Kurt Amplatz

Effect of partial ileal bypass surgery on mortality and morbidity from coronary heart disease in patients with hypercholesterolemia: Report of the program on the surgical control of the hyperlipidemias (posch)

BACKGROUND AND METHODS The Program on the Surgical Control of the Hyperlipidemias (POSCH), a randomized clinical trial, was designed to test whether cholesterol lowering induced by the partial ileal bypass operation would favorably affect overall mortality or mortality due to coronary heart disease. The study population consisted of 838 patients (417 in the control group and 421 in the surgery group), both men (90.7 percent) and women, with an average age of 51 years, who had survived a first myocardial infarction. The mean follow-up period was 9.7 years. RESULTS When compared with the control group at five years, the surgery group had a total plasma cholesterol level 23.3 percent lower (4.71 +/- 0.91 vs. 6.14 +/- 0.89 mmol per liter [mean +/- SD]; P less than 0.0001), a low-density lipoprotein cholesterol level 37.7 percent lower (2.68 +/- 0.78 vs. 4.30 +/- 0.89 mmol per liter; P less than 0.0001), and a high-density lipoprotein cholesterol level 4.3 percent higher (1.08 +/- 0.26 vs. 1.04 +/- 0.25 mmol per liter; P = 0.02). Overall mortality and mortality due to coronary heart disease were reduced, but not significantly so (deaths overall [control vs. surgery], 62 vs. 49, P = 0.164; deaths due to coronary disease, 44 vs. 32, P = 0.113). The overall mortality in the surgery subgroup with an ejection fraction greater than or equal to 50 percent was 36 percent lower (control vs. surgery, 39 vs. 24; P = 0.021). The value for two end points combined--death due to coronary heart disease and confirmed nonfatal myocardial infarction--was 35 percent lower in the surgery group (125 vs. 82 events; P less than 0.001). During follow-up, 137 control-group and 52 surgery-group patients underwent coronary-artery bypass grafting (P less than 0.0001). A comparison of base-line coronary arteriograms with those obtained at 3, 5, 7, and 10 years consistently showed less disease progression in the surgery group (P less than 0.001). The most common side effect of partial ileal bypass was diarrhea; others included occasional kidney stones, gallstones, and intestinal obstruction. CONCLUSIONS Partial ileal bypass produces sustained improvement in the blood lipid patterns of patients who have had a myocardial infarction and reduces their subsequent morbidity due to coronary heart disease. The role of this procedure in the management of hypercholesterolemia remains to be determined. These results provide strong evidence supporting the beneficial effects of lipid modification in the reduction of atherosclerosis progression.

Left retrograde cardioangiography in acquired cardiac disease: Technic, indications and interpretations in 700 cases∗☆

Abstract Application of retrograde left cardioangiography to 700 patients, both adults and children, with acquired valvular diseases is described. The technic employed for the test is described. Pressures from the aorta and left ventricle are obtained during the same procedure as angiography to determine whether stenosis of the aortic valve is present. The method may be used to estimate the degree of aortic or mitral insufficiency or both. Mitral stenosis may be identified by a fixed filling defect of the left ventricular cavity. The value of this information in the surgical management of many forms of cardiac disease is emphasized. Complications have occurred infrequently and, in most instances, the patients have responded to appropriate therapy. Three deaths occurred. These were caused by ventricular fibrillation in 1 patient and cardiac tamponade in 2. The most common complication was thrombosis of the femoral artery at the site of arteriotomy. This complication occurred in about 4 per cent of cases; but in none did gangrene occur, and pulsatile flow was restored in all cases by immediate re-exploration of the femoral artery as soon as the diagnosis was made.

Balloon dilation angioplasty of aortic coarctations in infants and children.

Balloon dilation angioplasty (BDA) was attempted nine times in eight infants and children with aortic coarctation. In three infants (all with associated ventricular septal defect or atrioventricular canal and marked hemodynamic instability) dilation was attempted at a site of aortic narrowing that had not been operated on previously. Although the coarctation gradient fell 40% or more over the short term in two of the three, there was no angiographic or late gradient evidence of improvement. All three underwent subsequent coarctation surgery. Five dilations were performed in four infants and children who had previously undergone coarctation surgery (end-to-end anastomosis, attempted jump graft, and subclavian flap) and had residual gradients. Dilation was successful in all five cases, resulting in an increase in the diameter at the coarctation site (4.7 +/- 2.6 to 7.7 +/- 4.0 mm, p less than .05) and a decrease in the gradient measured 24 hr after dilation (42.0 +/- 15.5 to 11.8 +/- 11.2 mm Hg, p less than .05). In one child with a long area of hypoplasia of the thoracic aorta and similar lesions of the brachiocephalic vessels, a preliminary attempt to dilate a severely narrowed subclavian artery was unsuccessful. Postdilation angiography demonstrated evidence of intimal tears in three of five successful dilations. Follow-up (1 to 6 months) has demonstrated continued gradient relief in four of five children. BDA is frequently, but not always, a successful treatment for human aortic coarctation. The chief determinant of success appears to be the nature of the lesion; short-term changes in coarctation gradient are unreliable indicators of success of failure. Although BDA was not associated with mortality or significant morbidity in this group of patients, its role in the management of children with coarctation is yet to be determined.

Transvenous Closure of Secundum Atrial Septal Defects Preliminary Results With a New Self-Expanding Nitinol Prosthesis in a Swine Model

BACKGROUND Our purpose was to evaluate a new prosthesis for percutaneous closure of secundum atrial septal defects (ASDs). METHODS AND RESULTS Percutaneous closure of surgically created fossa ovalis ASD was attempted in 15 minipigs. The mean balloon-stretched ASD diameter was 12.3+/-2.3 mm (range, 10 to 16 mm). The self-expanding prosthesis was braided from 0.005-in Nitinol wires in the shape of two flat buttons with a short connecting waist with a diameter corresponding to that of the defect to be closed. Polyester filling was added to enhance thrombogenicity. Pulmonary arteriography with levo-phase was obtained before placement; immediately after placement; and at 1-week, 1-month, and 3-month follow-ups. Four animals were killed at 1 week, 1 month, and 3 months for histopathological correlation. Three deaths resulted from ventricular fibrillation (one during anesthesia and two during the placement procedure). Successful placement of the prosthesis was achieved in the remaining 12 animals. Overall immediate ASD closure on angiography occurred in 7 of 12 animals (all polyester-filled prostheses). Absent or trace shunt by angiography was present in 11 of 12 devices at 1 week, with the remaining one demonstrating a small shunt. All septal defects were completely closed at 1 month with the exception of one case in which delayed partial dislodgment of an undersized prosthesis into the right atrium had developed. Closure rate at 3 months was 100%. Neoendothelialization and fibrous incorporation of the prosthesis were completed within 1 to 3 months. CONCLUSIONS Effective and permanent occlusion of secundum ASDs is feasible with a device that offers the advantages of easy placement, self-centering, and repositionability.

Termination of Left Superior Vena Cava in Left Atrium, Atrial Septal Defect, and Absence of Coronary Sinus A Developmental Complex

Eight cases of termination of the left superior vena cava in the left atrium are reviewed pathologically and clinically.In three of the five patients who died, pathologic examination revealed three anomalies which, together, are considered to form a developmental complex. The anomalies are (1) termination of the left superior vena cava in the left atrium, (2) absence of the coronary sinus, and (3) an atrial septal defect lying in the postero-inferior angle of the atrial septum. In the two remaining fatal cases, the aforementioned anomalies were associated with persistent common atrioventricular canal. In this situation, the atrial septal defect of the latter malformation was confluent with the atrial septal defect of the anomalous complex described.The coexistence of three anomalies-the left superior vena cava terminating in the left atrium, absent coronary sinus, and atrial septal defect-is considered to result from a single developmental abnormality. This takes the form of failure of complete formation of the left atriovenous fold, that fold which normally develops along the left side of the junction of the sinus venosus and the atrial portion of the heart.Clinically, features of increased pulmonary blood flow, coupled with duskiness of the skin, were the significant abnormalities.When cardiac catheterization was attempted through a right-sided vein, the data revealed a left-to-right shunt at atrial level, while levels of arterial oxygen desaturation were present.Except in cases with coexistent ventricular septal defect, pulmonary hypertension was absent.In each of the four patients in whom cardiac catheterization was performed through a left antecubital vein, the catheter was advanced into the left superior vena cava, left atrium, and left ventricle. This was substantiated by angiocardiography in three of the four patients. In our experience, angiocardiography was the most reliable procedure to substantiate the termination of the left superior vena cava in the left atrium.The present study suggests that, in the absence of pulmonary hypertension, a left-to-right transatrial shunt associated with systemic arterial oxygen desaturation may indicate the presence of a persistent left superior vena cava terminating in the left atrium. Moreover, an atrial septal defect identified surgically as lying in the postero-inferior angle of the atrial septum should suggest that an additional anomaly may be present in the form of termination of the left superior vena cava in the left atrium.

Percutaneous Nephrolithotomy: Extraction of Renal and Ureteral Calculi from 100 Patients

A percutaneous nephrostomy tract was used as a conduit to the kidney and ureter for extraction of 149 calculi in 100 patients. A variety of grasping and fragmentation techniques under fluoroscopic and endoscopic control were used to extract calculi in 88 per cent of the patients. With experience, operator efficiency and rate of stone extraction increased from 76 per cent early in the series to 91 per cent in the most recent patients, and the incidence of complications decreased from 17 to 5 per cent. Percutaneous removal of upper tract urinary calculi appears to be an appropriate alternative to an open operation in most patients with symptomatic urolithiasis.

Aortico-Left Ventricular Tunnel

To be distinguished from aneurysm of an aortic sinus (Valsalva) is the rare condition in which an abnormal channel begins in the ascending aorta (above the right coronary artery), bypasses the aortic valve, and leads through the ventricular septum into the left ventricular cavity. This entity, which has not previously been diagnosed during life, to our knowledge, is herein named aortico-left ventricular tunnel. The cases of three patients (aged 3, 5, and 10 years) with this rare condition are described. The clinical, electrocardiographic, and radiological features were similar in each case and resembled those in aortic valvular insufficiency. The diagnosis may be established clinically through selective aortography. This reveals that the origin of the abnormal communication lies in the anterior wall of the ascending aorta above the levels of the coronary arterial origins. The abnormal communication leads to the left ventricle. The condition is distinguished from aortic sinus aneurysm by its origin above t...

Arterial Thrombus Formation During Clinical Percutaneous Catheterization

Deposition of thrombotic material on catheters was observed following more than 50% of 93 diagnostic catheterizations. The incidence of deposition of thrombotic material on catheters remaining in the body for more than 1 day was 100%. Polyethylene and siliconized polyurethane catheters were less thrombogenic than Teflon end-occluded catheters.A definite time relationship between the thrombus formation and the duration of the catheterization procedure was noted.The growth of thrombi on the outside of catheters does not appear to be linear since catheters can remain in place for 10 days or more.Postcatheterization thrombosis is believed to be due to thrombi stripped from the catheter by the arterial wall. The thrombus which originally encases the catheter will pile up at the puncture site as the catheter is withdrawn. The thrombus may remain attached at the puncture site or embolize peripherally.

Percutaneous removal of renal and ureteral calculi: experience with 400 cases.

Percutaneous removal of renal and ureteral calculi was performed in 500 patients since 1979. Experience with our first 100 cases enabled us to accumulate a variety of techniques. We report our experience with the subsequent 400 cases. As judged by plain films of the kidneys, ureters and bladder, and renal tomograms without contrast medium we attained a status free of stones in 99 per cent of the patients with renal and 94.5 per cent with ureteral calculi. Intravenous-assisted local anesthesia was used in 94 per cent of the cases. There was no mortality and the incidence of complications was low. Most patients with renal and ureteral calculi can be managed successfully and safely by percutaneous methods with good patient tolerance and minimal convalescence.

New device for closure of muscular ventricular septal defects in a canine model

BACKGROUND Repair of muscular ventricular septal defects (MVSDs) has always been challenging to the surgeon. Long-term morbidity and mortality are significantly increased if the defects are closed via left ventriculotomy or if they are associated with other complex congenital anomalies. The purpose of this study was to close MVSDs with the Amplatz ventricular septal defect device. This device is constructed from 0.004-in nitinol wire mesh filled with polyester fibers. It is retrievable, repositionable, self-centering, and of low profile. METHODS AND RESULTS MVSDs were created with the help of a sharp punch in 10 dogs. The location of the defects was anterior muscular (n=3), midmuscular (n=3), apical (n=3), and inlet muscular (n=1). The diameter of the defects ranged from 6 to 14 mm. All defects were closed in the catheterization laboratory. The device was placed with the help of transesophageal echocardiography and fluoroscopy. A 7F sheath was used to deploy the device from the right ventricular side in 8 and the left ventricular side in 2 dogs. Placement was successful in all animals. The complete closure rate was 30% (3/10) immediately after placement and 100% at 1-week follow-up. Pathological examination of the heart revealed complete endothelialization of the device in dogs killed after 3 months. CONCLUSIONS The Amplatz ventricular septal defect device appears highly efficacious in closing MVSDs. The advantages include a small delivery sheath, complete retrievability before release, and the fact that it is self-centering and self-expanding, thereby making it an attractive option in smaller children.