Faculty Bibliography

We report the successful treatment of a moribund patient as a result of amniotic fluid embolism with cardiopulmonary bypass and open pulmonary artery thromboembolectomy. Review of the literature indicates that this is the first reported case of treatment of amniotic fluid embolism with cardiopulmonary bypass and pulmonary thromboembolectomy

A retrospective analysis of an institutional experience with aortic valve replacement (AVR) in patients 70 years of age or older during 1976 to 1987 was performed. The study was prompted in part by the current interest in palliative aortic valvoplasty, an interest based to a certain extent on the impression that AVR in the elderly has a high mortality. The mean age of the patients was 75.0 +/- 4.0 years (+/- the standard deviation) (range, 70 to 89 years). Eighty-three percent of patients received porcine valves and 17%, mechanical valves. Preoperatively 32% were in New York Heart Association class III, and 59% were in class IV. Operative mortality was 5.6% for elective isolated AVR for aortic stenosis (19% of all patients), 8.2% for all isolated AVR (38%), and 12.4% overall. Concomitant operative procedures were done in 62.0%; AVR with coronary artery bypass grafting (42%) had an operative mortality of 14.3%. Multivariate analysis showed significant predictors of operative mortality to be emergency operation (p less than 0.01), isolated aortic regurgitation (p = 0.01), and previous cardiac operation (p = 0.02). Follow-up (34 +/- 27 months) was 94% complete. Five-year survival from late cardiac-related death was 81.0%. The constant yearly hazard rate for late death for patients 70 years of age or older who underwent AVR was 5.42% per year, which is similar to the 5.77% per year rate calculated for age-matched and sex-matched controls. Five-year freedom from reoperation was 99%; from late thromboembolic complications, 91%; and from late anticoagulant-related complications, 94%. Freedom from all valve-related morbidity and mortality was 61% at 5 years.(ABSTRACT TRUNCATED AT 250 WORDS)

Real-time electrocardiographic monitoring for silent myocardial ischemia was performed on 200 patients undergoing peripheral vascular surgery to try to better define those at high risk of perioperative myocardial infarction. The patients were divided into those undergoing abdominal aortic aneurysm or lower extremity revascularization procedures (group I, n = 120) and those undergoing carotid artery endarterectomy (group II, n = 80). Silent ischemia was detected during the preoperative, intraoperative, or post-operative periods in 60.8% of group I and 67.5% of group II patients. Six group I and three group II patients suffered an acute perioperative myocardial infarction with two cardiac deaths. In both groups I and II a variety of parameters based on monitoring of silent myocardial ischemia were compared between the subgroups of patients who had myocardial infarction and those who did not. The results show that in both groups there was a significantly (p less than or equal to 0.05) greater total duration of perioperative ischemic time, total number of perioperative ischemic episodes, and total duration of perioperative ischemic time as a percent of total monitoring time in patients who suffered a perioperative myocardial infarction compared to those who did not. Multivariate logistic regression analysis of preoperative characteristics in all 200 patients showed the occurrence of preoperative silent myocardial ischemia and angina at rest to be the only significant predictors of perioperative myocardial infarction. Thus perioperative monitoring for silent myocardial ischemia might noninvasively identify those patients undergoing peripheral vascular surgery who are at increased risk for perioperative myocardial infarction, permitting implementation of timely preventive measures in selected patients

Results of surgery in 165 patients with aneurysms of the ascending aorta and aortic arch during 1978-1988 were analyzed retrospectively. Etiology included 29% dissection, 22% atherosclerosis, 22% cystic-medial necrosis, and 27% other causes. Concomitant procedures on the aortic valve were performed in 65% of patients (valvular replacement in 37%, valve-conduit in 23%, and valvular resuspension in 5%), and 13% underwent concomitant coronary artery bypass surgery. Major changes in our operative technique for such aneurysms have been introduced during the last 5 years, especially use of a continuous suture-graft-inclusion technique in 99% of patients, use of circulatory arrest in 59%, and use of an open hemiarch repair in 32%. Hospital mortality dropped from 17.9% during the first 5 years of the study period to 12.3% in the last 5 years despite increasing complexity of the cases encountered. Operative mortality was 7.6% for ascending aortic aneurysmal repair; 5.3% for valve-conduit procedure; 8.8% for open hemiarch repair; and 30.8% for repair of extensive aneurysms involving the aortic arch and significant portions of the descending aorta. Multivariate analysis showed that, of the variables examined, significant predictors of increased operative risk were age (p less than 0.05) and extension of an ascending aortic aneurysm to the descending aorta or involvement of the aortic arch (p less than 0.001). The incidence of stroke was 2.4%, with only one stroke since 1983 despite more extensive use of circulatory arrest since that time. Follow-up was 94% complete, with a mean (+/- SD) follow-up interval of 28 +/- 24 months.(ABSTRACT TRUNCATED AT 250 WORDS)

The incidence and duration of intraoperative silent myocardial ischemia have been shown to be significantly correlated with the incidence of perioperative myocardial infarction in patients undergoing peripheral vascular surgery. To assess the effectiveness of intraoperative beta blockade in limiting such silent myocardial ischemia, a group of 48 patients was treated with oral metoprolol immediately prior to peripheral vascular surgery. The total duration of intraoperative silent myocardial ischemia, the percentage of intraoperative time silent myocardial ischemia was present, the number of intraoperative episodes of silent myocardial ischemia, and the intraoperative heart rate in the treated patients were compared with those in 152 similar but untreated peripheral vascular surgery patients. The patients treated with oral metoprolol had significantly less intraoperative silent ischemia with respect to relative duration and frequency of episodes, a significantly lower intraoperative heart rate, and less intraoperative silent myocardial ischemia in terms of total absolute duration. These results suggest that beta-adrenergic activation may play a major role in the pathogenesis of silent myocardial ischemia during peripheral vascular surgery

The continued good results after mitral valve reconstruction prompted this retrospective study to compare operative and late results from our institutional experience since 1976 with 975 porcine mitral valve replacements (MVRs) (1976 to December 1987), 169 mechanical MVRs (1976 to December 1987), and 280 Carpentier-type mitral valve reconstructions (CVRs) (1980 to mid-1988). The operative mortality was 2.0% for isolated CVR, 6.6% for isolated mechanical MVR, and 8.5% for isolated porcine MVR. The overall operative mortality was 5.0% for CVR, 16.6% for mechanical MVR, and 10.6% for porcine MVR. The overall 5-year survival including hospital deaths was 76% for CVR, 72% for mechanical MVR, and 69% for porcine MVR. By multivariate analysis, the predictors of increased operative risk and of decreased survival were age, New York Heart Association functional class IV status, previous cardiac operation, and performance of concomitant cardiac surgical procedures. The type of valvular procedure was not predictive of operative risk or overall survival. The 5-year freedom from reoperation was 94.4% for nonrheumatic patients having CVR, 77.4% for rheumatic patients having CVR, 96.4% for mechanical MVR, and 96.6% for porcine MVR (p less than 0.05, rheumatic patients with CVR versus both MVR groups). The 5-year freedom from all valve-related morbidity and mortality was significantly better for valve reconstruction compared with both types of valve replacement. Thus, the operative risk and late survival obtained after mitral valve reconstruction were at least equivalent to those obtained after MVR. In addition, patients receiving mitral valve reconstruction had less valve-related combined morbidity than patients receiving valve replacement, thus making mitral valve reconstruction preferable in some patients with mitral insufficiency