Richard J. Thurer

Time to first shock and clinical outcome in patients receiving an automatic implantable cardioverter-defibrillator

The relation between time to first shock and clinical outcome was studied in 60 patients who received an automatic implantable cardioverter-defibrillator (AICD) from August 1983 through May 1988. The mean (+/- SD) patient age was 64 +/- 10 years, 82% were men and the mean ejection fraction was 33 +/- 13%. During follow-up, 38 patients (63%) had one or more shocks; there were no differences in age, gender distribution or ejection fraction at entry between the shock and no shock groups. Among 51 patients with coronary artery disease, 31 (61%) had one or more shocks, whereas all seven patients with cardiomyopathy had one or more shocks (p less than 0.05). Neither of the two patients with idiopathic ventricular fibrillation had shocks. Of the 13 deaths, 12 occurred during post-hospital follow-up and 1 during the index hospitalization. Of the four sudden post-hospital deaths, only one was due to tachyarrhythmia in the absence of acute myocardial infarction. All four sudden deaths and five of eight post-hospital nonsudden deaths occurred in patients who had had one or more appropriate shocks during follow-up. Eight of the nine first appropriate shocks among patients who subsequently died occurred within the first 3 months of follow-up, but the actual deaths were delayed to a mean of 14.1 +/- 13.9 months (p less than 0.05). The mean time to all deaths was 14.8 +/- 13.1 months. The ejection fraction was significantly lower among patients who died than among patients who survived (25 +/- 7% versus 35 +/- 14%, p less than 0.02), but it did not distinguish risk of first shocks.(ABSTRACT TRUNCATED AT 250 WORDS)

New strategies are needed in diffuse malignant mesothelioma

Background. Medical records of 50 patients with malignant mesothelioma were reviewed to determine the clinical features and factors influencing survival.

Clinical Experience With Subxiphoid Drainage of Pericardial Effusions

To assess the effectiveness of subxiphoid pericardial tube drainage for treatment of pericardial effusion, we reviewed 41 consecutive patients who underwent this procedure during a 14-year period. The patients ranged in age from 7 months to 75 years. All were symptomatic preoperatively. The diagnosis of pericardial effusion was confirmed by echocardiogram in all but 2 patients. Eight patients had acute pericardial tamponade. Subxiphoid pericardial drainage was performed under general (n = 35) or local anesthesia (n = 6). A portion of the anterior pericardium was excised in each patient. There were no perioperative deaths. Thirty-day mortality was 19.5%; there were five late deaths. All deaths were unrelated to pericardial effusion or to the operation. One patient had recurrent effusion requiring pericardiocentesis on the 21st postoperative day. He died five days later of extensive lymphoma. Twenty-eight patients were followed from 1 month to 10 years; mean follow-up was 31.5 months. None developed recurrent effusion or pericardial constriction. We conclude that subxiphoid pericardial drainage is effective for treatment of pericardial effusion.

Usefulness of the automatic implantable cardioverter defibrillator in improving survival of patients with severely depressed left ventricular function associated with coronary artery disease

Clinical outcome was analyzed among a group of 39 consecutive patients with coronary artery disease, left ventricular (LV) ejection fractions less than 30% and arrhythmias that required an automatic implantable cardioverter defibrillator (AICD) in an attempt to better define the role of the device in patients with severely depressed LV function. Twenty-nine (74%) were survivors of out-of-hospital cardiac arrest and 10 (26%) had ventricular tachycardia that was refractory to electrophysiologically guided antiarrhythmic therapy. The study group had the following demographic characteristics: 90% were men, mean age was 64 years (range 41 to 79) and mean LV ejection fraction was 21 +/- 4%. Concomitant pharmacotherapy included antiarrhythmic drugs 31 (79%), vasodilators in 22 (56%) and digoxin in 20 (51%). There was no statistical difference in baseline characteristics between survivors and nonsurvivors. Patients were followed for a mean of 24 months (range 2 to 72) from implantation. The difference between actuarial survival--77% at 1 year and 72% at 2 years--and projected survival without the AICD (patients who survive without appropriate device discharge)--30% at 1 year and 21% at 2 years--was significant (p less than 0.01 and less than 0.05 at 1 and 2 years, respectively). This study suggests that the AICD improves survival in patients with coronary artery disease despite severely depressed LV function.

SURGICAL MANAGEMENT OF EMPYEMA

The cause and presentation of empyema thoraces has changed little since it was first described. The natural history of the disease can be divided into different stages. Different therapeutic measures, medical and surgical, are available for the treatment at various stages. The management of empyema is discussed, emphasizing the surgical aspects.

Mechanism of Death in Patients with the Automatic Implantable Cardioverter Defibrillator

Fifty patients underwent primary implantation of an automatic implantable cardioverter defibrillator between August 1983 and April 1988 and were entered into a long‐term surveillance program. There were a total of 14 deaths (28%) in the entire group occurring at a mean of 8.7 months postimplantation. Eleven deaths were cardiac and three were noncardiac (two pneumonia, one leukemia). The group of deceased patients were similar to the survivors in all respects except for a statistically lower ejection fraction (23% vs 32%) at the time of implantation. In addition, 13/14 (93%) of the deceased patients experienced at least one appropriate AICD discharge at a mean of 4.5 months post implantation. Recorded ECGs at the time of death revealed that most of the sudden deaths were due to electromechanical dissociation and not to AICD‐treatable arrhythmias. These data suggest therefore that death in AICD patients is usually cardiac, due primarily to low ejection fraction and occurs in patients who have previously received AICD discharges.

Factors affecting late survival after surgical remodeling of left ventricular aneurysms

OBJECTIVES Surgical remodeling of the left ventricle has involved various techniques of volume reduction. This study evaluates factors that influence long-term survival results with 3 operative methods. METHODS From 1979 to 2000, 157 patients (134 men, mean age 61 years) underwent operations for class III or IV congestive heart failure, angina, ventricular tachyarrhythmia, and sudden death after anteroseptal myocardial infarction. The preoperative ejection fraction was 28% +/- 0.9% (mean +/- standard error), and the pulmonary artery occlusive pressure was 15 +/- 0.07 mm Hg. Cardiogenic shock was present in 26 patients (16%), and an intra-aortic balloon pump was used in 48 patients (30%). The type of procedure depended on the extent of endocardial disease and was aimed at maintaining the ellipsoid shape of the left ventricle cavity. In group I patients (n = 65), radical aneurysm resection and linear closure were performed. In group II patients (n = 70), septal dyskinesis was reinforced with a patch (septoplasty). In group III patients (n = 22), ventriculotomy closure was performed with an intracavitary oval patch. RESULTS Hospital mortality was 16% (25/157) and was similar among the groups. Actuarial survival up to 18 years was better with a preoperative ejection fraction of 26% or greater (P =.004) and a pulmonary artery occlusive pressure of 17 mm Hg or less (P =.05). Survival was worse in patients who had intra-aortic balloon pump support (P =.03). Five-year survival for all patients in group III was higher than for patients in group II (67% vs 47%, P =.04). CONCLUSIONS Factors that improved long-term survival after left ventricular surgical remodeling were intraventricular patch repair, preoperative ejection fraction of 26% or greater, and pulmonary artery occlusive pressure of 17 mm Hg or less without the need for balloon pump assist.

Late complications of plombage

Plombage was used commonly in the management of tuberculosis before the early 1950s. From 1977 through 1990, 4 patients were seen with complications of plombage performed decades previously. Lucite spheres were used in 3 patients and paraffin in 1. One patient had bilateral apical plombage. In all cases, complications were related to infection or migration of the foreign material. Two patients had extrusion of foreign material or fluid into the chest wall. One patient had hemoptysis and infection due to erosion of a Lucite sphere into the lung. Another had intestinal obstruction subsequent to erosion into the esophagus. The patient with bilateral plombage had development of asynchronous complications on both sides. Treatment consisted of removal of the foreign material and individualized management of the remaining space. There were no operative deaths and the outcome was good in all cases.

Failure of Hancock Xenograft Valve: Importance of Valve Position (4- to 9-Year Follow-up)

To evaluate long-term durability of Hancock valves, we reviewed our results in 107 hospital survivors (120 valves) who were operated on during 1974 through mid-1979. Mitral valve replacement was done in 63 patients, aortic valve replacement in 20, and mitral valve replacement combined with other procedures in 24. The 7-year survival was 84 +/- 4% (standard error of the mean) for 91 patients and 97 valves. During a follow-up of 590 patient-years, 15 (12 mitral and 3 aortic) of 120 valves at risk (87 mitral, 32 aortic, 1 tricuspid) were removed from 14 patients. Six valves (3 mitral and 3 aortic) were removed because of bacterial endocarditis. One mitral valve was removed because of thromboembolism. Eight mitral valves were removed because of valve structural failure, which occurred at a mean follow-up of 42 months. These valves showed extensive calcification, leaflet perforation, or cusp tear. Structural failure was unrelated to valve size, year of implantation, or valve shelf-life. Structural failure was not seen after aortic valve replacement. Results show that structural failure of the Hancock xenograft valve in the mitral position is related primarily to valve position. After aortic valve replacement, valve failure is predominantly due to endocarditis. Although medium-term (mean, 6-year) durability of this xenograft valve compares satisfactorily with prosthetic valves, its high failure rate in the mitral position indicates the necessity for improvement in valve mounting, design, and preservation.

MDR-1 gene expression, anthracycline retention and cytotoxicity in human lung-tumor cells from refractory patients

SummaryLung-tumor cells from pleural effusion of four refractory patients and in cell lines established from them were analyzed for anthracycline retention, cytotoxicity, and MDR-1 gene and P-glycoprotein expression. Murine leukemic P388 and doxorubicin-resistant P388/R84 lines were used as controls. The 50% growth-inhibitory concentration (IC50) for doxorubicin among lung-tumor lines varied from 0.16 to 0.31 μM in soft agar. Heterogeneity in doxorubicin or daunorubicin retention and response to the efflux-blocking action of 25 μm prochlorperazine was noted in pleural effusion of FCCL-1,-4, and-8. Among the cell lines established, an efflux-blocking effect in a subpopulation was noticed only in FCCL-1 and-4. Although the MDR-1 gene was present in all cell lines, including P388, its expression was pronounced only in P388/R84 and FCCL-1. In situ hybridization of antisense RNA probe to tumor cells showed high heterogeneity for MDR-1 message in the human lung-tumor cells as compared with the murine cells. Northern and slot blot hybridization confirmed in situ hybridization in lines with high levels of MDR-1 expression. The synthesis of MDR-1 mRNA and P-glycoprotein in tumor lines was correlated. The results suggest that because of extensive tumor-cell heterogeneity in human tumors, monitoring of MDR expression by in situ hybridization, quantitation of P0glycoprotein content by laser flow cytometry (and/or immunohistochemical methods), and drug efflux (by laser flow cytometry) may be the best ways to monitor multidrug resistance in human tumors.