Laurence K. Groves

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.

Isolated left anterior descending coronary atherosclerosis: long-term comparison of internal mammary artery and venous autografts.

A consecutive series of 100 patients receiving left internal mammary artery grafts and a consecutive series of 100 patients receiving saphenous vein grafts as treatment of isolated left anterior descending coronary artery stenosis were reviewed to determine survival, graft patency, disease progression and New York Heart Association functional class. The mean follow-up was 67 months, and the mean catheterization interval was 20 months.Recommendations for revascularization can be made selectively to patients with critical isolated left anterior descending stenoses who have limiting symptoms and large areas of viable myocardium at risk.

Emergency myocardial revascularization

From April 1968 to December 1972, 100 patients received emergency aortocoronary artery saphenous vein bypass grafts at the Cleveland Clinic Hospital. Thirty-seven of these 100 patients received grafts during acute myocardial infarction and 63 during impending infarction. Coronary arteriograms were obtained in all patients before operation. In the group with acute infarction, operations were performed within 12 hours after the onset of acute chest pain in 29 patients and from 3 to 14 days after infarction in 8. In the group with impending infarction, most patients received grafts within 3 to 4 hours after the onset of chest pain. Six of the 100 patients died in the postoperative period, 2 with acute and 4 with impending infarction. Thirty patients with acute infarction and 55 with impending infarction became asymptomatic. Sixteen of the 37 patients with impending infarction and 20 of the 63 patients with acute infarction were restudied. The graft patency rate in these patients was 92 percent. Coronary arteriography can be performed during acute and impending myocardial infarction with minimal risk. Aortocoronary saphenous vein bypass grafting can prevent the development of acute infarction when properly performed during the stage of impending infarction. It may also prevent the extension of acute infarction when , performed during the early phase of this lesion.

Heart Valve Replacement: Clinical Experience

HIS REPORT discusses our clinical experience in aortic and initral valve replacenient utilizing the Starr-Edwards prosT thesis. T h e basis for this report is a consecutive series of 224 operations performed in the period of September, 196 1, through February, 1964.t T h e reasons for the decision to utilize the Starr-Edwards prosthetic valve and to abandon the various types of valvuloplasty procedures have been detailed in previous coniniunications [ 10-1 51. Beginning in 1956, we tried a number of procedures designed to reestablish coinpetency of the aortic and the niitral valves, including corninissurotoiny, decortication, and a variety of plastic procedures designed to refurbish the valve cusps or leaflets. Many of these procedures warranted initial enthusiasm, but the late results were disappointing: Valves that were

Double Internal Mammary Artery-Myocardial Implantation Clinical Evaluation of Results in 150 Patients

A total of 248 double internal mammary artery-myocardial implantations have been performed at the Cleveland Clinic up to October 31, 1967. This report presents an analysis of the clinical experience with the first 150 patients. The majority of the patients were between 40 and 60 years of age. The overall hospital mortality was 9.3%. The lowest mortality rate (4.9%) was among patients between 51 and 60 years of age. The most common complication encountered in this series (22 patients) was atrial fibrillation. Acute myocardial infarction developed in 14 patients; all of them recovered with the usual medical treatment. All of the patients have been studied by Soness technique of selective coronary angiography and left ventriculography. We believe that this is mandatory in the selection of patients for coronary artery operations. The postoperative evaluation shows significant clinical improvement in the majority, 116 patients. Thirty-one have undergone postoperative angiographic studies. Of 61 opacified arteries, 58 remained patent, and 37 showed definite communication with coronary arteries. We believe our present operative technique allows us to increase myocardial perfusion in any region of the left ventricle.

Emergency revascularization for unstable angina.

Emergency revascularization for unstable angina (defined according to criteria of the National Cooperative Study Group) was performed in 100 consecutive patients. The mean interval from onset of pain to operation was one day. Nineteen patients had single-vessel narrowing of greater than 70% of lumen diameter, 32 double-vessel obstruction and 49 triple-vessel disease. Fourteen of these patients had left main trunk obstruction. Four patients died within 30 days, three from complications of myocardial infarction. Seventeen of 96 (18%) early survivors sustained perioperative infarction. After a mean follow-up of 42 months, four late deaths and three late infarctions occurred. Postoperative angiography in 47 patients (mean interval 14 months) showed 86% graft patency. Of 92 survivors, 72 are symptom-free. Three of the four operative deaths occurred within 24 hours postoperatively; in each of these, postmortem examination confirmed a recent myocardial infarction which antedated the operation, despite the absenc...

Pulmonary Embolus Presenting as the Initial Manifestation of Renal Cell Carcinoma

Recent literature suggests that pulmonary embolus secondary to renal cell carcinoma may by more common than previously suspected. Renal tumors are known for their ability to metastasize early, often before the primary lesion is apparent. A patient with renal cell carcinoma and having massive pulmonary tumor embolus is presented. Attention was called to the occult tumor by the identification of clear cell carcinoma in the pulmonary embolic material. Pulmonary embolectomy and surgical extirpation of the primary tumor resulted in long-term survival.

Posterior ventricular aneurysms. Etiologic factors and results of surgical treatment.

Abstract An extensive infarction of the posterior (diaphragmatic) left ventricular wall often compromises the posterior papillary muscle and causes early death from severe mitral regurgitation. This single fact explains the scarcity of posterior aneurysms as a clinical entity. In 11 cases of large posterior ventricular aneurysms that infringed upon but did not damage the mitral-valve mechanism, aneurysmectomy was performed. Repair of postinfarction ventricular septal defects was also necessary in two patients. The clinical diagnoses were made or confirmed by ventriculography and coronary arteriography. Of the major symptoms associated with posterior ventricular aneurysms, congestive heart failure was the most common indication for surgery. No operative deaths occurred; one patient died of a myocardial infarction in the late postoperative period. The 10 surviving patients are active, with improvement over their preoperative condition.

Aortic valve replacement combined with myocardial revascularization. Late clinical results and survival of surgically-treated aortic valve patients with and without coronary artery disease.

SUMMARYFrom 1967 through 1973, 80 consecutive patients underwent simultaneous aortic valve replacement (AVR) and coronary bypass grafting. Fourteen (18%) experienced no angina pectoris and had no history or electrocardiographic evidence of coronary atherosclerosis. Seven of these 14 had severe multiple vessel disease. All operations were performed under normothermic conditions without coronary perfusion. Seven patients (9%) died during operation. Intraoperative myocardial infarction was documented in eight (10%). After a mean follow-up of 35 months, overall mortality was highest in aortic regurgitation patients [seven of 13 (54%)] compared to aortic stenosis [17 of 54 (31%)] (P < 0.07), and mixed pathology [I of 13 (8%)]. Thirty-one of 34 (91%) grafts in 25 patients were patent an average of 12 months postoperatively. After 42 months a 65% actuarial survival was found in the combined AVR and graft(s) series versus a 76% survival in 300 AVR patients proven by angiography not to have severe coronary atherosclerosis.

Initial Clinical Experience with a New Temporary Left Ventricular Assist Device

A new, simple left ventricular assist system has been developed and its use in experimental animals has been evaluated. The system achieves ventricular drainage by a transaortic valve cannula and utilizes a new centrifugal pump; the blood access is unique in requiring only a simple end-to-side synthetic graft anastomosis to the ascending aorta. Adequate pulsatility is obtained by concomitant use of an intraaortic balloon pump. This case report documents our initial clinical experience with this system in a postoperative patient with profound left ventricular failure unresponsive to all usual treatment. There was temporary recovery of left ventricular function upon decannulation after five and a half days of assist pumping. Despite the eventual death of the patient, the system functioned adequately, suggesting that it has good potential for use in a small, selected group of patients.