller aortic valve prosthesis (p = 0.10). All 46 hospital survivors were followed up at a mean of 28.8 months after hospital discharge. There were 11 late deaths (23.9%), occurring at a mean of 32.3 months postoperatively. Survival analysis indicated that increased age (p = 0.06) and increased pulmonary artery diastolic pressure preoperatively (p less than 0.07) were multivariate risk factors for overall mortality. Actuarial survival at 5 years was 44%, with no difference from survival in an age-, sex-, and race-matched population. We conclude that octogenarians in the modern era have good chance for survival following valvular surgery. As hazards for full anticoagulation were low in this series, if valve repair is not feasible, we presently recommend the use of mechanical valves in the elderly to reduce the requirement for late reoperation due to bioprosthesis degeneration.

Insertion of Björk-Shiley Aortic Prosthesis by Continuous Suture Technique

Abstract A new technique for insertion of the Bjork-Shiley aortic prosthesis using a continuous suture is described. This technique, which can be used in selected patients, cuts down bypass time and eliminates the need for coronary perfusion.

Herniation of emphysematous bulla through a chest tube site

A 69-year-old male cigarette smoker with bullous emphysema presented with progressive dyspnea, chest pain, and hemoptysis. Chest radiograph revealed 100% right-sided pneumothorax. A 28 F chest tube was inserted through the fifth intercostal space in the anterior axillary line. The chest tube was removed in 36 hours. The following day, the patient had an episode of coughing, which resulted in sudden protrusion of a 9-cm bulla through the chest tube site (Fig 1). The patient remained comfortable and afebrile. Computed tomography of the chest confirmed severe bullous disease, herniated bulla, and compression atelectasis in lower lung fields (Fig 2). The patient underwent emergency bullectomy through antero-lateral thoracotomy. Surgical findings revealed the eviscerated bulla to be a part of the right lower lobe. The patient was discharged home on the ninth postoperative day. Address reprint requests to Dr Konecny, Deborah Heart and Lung Center, 200 Trenton Rd, Browns Mills, NJ 08015.

Valve-related events and valve-related mortality in 340 mitral valve repairs. A late phase follow-up study.

To assess the early and late valve-related events, 340 consecutive patients undergoing mitral valve repair from 1969 to 1988 were evaluated. Follow-up was complete, with a mean of 7.5% years and range from 2 to 22 years (cumulative 2456 patient-years). There were 221 (65%) female patients. Rheumatic valvular disease was present in 246 (68%) patients. The remaining patients had ischemic or congenital valve disease, floppy valve or infective endocarditis. At surgery, 47% of the patients had pure mitral incompetence, 43% had mixed mitral stenosis and incompetence and 10% had predominant mitral stenosis. Seventy-three percent of the patients were in functional class III or IV. Twelve percent had had prior heart surgery. Concomitant valve procedures including coronary revascularization were performed in 62.3%. There were 23 hospital deaths (6.8%) but only 3 of these (0.8%) were valve-related in patients who died at reoperation for valve repair failure. There were 4 other early repair failures who survived early reoperation. Of the 317 hospital survivors, there were 127 late deaths, and an actuarial survival of 44 +/- 3.7% (70% CL) at 14 years. Of these, 13 were valve-related or 0.5% patient-year. Late events included thromboembolism (TE) 1% patient-year, anticoagulant bleeding 0.4% patient-year, infective endocarditis (IE) 0.2% patient-year and late reoperation for mitral valve repair failure in 63 patients or 2.8% patient-year. At the late follow-up, 88% of the hospital survivors were in functional class I or II.(ABSTRACT TRUNCATED AT 250 WORDS)

The Cryopreserved Stented Pulmonary Homograft Valve in the Tricuspid Position

Abstract This study was designed to evaluate the early phase events occurring in a stented pulmonary homograft valve implanted in the tricuspid position. A human pulmonary homograft was sterilized in antibiotic solution for 48 hours and cryopreserved in liquid nitrogen (–176°C). Following thawing and trimming, the pulmonary valve was mounted on a Dacron cloth‐covered Delrin stent and implanted into the tricuspid position in 3‐month‐old sheep, for a mean of 95 ± 5 days. Seven animals were studied. Morphological assessment indicated good structural tissue preservation despite a decrease in viable fibroblasts noted in the distal part of the leaflets. The collagen fibers remained unchanged, and no tissue calcification was found. Viability of the mounted homograft was evaluated using an in vitro tissue culture method, and the viable cells underwent chromosomal analysis to identify whether they originated from the donor or host. Cells with 56 chromosomes, a number intrinsic to sheep cells, were cultured from the donor‐recipient junctional area. Hemodynamic and angiographic data, which were collected at the time of both implantation and explantation, revealed no functional deterioration of the implanted valve over 3 months. At the time of explantation, six of the seven valves were competent and no cusp retraction or thickening was noted. The seventh valve had deteriorated due to endocarditis. We conclude that stented cryopreserved pulmonary homografts may be useful as bioprostheses in the tricuspid position.

Massive Mitral Regurgitation from Chordal Rupture and Coronary Artery Disease

The precise mechanism that causes spontaneous rupture of chordae tendineae remains unknown. That it may occur in patients with no disease other than underlying or associated coronary artery occlusion has not been previously reported. Six patients with chordal rupture were found among 600 patients who underwent operation for mitral regurgitation in a 6-year period. All 6 patients without exception underwent simultaneous mitral valve replacement and coronary revascularization. The salient clinical features of these patients are summarized, and 1 case is reported in detail.

THE ROLE OF GENETICS IN VENTRICULAR TACHYARRHYTHMIA RISK STRATIFICATION: PRIMARY RESULTS FROM THE DISCOVERY TRIAL

Population-based studies suggest that genetic factors contribute to sudden cardiac death (SCD), but few genetic loci have been identified. DISCOVERY investigated if 7 single nucleotide polymorphisms (SNPs) in 3 genes coding G-protein subunits were predictive for ventricular tachyarrhythmias (VT) in