Marvin D. Peyton

Ross operation: 16-year experience

OBJECTIVE We performed a review of a consecutive series of 487 patients undergoing the Ross operation to identify surgical techniques and clinical parameters that affect outcome. METHODS We performed a prospective review of consecutive patients from August 1986 through June 2002 and follow-up through August 2004. Patient age was 2 days to 62 years (median, 24 years), and 197 patients were less than 18 years of age. The Ross operation was performed as a scalloped subcoronary implant in 26 patients, an inclusion cylinder in 54 patients, root replacement in 392 patients, and root-Konno procedure in 15 patients. Clinical follow-up in 96% and echocardiographic evaluation in 77% were performed within 2 years of closure. RESULTS Actuarial survival was 82% +/- 6% at 16 years, and hospital mortality was 3.9%. Freedom from autograft failure (autograft reoperation and valve-related death) was 74% +/- 5%. Male sex and primary diagnosis of aortic insufficiency (no prior aortic stenosis) were significantly associated with autograft failure by means of multivariate analysis. Freedom from autograft valve replacement was 80% +/- 5%. Freedom from endocarditis was 95% +/- 2%. One late thromboembolic episode occurred. Freedom from allograft reoperation or reintervention was 82% +/- 4%. Freedom from all valve-related events was 63% +/- 6%. In children survival was 84% +/- 8%, and freedom from autograft valve failure was 83% +/- 6%. CONCLUSIONS The Ross operation provides excellent survival in adults and children willing to accept a risk of reoperation. Male sex and a primary diagnosis of aortic insufficiency had a negative effect on late results.

Linear left atrial lesions in minimally invasive surgical ablation of persistent atrial fibrillation: techniques for assessing conduction block across surgical lesions.

Minimally invasive surgical (MIS) ablation, with pulmonary vein (PV) isolation and ganglionated plexi (GP) ablation, has proven highly successful for paroxysmal atrial fibrillation but has limited success in patients with persistent and long-standing persistent (P-LSP) AF. A set of linear left atrial (LA) lesions has been added to interrupt some macroreentrant components of P-LSP AF. This includes a Transverse Roof Line and Left Fibrous Trigone Line (from Roof Line to mitral annulus at the left fibrous trigone). With complete conduction block (CCB), these lesions should prevent single- or double-loop macroreentrant LA tachycardias from propagating around the PVs or mitral annulus. It is critical to identify whether CCB has been achieved and, if not, to locate the gap for further ablation, since residual gaps will support macroreentrant atrial tachycardias. Confirming CCB involves pacing close to one side of the ablation line and determining the direction of activation on the opposite side, by recording close bipolar electrograms at multiple paired sites (perpendicular and close to the ablation line) along the entire length of the line. Simpler approaches have been used, but all have limitations, especially when the conduction time across a gap is long. The extended lesion set was created after PV isolation and GP ablation in 14 patients with P-LSP AF. Mapping after the first set of radiofrequency applications for the Transverse Roof and Left Trigone Lines confirmed CCB in only 3/14 (21%) patients for each line, showing the importance of checking for CCB. During follow-up (median 8 months), 10/14 (71%) patients had no symptoms of atrial arrhythmia (7/10 off antiarrhythmic drugs). Of the remaining four patients, three have only infrequent episodes (self-terminating in 2/3). These preliminary results suggest that adding Roof and Trigone Lines may increase MIS success in patients with P-LSP AF. Accurate mapping techniques verify CCB and effectively locate gaps in ablation lines for further ablation.

Transvenous Management of Pulmonary Embolic Disease

Clinical pulmonary embolic disease was categorized into four classes according to hemodynamic and respiratory effects of the occlusion at the time of diagnosis. A new approach to management of massive embolization (Class III and IV) by transvenous catheter embolectomy was attempted in ten patients with initial success in eight. Three additional deaths occurred postoperatively, two from recurrent embolization prior to vena caval plication. In view of this preventable complication, a wire filter device was developed for insertion at the time of embolectomy. The filter has also been utilized in 15 additional patients with lesser degrees of embolization (Class II). The conal shape of the device permits preservation of flow after embolic capture and followup venacavagrams in nine patients up to 20 months postoperative shows patency in all. Complications occurred in both groups related both to the underlying disorder and to the catheter technics.

Combined myotomy and hiatal herniorrhaphy: A new approach to achalasia☆

Abstract A review of fourteen cases of achalasia is presented in which the value of intraesophageal manometry and the standard acid reflux test in diagnosis and postoperative evaluation is emphasized. A significant incidence of preoperative esophageal reflux was noted, stressing the necessity for additional surgical procedures to insure functional integrity of the lower esophageal sphincter. Successful results were observed after Heller esophagomyotomy and Belsey Mark IV hiatus herniorrhaphy.

Lower extremity amputation: Review of 110 cases

Very significant morbidity and mortality continue to accompany lower extremity amputations. In this study 90 patients underwent 110 amputations over a 4 year period. The overall complication rate was 40 per cent and the overall mortality rate 12.2 per cent. The patients at greatest risk were the above knee amputees greater than 60 years of age with peripheral vascular disease. Amputation of the lower extremity must be recognized as a major, life-threatening procedure. Careful preoperative evaluation of cardiac, pulmonary, and nutritional status along with efforts to prevent sepsis, pneumonia, pulmonary embolism, gastrointestinal ulceration, and renal failure are necessary if the mortality accompanying these procedures is to be reduced.

Successful near-term pregnancy outcome after repair of a dissecting thoracic aortic aneurysm at 14 weeks gestation

PurposeWe report the anesthetic management for a scheduled Cesarean section of a 29-yr-old female who previously had a repair of her dissecting thoracic aortic aneurysm during the 14th week of her pregnancy.Clinical featuresA 29-yr-old female with a history of hypertension and previously diagnosed aortic dissection secondary to suspected Marfan’s syndrome, presented to our institution for the first time after she became pregnant. A transesophageal echocardiogram revealed a dissecting aortic aneurysm greater than 8 cm in diameter beginning distal to the left subclavian artery and extending into the descending thoracic aorta. The patient was counseled in great detail about the risk of rupture with continuing pregnancy. She refused termination and chose elective repair of the aneurysm, with continuation of the pregnancy. Partial repair of the thoracic aneurysm was undertaken when the pregnancy was 135/7 weeks by ultrasound dates. She was subsequently maintained on labetolol and hydralazine for blood pressure control. A decision was made to proceed with a Cesarean section at 32 weeks. After placement of a radial artery catheter and two large peripheraliv catheters, she received a combined spinal-epidural anesthetic. A male infant with Apgars of 7 and 7 at one and five minutes was delivered.ConclusionsAortic dissection in pregnancy may have catastrophic results. Undoubtedly, it presents unique challenges for anesthetic and obstetrical management. With appropriate care and surgical correction of the dissecting aneurysm early in pregnancy, a successful outcome for the pregnancy was possible.RésuméObjectifPrésenter ľanesthésie réalisée pour une césarienne réglée chez une femme de 29 ans, opérée pour la réparation ďune dissection aortique pendant la 14e semaine de grossesse.Éléments cliniquesUne femme de 29 ans, connue pour hypertension et chez qui une dissection aortique secondaire à un syndrome de Marfan présumé avait été diagnostiquée, a consulté pour la première fois après le début de sa grossesse. Une échocardiographie transœsophagienne a révélé un anévrysme disséquant de ľaorte plus grand que 8 cm de diamètre, s’étendant de la partie distale de ľartère sous-clavière gauche touchant ľaorte thoracique descendante. La patiente a reçu des informations détaillées sur le risque de rupture aortique avec la poursuite de la grossesse. Elle a choisi de poursuivre la grossesse et de subir la réparation réglée de ľanévrysme. La réparation partielle de ľanévrysme thoracique a été entreprise à 135/7 de grossesse, ďaprès les dates fournies par ľéchographie. La tension artérielle a ensuite été contrôlée avec du labétolol et de ľhydralazine. La césarienne a été faite à 32 semaines. Elle comportait la mise en place ďun cathéter de ľartère radiale et de deux grands cathéters périphériques iv ainsi qu’une anesthésie rachidienne et péridurale combinée. Un enfant mâle est né, avec un indice ďApgar de 7 et 7 à une et cinq minutes après la naissance.ConclusionUne dissection aortique pendant la grossesse peut avoir des conséquences catastrophiques. Elle représente, à n’en pas douter, des défis à part pour la prise en charge anesthésique et obstétricale. Dans le cas présent, des soins appropriés et la correction chirurgicale de ľanévrysme, tôt pendant la grossesse, ont assuré un dénouement heureux.

Comparison of Nissen fundoplication and Belsey Mark IV in the management of gastroesophageal reflux

Our experience for the past four years with antireflux surgery has been reviewed. The Nissen fundoplication resulted in symptomatic improvement in 87.5 per cent of cases as compared with 64 per cent who were improved after the Belsey Mark IV procedure. Objective evaluation as measured by the standard acid reflux test (SART) revealed recurrent reflux in 9 per cent of those who underwent fundoplication and in 47 per cent of those treated with the Belsey repair. Mortality rates were similar. These results indicate that Nissen fundoplication is superior to the Belsey Mark IV procedure in the management of gastroesophageal reflux.

Genome-Wide Association Study Identifies Variants in Casein Kinase II (CSNK2A2) to be Associated With Leukocyte Telomere Length in a Punjabi Sikh Diabetic Cohort

Background—Telomere length is a heritable trait, and short telomere length has been associated with multiple chronic diseases. We investigated the relationship of relative leukocyte telomere length with cardiometabolic risk and performed the first genome-wide association study and meta-analysis to identify variants influencing relative telomere length in a population of Sikhs from South Asia. Methods and Results—Our results revealed a significant independent association of shorter relative telomere length with type 2 diabetes mellitus and heart disease. Our discovery genome-wide association study (n=1616) was followed by stage 1 replication of 25 top signals (P<10–6) in an additional Sikhs (n=2397). On combined discovery and stage 1 meta-analysis (n= 4013), we identified a novel relative telomere length locus at chromosome 16q21 represented by an intronic variant (rs74019828) in the CSNK2A2 gene (&bgr;=−0.38; P=4.5×10−8). We further tested 3 top variants by genotyping in UK cardiovascular disease (UKCVD) (whites n=2952) for stage 2. Next, we performed in silico replication of 139 top signals (P<10–5) in UK Twin, Nurses Heart Study, Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial, and MD Anderson Cancer Controls (n=10 033) and joint meta-analysis (n=16 998). The observed signal in CSNK2A2 was confined to South Asians and could not be replicated in whites because of significant difference in allele frequencies (P<0.001). CSNK2A2 phosphorylates telomeric repeat binding factor 1 and plays an important role for regulation of telomere length homoeostasis. Conclusions—By identification of a novel signal in telomere pathway genes, our study provides new molecular insight into the underlying mechanism that may regulate telomere length and its association with human aging and cardiometabolic pathophysiology.

Distinguishing early-stage pancreatic cancer patients from disease-free individuals using serum profiling

This study evaluated the usefulness of electrospray mass spectrometry to distinguish sera of early-stage pancreatic cancer patients from disease-free individuals. Sera peak data were generated from 33 pancreatic cancer patients and 30 disease-free individuals. A “leave one out” cross-validation procedure discriminated stage I/II pancreatic cancer versus disease-free sera with a p value <.001 and a receiver–operator characteristic curve area value of 0.85. Predictive values for cancer stage I/II test efficiency, specificity, and sensitivity were 78%, 77%, and 79%, respectively. These studies indicate that electrospray mass spectrometry is useful for distinguishing sera of early-stage pancreatic cancer patients from disease-free individuals.

The asymptomatic bruit

A review of 144 carotid endarterectomies performed in 108 patients at the Oklahoma Health Science Center over the past six years showed an acceptable operative morbidity and mortality in group of patients with an asymptomatic midcervical bruit who underwent prophylactic carotid endarterectomy prior to anticipated elective surgery. Long-term follow-up showed these patients to be free of neurologic symptoms of fatalities in 100 per cent of long-term survivors and suggests that carefully selected patients with an asymptomatic bruit may undergo carotid endarterectomy to prevent future neurologic complication.