R. M. L. Whitlock

Results after repair of coarctation of the aorta beyond infancy: A 10 to 28 year follow-up with particular reference to late systemic hypertension☆

The late outcome in 160 patients aged 1 to 54 years who had surgical repair of coarctation of the aorta was examined 10 to 28 years postoperatively. Twenty years postoperatively the probability of survival of patients discharged from the hospital aged 1 to 19 years at operation was a little less than that of the general population (95% versus 97%). The discrepancy between patients and the general population was more marked in those aged 20 to 39 years and was grossly different when surgical repair was undertaken beyond age 40. There were 19 late deaths (12%), 79% due to cardiovascular disease. Thirteen patients had a poor result because of recoarctation (11 patients) or the development of complications at the site of repair (2 patients). Most patients were hypertensive before operation. The frequency of hypertension decreased markedly in the first few postoperative years. Blood pressure was normal in most patients 5 to 10 years after operation, but when followed up for longer periods the proportion of patients with hypertension increased. Hypertension was more common in patients operated on after 20 years of age than in those aged 5 to 19 years at operation (p = 0.007). The likelihood of being alive without complications and with a normal blood pressure was 69% at 10 years, 55% at 15 years, and 20% at 25 years postoperatively.

Long-term outcome after the mustard repair for simple transposition of the great arteries: 28-year follow-up

OBJECTIVES This study examines the late outcome in patients with simple transposition of the great arteries (TGA) after a Mustard operation. BACKGROUND Continuing medical follow-up for patients after the Mustard procedure, now extending to three decades, is required. The quality of life of adult survivors has not been well documented. METHODS Survival and quality of life among 113 hospital survivors of the Mustard operation performed for simple TGA between 1964 and 1982 were assessed by medical review and a lifestyle questionnaire. The incidence of right ventricular failure and echocardiographic right ventricular dysfunction (RVD) were determined. A measure of lifestyle, the ability index, was determined. RESULTS Actuarial survival was 90%, 80%, and 80% at 10, 20, and 28 years, respectively, with 76% of survivors being New York Heart Association class 1. Sudden death, with an incidence of 7% without identifiable risk factors, was the most common cause of late demise. RVD was identified in 18% of patients who had echocardiography, but there was right ventricular failure in only two patients. Seventy-five percent of current survivors lead a normal life, 20% have some symptoms or lifestyle modification, and 5% are unable to work. CONCLUSIONS The survival of patients to 28 years with the Mustard repair has been good. Late sudden death is the most worrisome feature. There is a 97% freedom from right ventricular failure to date. The quality of life of late survivors is good, most achieving a normal level of education and employment.

Long-term follow-up of patients with the antibiotic-sterilized aortic homograft valve inserted freehand in the aortic position.

A series of 252 isolated aortic homograft valves in 248 patients have been followed for 9 to 16.5 years (mean 10.8). The valves were sterilized in antibiotic solution and stored in a nutrient medium at 4 degrees C and were nonvital. There were 15 in-hospital deaths (6%) and a mortality of 2.7% in patients undergoing an elective first operation. Actuarial survival with the study valve in situ was 57% at 10 years and 38% at 14 years. Only 8.4% of the patients died late from homograft valve failure, chiefly because of failure to refer patients with endocarditis for reoperation or because reoperation was refused in elderly, frail subjects. Incompetence was the sole cause of valve failure and was due either to valve wear or endocarditis. Significant incompetence required reoperation. On actuarial analysis, freedom from significant incompetence for the entire group was 95% at 5 years, 78% at 10 years, and 42% at 14 years. Factors increasing the risk of significant incompetence due to valve wear on multivariate analysis were increasing donor valve age (greater than or equal to 55 years), recipient age (less than 15 years), and an aortic root diameter over 30 mm. Analysis of the patient group that excluded each of these variables (low-risk group), which comprised 61% of the study population, indicated freedom from significant incompetence due to valve wear of 98% at 5 years, 94% at 9 years, and 56% at 13 years.

Prognosis after recovery from first acute myocardial infarction: Determinants of reinfarction and sudden death

Factors associated with total cardiac mortality, sudden cardiac death and reinfarction were studied in 325 male survivors aged younger than 60 years of age (mean 50) of a first myocardial infarction (MI). All patients had undergone exercise testing and cineangiocardiography 4 weeks after MI, 24% underwent coronary artery surgery and 30% received beta-blocking therapy. Patients were followed 1 to 6 years (mean 3.5). Total cardiac mortality was best predicted by the left ventricular (LV) ejection fraction (EF) and by a coronary prognostic index. In contrast, neither the severity of coronary arterial lesions measured with a scoring system nor the results of the exercise test gave significant prediction of mortality. Of the 2 major late sequelae of MI, reinfarction could not be predicted by any clinical or cineangiocardiographic variable. However, sudden death not associated with reinfarction was significantly more common (p less than 0.001) when EF was less than or equal to 40% than when it was greater than 40%. Comparison of patients with an EF less than or equal to 40% who did or did not die suddenly showed that LV dilation (high volumes at ventriculography) was an added risk factor, but the extent of coronary occlusions and stenoses was not. It is concluded that, at least for groups of patients treated with standard modern methods after MI, the main determinant of medium-term survival is the extent of LV damage. The state of the coronary arteries and the presence of ischemic myocardium during exercise are only of secondary importance for survival.

Four-year survival of patients with acute coronary syndromes without ST-segment elevation and prognostic significance of 0.5-mm ST-segment depression

We prospectively evaluated all patients admitted to our coronary care unit during 1993 with ischemic chest pain but without ST-segment elevation on the presenting electrocardiogram, and determined the influence of the extent of ST-segment depression, measured using calipers and blinded to the outcome, on 4-year survival. The presenting symptoms of 367 patients (mean age 64 years) were coded according to the Braunwald classification, 86% being in class IIIB (primary unstable angina with rest angina within 48 hours) and 7.4% in class IIIC (postinfarction angina). Thirty-two patients (8.6%) had myocardial infarction at presentation (defined as a creatine kinase level exceeding twice the reference range within 18 hours). During hospitalization 97% of patients received aspirin, 67% received intravenous heparin, 37% underwent angiography, and 35% underwent revascularization. The vital status of 99% of the patients was determined after a median of 52 months (interquartile range 48 to 55). At follow-up, 88% of patients were taking aspirin, 45% were taking beta blockers, and 50% had undergone revascularization. The survival rate was 70% in patients with > or = 0.5-mm ST-segment depression (53%, 77%, and 82% survival for > or = 2-, 1-, and 0.5-mm ST-segment depression, respectively; p <0.0001). Patients with a normal electrocardiogram had a greater survival rate (94%) than that of patients with 0.5-mm ST-segment depression (82%, p = 0.020), but not significantly different from that of patients with T-wave inversion (84%, p = NS). Independent predictors of mortality (odds ratio [95% confidence interval]) were: age in yearly increments (1.05 [1.03 to 1.06], p = 0.003), revascularization during follow-up (0.40 [0.29 to 0.56], p = 0.006), pulmonary edema (3.45 [2.19 to 5.45], p = 0.007), and ST-segment depression (1.37 [1.20 to 1.55], p = 0.015). Thus, ST-segment depression of > or = 0.5 mm predicts 4-year survival in patients with acute ischemic syndromes.

Six year review of the results of freehand aortic valve replacement using an antibiotic sterilized homograft valve.

The long-term behavior of an antibiotic-treated homograft aortic valve inserted in a freehand fashion was assessed in 121 patients operated upon for aortic valve disease and followed from four to six and one-half years. There were seven hospital deaths (5.7%) and 30 late deaths, only one of which was related to the homograft valve. The six year survival was 69% (77% for single valve and 52% for multiple valve surgery). At six years 9% had important homograft aortic valve incompetence (HAVI) and most of these required reoperation. Important HAVI occurred in only 5% of patients with an aortic root diameter < 24 mm and in 38% of those with a markedly dilated or distorted proximal aorta (P < 0.01). The freehand aortic homograft was considered superior to prosthetic devices because of the absence of chronic anticoagulation, thromboembolism, sudden death from valve failure and significant obstruction in a small aortic root. With slightly restricted patient selection the valve failure rate is expected to fall to less than 1% per year.

Developmental progress after cardiac surgery in infancy using hypothermia and circulatory arrest.

Seventy-two of 76 long-term survivors who had surgical repair of congenital heart lesions at 11 days to 26 months of age using profound hypothermia and circulatory arrest underwent psychometric testing (Stanford-Binet) late postoperatively. The mean IQ of the 72 patients was 92.9 ± 16.5 (SD). Stanford-Binet scores bore no relationship to the duration of circulatory arrest or other aspects of surgical technique. Scores were significantly lower in those who had a low birth weight for gestational age, important neurologic problems preoperatively or were in the lower socioeconomic classes. An “ideal” control group of 69 children randomly selected from patients satisfying certain criteria based on birth and neonatal characteristics had a mean IQ of 106.2 ± 11.6. Twenty-five patients who had surgical treatment of congenital heart disease met the criteria for the control group except for their heart lesions. Their mean IQ was 101.4 ± 15.0 (NS). We could not demonstrate any significant deleterious effect that could be attributed to the surgical methods. Rather, the postoperative IQ scores reflected characteristics related to individual patients.

Coronary surgery after recurrent myocardial infarction: progress of a trial comparing surgical with nonsurgical management for asymptomatic patients with advanced coronary disease.

A randomized trial of surgical vs nonsurgical management was carried out in men 60 years of age or younger who had recovered from a recurrent myocardial infarction. Of 205 patients considered, 100 had few or no symptoms and had coronary vessels favorable for bypass grafting; these patients fulfilled the trial conditions and were randomized (50 surgical and 50 nonsurgical). In 41 patients (elective nonsurgical group), randomization was not considered justifiable because of relatively unfavorable coronary anatomy or severe left ventricular dysfunction. Nineteen patients had elective surgery because of disabling angina despite full medical treatment or because of significant left main coronary stenosis. In 45 patients, coronary angiography was not undertaken because of medical contraindications or reluctance of the patient to enter the study.Actuarial survival curves (mean follow-up 4.5 years) show an annual mortality rate of 3–4% per year for all investigated patients, and no advantage for the randomized surgical over the randomized nonsurgical group. The results suggest that in the absence of disabling angina or left main coronary artery stenosis, coronary artery surgery need not be advised for survivors of recurrent infarctions who have severe coronary artery disease. Moreover, the prognosis for the group of patients not treated surgically appears to be better than has been previously described.

Abnormal Coronary Flow in Infarct Arteries 1 Year After Myocardial Infarction Is Predicted at 4 Weeks by Corrected Thrombolysis in Myocardial Infarction (TIMI) Frame Count and Stenosis Severity

Because 24% to 30% of patent infarct-related arteries occlude in the year following thrombolytic therapy for acute myocardial infarction, angiographic factors including corrected Thrombolysis in Myocardial Infarction (TIMI) frame count which may predict abnormal infarct-artery flow, require definition. We examined changes in coronary flow and infarct-artery lesion severity by computerized quantitative angiography over 1 year in 154 patients with a patent infarct-related artery 4 weeks after myocardial infarction. These patients were randomized to receive either ongoing daily therapy of 50 mg aspirin and 400 mg dipyridamole, or placebo. All angiograms were interpreted blind in our core angiographic laboratory. Infarct-artery flow, assessed by corrected TIMI frame counts, was normal (< or = 27) in 46% and 45% of patients at 4 weeks and 1 year, respectively. At 4 weeks, patients with corrected TIMI frame counts < or = 27 had higher ejection fractions (60+/-11% vs 56+/-12%; p = 0.04) than those with corrected TIMI frame counts >27. On multivariate analysis, corrected TIMI frame count and stenosis severity were predictive of late abnormal infarct-artery flow (TIMI 0 to 2 flow, both p <0.01). Only stenosis severity at 4 weeks predicted reocclusion at 1 year (p <0.0001). Aspirin and dipyridamole had no effect on flow or reocclusion. Thus, corrected TIMI frame count and stenosis severity at 4 weeks was highly correlated with infarct-artery flow at 1 year.

Late Regression of the Dilated Site After Coronary Angioplasty

Background Limited data are available on the changes that occur at the dilated site late after coronary angioplasty. The aim of this study was to evaluate with quantitative angiography the natural history of changes that occur in the dilated segment between “early” (≈6 months) and “late” (≈5 years) follow-up after angioplasty. Methods and Results Of 127 consecutive patients (174 lesions) with successful angioplasty, 125 underwent early angiography. Three patients subsequently died, and 24 underwent revascularization surgery or repeated angioplasty, giving a study-eligible population of 98 patients. Quantitative angiographic analysis was performed before and immediately after angioplasty and at early and late follow-up in the study population of 84 patients (115 lesions), which was 86% of study-eligible patients. Mean lesion diameter stenosis decreased from 36.3±14.2% at early to 29.6±13.5% at late follow-up (P<.0001). No lesion developed late restenosis by the 50% diameter loss criterion. Late regression ...