- [Show abstract] [Hide abstract] ABSTRACT: L'expérience acquise lors des essais cliniques avec le défibrillateur implantable souligne l'importance d'un bilan physiopathologique précis dans la période préopératoire. Cette évaluation demande une documentation précise de la tachyarrythmie ventriculaire, une évaluation de la possibilité d'autres interventions éventuelles aussi bien que la considération de l'intéraction entre stimulateurs et médicamments antiarrythmiques. The experience obtained from the clinical trials with the automatic implantable cardioverter-defibrillator have reemphasized the need for a detailed pathophysiologic evaluation of the patient preoperatively. This evaluation requires careful documentation of the probable cause of the ventricular tachyarrhythmia and evaluation of other surgical needs of the patient, as well as consideration of the interactive effects of pacemakers and concurrent pharmacologic therapy post-operatively.
- [Show abstract] [Hide abstract] ABSTRACT: Objective: The current study was undertaken to determine long-term results of aortic valve replacement (AVR) in the elderly, to ascertain predictors of poor outcome, and to assess quality of life. Summary Background Data: Aortic valve replacement is the procedure of choice for elderly patients with aortic valve disease. The number of patients aged 70 and older requiring AVR continues to increase. However, controversy exists as to whether surgery devoted to this subset reflect a cost-effective approach to attaining a meaningful quality of life. Methods: This study reviews data on 247 patients aged 70 to 89 years who underwent isolated AVR between 1980 and 1995; there were 126 men (51%) and 121 women (49%). Follow-up was 97% complete (239/247 patients) for a total of 974.9 patient-years. Mean age was 76.2 ± 4.8 years. Operative mortality and actuarial survival were determined. Patient age, gender, symptoms, associated diseases, prior conditions, New York Health Association class congestive heart failure, native valve disease, prosthetic valve type, preoperative catheterization data, and early postoperative conditions were analyzed as possible predictors of outcome. Functional recovery was evaluated using the SF-36 quality assessment tool. Results: Operative mortality was 6.1% (15/247). Multivariate logistic regression showed that poor left ventricular function and preoperative pacemaker insertion were independent predictors of early mortality. After surgery, infection was predictive of early mortality. Overall actuarial survival at 1, 5, and 10 years was 89.5 ± 2% (198 patients at risk), 69.3 ± 3.4% (89 patients at risk), and 41.2 ± 6% (13 patients at risk), respectively. Cox proportional hazards model showed that chronic obstructive pulmonary disease and urgency of operation were independent predictors of poor long-term survival. Postoperative renal failure also was predictive of poor outcome. Using the SF-36 quality assessment tool, elderly patients who underwent AVR scored comparably to their age-matched population norms in seven of eight dimensions of overall health. The exception is mental health. Conclusions: Aortic valve replacement in the elderly can be performed with acceptable mortality. Significant preoperative risk factors for early mortality include poor left ventricular function and preoperative pacemaker insertion. Predictors of late mortality include chronic obstructive pulmonary disease and urgency of operation. These results stress the importance of operating on the elderly with aortic valve disease; both long-term survival and functional recovery are excellent.
- [Show abstract] [Hide abstract] ABSTRACT: Background: Controversy still exists as to whether patients with previous stroke are at increased risk for neurologic complications after heart operations. Methods: We performed a prospective analysis of 1,000 consecutive patients undergoing cardiac operations requiring cardiopulmonary bypass, without hypothermic circulatory arrest. Of the 1,000 patients, 71 had previously documented stroke (study group); 2 control patients with no history of stroke were selected for each of these patients (control group, n = 142). There were no significant differences between the study and control patients with respect to established risk factors for neurologic complications. Results: Compared with controls, study patients took longer to awaken (12.6 +/- 10.9 versus 3.5 +/- 2.1 hours; p < 0.0001) and longer to extubate (29.5 +/- 29.3 versus 9.1 +/- 5.2 hours; p < 0.001), and had a greater incidence of reintubation (7 of 71, 9.9% versus 2 of 142, 1.4%; p < 0.01) and postoperative confusion (26 of 71, 36.6% versus 7 of 142, 4.9%; p < 0.001). There was a higher incidence of focal neurologic deficit among study patients (31 of 71, 43.7% versus 2 of 142, 1.4%; p < 0.001). These deficits included new stroke (6 of 71, 8.5%) as well as the reappearance of previous deficits (19 of 71, 26.8%) or worsening of previous deficits (6 of 71, 8.5%), without new abnormalities on head computed tomography or magnetic resonance imaging. Study patients with neurologic deficit had longer cardiopulmonary bypass times than did study patients without deficit (146 +/- 48.5 versus 110 +/- 43.3 minutes; p < 0.001). The 30-day mortality rate was greater in study patients than in controls (5 of 71, 7% versus 1 of 142, 0.7%; p < 0.02), with four deaths among the 6 study patients with a new stroke (66.7%). Conclusion: This analysis identifies a group of patients at high risk for neurologic sequelae and confirms the vulnerability of the previously injured brain to cardiopulmonary bypass, as evidenced by reappearance or exacerbation of focal deficits in such patients.
- [Show abstract] [Hide abstract] ABSTRACT: To determine the morbidity and mortality associated with use of centrifugal ventricular assist devices for postcardiotomy cardiogenic shock and to determine factors that might influence outcome and thus, aid in patient selection. A retrospective study. Surgical intensive care unit in a university hospital. During a 6-yr period, a total of 7,385 adult patients underwent cardiac operations requiring cardiopulmonary bypass. Myocardial protection consisted of single-dose cold crystalloid cardioplegia and continuous topical hypothermia by saline lavage. A total of 72 (1%) patients developed postcardiotomy cardiogenic shock. Of 72 patients, 28 met the institutional criteria and were placed on centrifugal ventricular assist devices. Twenty-eight adult patients with postcardiotomy cardiogenic shock were supported with centrifugal ventricular assist devices. A total of 15 patients received left ventricular assist devices, five received right ventricular assist devices, and eight received both right and left ventricular assist devices. Mean age of ventricular assistance patients was 50.8 +/- 12.9 yrs (range 22 to 72), and mean duration of ventricular assistance was 2.8 +/- 2.5 days (range 4 hrs to 10 days; median 2 days). Twenty-five complications occurred in 16 patients and included bleeding (13), tamponade (2), systemic embolism (6), seizures (2), and sepsis (2). Nine patients required reexploration for bleeding or tamponade. Nine (32%) of 28 patients were discharged from the hospital. Ventricular assistance for cardiac failure after transplantation was associated with improved survival (p < .10), while age > 50 yrs and postoperative tamponade each showed trends toward association with mortality (p = .10). Survival was not predicted by gender, weight, time on cardiopulmonary bypass, aortic cross-clamp time, urgency of operation, or preoperative congestive heart failure. At 27 +/- 20 months follow-up, all survivors were alive and New York Heart Association functional class I or II. These results document a low incidence of ventricular assist device use in a surgical practice that employs a relatively simple method of myocardial protection. When postcardiotomy ventricular assistance was necessary, a centrifugal pump was used and successful outcome and satisfactory long-term results were possible in nearly one third of patients. Ventricular assistance for cardiac failure after transplantation was associated with improved survival. Older age is a relative contraindication to mechanical ventricular assistance.
- [Show abstract] [Hide abstract] ABSTRACT: Aortic valve disease in the elderly is primarily calcific stenosis with preservation of left ventricular function. In contrast, mitral valve disease in the elderly often is ischemic in nature with damage occurring to both valve and myocardium. The present study was undertaken to compare results of aortic (AVR) and mitral valve replacement (MVR) in the elderly and to ascertain predictors of poor outcome. Because patients who had concomitant coronary artery bypass grafting (CABG) are included (51% for AVR, 55% for MVR), patients who had isolated CABG were used as a comparison group. Between January 1, 1984, and June 30, 1991, 1,386 patients aged 70 years and older underwent CABG (n = 1,043), AVR (n = 245), or MVR (n = 98). The operative mortality rates were 5.3% for AVR, 20.4% for MVR, and 5.8% for CABG. Late follow-up of patients undergoing operation in 1984 and 1985 was available for 98% (231/237). Overall survival was comparable for all three groups through the first 5 years of follow-up (AVR, 68% +/- 8%; MVR, 73% +/- 8%; CABG, 78% +/- 3%). After 5 years, survival for patients having AVR and MVR was less than that for those having CABG. Patient age, sex, New York Heart Association functional class, concomitant CABG, prosthetic valve type, native valve pathology, and preoperative catheterization data were examined as possible predictors of outcome by multivariate logistic regression.(ABSTRACT TRUNCATED AT 250 WORDS)
- [Show abstract] [Hide abstract] ABSTRACT: Surgical approaches for implantation of the automatic cardioverter defibrillator are sternotomy, left thoracotomy, subxiphoid, and subcostal. Although any one of these may be combined with insertion of one or more of the electrodes transvenously, surgical entry into the chest is required for every noninvestigational defibrillator implantation operation. The approaches differ in exposure provided for selecting electrode sites and for handling untoward events, in amount and location of tissue that must be divided or dissected, and in average time required. The operation is an electrical one. Its purpose is to obtain reliable rhythm sensing so that defibrillation or cardioversion shocks will occur only when necessary, and to obtain low enough defibrillation thresholds for shocks of 30 joules or less to have a 10-joule defibrillation safety margin. Many of the patients have had previous cardiac operations. They usually have low or very low ejection fractions. Intraoperative electrophysiological testing with often multiple defibrillation episodes is required. The choice of approach varies with the state of the patient, the institutional experience, and the surgeon. This article describes technique, and the advantages and disadvantages of the four approaches as used by four surgeons in four different institutions.
- [Show abstract] [Hide abstract] ABSTRACT: A retrospective analysis of the records of 60 patients who underwent pericardiectomy over a 10-year period (1980 to 1990) at The Johns Hopkins Hospital was performed. Indications for operation were effusive disease in 24 patients and constriction in 36 patients. Six patients (10%) with pericardial effusion had pain as the primary symptom necessitating intervention. The operative approach for pericardiectomy was median sternotomy in 52 patients (4 patients required cardiopulmonary bypass) and left anterior thoracotomy in 8 patients. Nine patients (5 with constriction and 4 with effusion) with a prior limited pericardial procedure required formal pericardiectomy. The operative mortality rate for pericardial effusion and constriction was 4.2% and 5.6%, respectively. Follow-up (median follow-up, 56.9 +/- 38.2 months) was obtained on 56 patients (93.3%). Actuarial survival at 1 year, 5 years, and 10 years for all patients was 82.1% +/- 5.1%, 71.7% +/- 6.7%, and 59.8% +/- 12.2%, respectively. A Cox proportional hazards regression analysis was performed using 20 clinical variables. A history of malignancy, previous pericardial procedure, and preoperative New York Heart Association class IV were found to be predictors of poor survival. All patients who underwent operation primarily for effusion with associated pain are alive and have improved functional capacity without steroid use. We conclude that pericardiectomy can be performed with low mortality and can result in good long-term survival and improved functional capacity. Patients who are seen primarily with pain refractory to steroid therapy can be relieved of symptoms with operation.
- [Show abstract] [Hide abstract] ABSTRACT: Left internal mammary artery (LIMA) grafts have better long-term patency rates than do saphenous vein grafts and result in improved late survival. The present study was undertaken to assess the results of LIMA grafting in the elderly. From 1980 through 1988, 723 patients 70 years of age or older had isolated coronary artery bypass grafting performed. During the first 5 years, only 11% of the elderly patients received LIMA grafts, whereas 86% having coronary artery bypass grafting since 1985 had LIMA grafts. Since 1986, LIMA use in the elderly has become routine, with 92% of patients receiving internal mammary artery grafts. During the first 5 years, elderly patients had a hospital mortality rate of 9.3%. Since 1985, the hospital mortality rate fell to 5.5%. In addition, the occurrence of major surgical complications was either unchanged or reduced in patients receiving LIMA grafts. Furthermore, late follow-up indicates a significantly improved 4-year survival rate in patients with internal mammary artery grafts compared with those without: 86 ± 0.02% versus 77 ± 0.03% (p < 0.01). Analysis of multiple potential risk factors for early mortality was performed using multiple logistic regression and late survival wing the Cox proportional hazards model. Although unmeasured predictor variables may confound retrospective analyses, LIMA grafting appears to be an independent predictor both of improved early and late survival.
- [Show abstract] [Hide abstract] ABSTRACT: To determine the influence of valve selection on valve-related morbidity and mortality and patient survival, comparative long-term performance characteristics of mechanical (N = 68) and bioprosthetic (N = 73) heart valves were analyzed for 141 patients more than 70 years old who underwent isolated aortic valve replacement between 1970 and 1985. Cumulative patient follow-up was 491 patient-years (average, 4.3 years per patient). Hospital mortality was 18% and 19% for patients with mechanical valves and bioprosthetic valves, respectively. Survival at 5 years was 61 +/- 7% (+/- the standard error) and 67 +/- 10% for recipients of mechanical valves and bioprosthetic valves, respectively. Male sex (p = 0.014) and urgency of operation (p = 0.006) were independent risk factors for hospital mortality. Atrial fibrillation increased valve-related mortality (p = 0.01). No patient required reoperation or experienced structural valve failure. While anticoagulant-related hemorrhage was increased in recipients of mechanical valves (9.2 +/- 2.1%/patient-year) compared with recipients of bioprosthetic valves (2.3 +/- 1.1%/patient-year), it did not result in a death or lead to permanent disability. There was no difference in freedom from any valve-related complication at 5 years. However, when all morbid events are considered, recipients of bioprosthetic valves experienced fewer valve-related complications than patients receiving mechanical valves (10.7 +/- 2.3%/patient-year versus 17.6 +/- 2.5%/patient-year, respectively; p less than 0.05). The reduced incidence of anticoagulant-related hemorrhage and the infrequent need for warfarin sodium anticoagulation favor selection of a bioprosthetic heart valve in patients older than 70 years.
- [Show abstract] [Hide abstract] ABSTRACT: Myocardial revascularization and implantation of the automatic implantable cardioverter defibrillator (AICD) have individually been shown to improve survival in patients after sudden cardiac death. Their combined role has not been well defined. Twenty-three survivors of sudden death underwent revascularization and AICD implantation at an average age of 59 years. The initial arrest was caused by ventricular fibrillation in 15 and ventricular tachycardia in 8. Exercise stress tests, ambulatory ECGs, and electrophysiological monitoring with programmed electrical stimulation were done preoperatively and postoperatively. Follow-up averaged 24 months with a two-year survival of 91%. Eight patients (35%) required AICD resuscitation an average of 8 months postoperatively, and electrophysiological testing did not accurately predict arrhythmia recurrence. The addition of AICD implantation to revascularization substantially improves survival of patients with sudden cardiac death.
- [Show abstract] [Hide abstract] ABSTRACT: Because the automatic internal cardioverter defibrillator's long-term ability to reduce arrhythmic mortality in patients with ventricular tachycardia/fibrillation is unknown, it is important to determine whether the threshold for defibrillation changes over time. Serial defibrillation thresholds were measured in 23 patients over a mean replacement time of 24.8 +/- 7.5 months. In all cases the lead system was a superior vena cava coil to a left ventricular epicardial patch. The defibrillation threshold for the entire group increased from 12.3 +/- 4.7 J to 16.9 +/- 5.9 J (p less than 0.05). Striking increases in the defibrillation threshold were seen in the subgroup of patients taking amiodarone (from 10.9 +/- 4.3 J at implantation to 20.0 +/- 4.7 J at replacement, p less than 0.05). Defibrillation threshold decreased in patients taking no antiarrhythmic drugs or taking class I agents. Thus, the increase in mean defibrillation threshold was the result of an increase in the patients taking amiodarone. These data suggest that at initial implantation lead systems associated with the lowest defibrillation threshold should be used and the defibrillation threshold should be measured at generator change to guarantee an adequate margin of safety.
- [Show abstract] [Hide abstract] ABSTRACT: A 78-year-old man treated with amiodaronce for recurrent ventricular tachycardia, had soquential placement of a bipolar VVI pacemaker and an automatic implantable cardioverter defibrillator (AICD). During defibrillation threshold testing, there was failure to capture of the pacer in the post-shock period. The time of failure to capture appeared energy-related: the greater the energy delivered, the longer the failure to capture. Careful attention will be necessary in constructing combined AICD/pacemaker units.
- [Show abstract] [Hide abstract] ABSTRACT: Long-term performance characteristics of the Björk-Shiley standard aortic valve were determined by analyzing the follow-up of 514 patients undergoing operation between 1971 and 1981. Cumulative follow-up was 2,601 patient-years (average, 5.3 +/- 3.8 years); 53% (238/452) of hospital survivors have been followed more than 5 years. Valve-related complications expressed as both actuarial event-free percents (+/- standard error at 10 years) and first-event linearized determinations (percent per patient-year) occurred at the following rates: thromboembolism, 82 +/- 3 and 2.3 +/- 0.3, respectively; anticoagulant-related hemorrhage, 60 +/- 4 and 5.6 +/- 0.5; prosthetic valve endocarditis, 94 +/- 2 and 0.8 +/- 0.2; valve thrombosis, 97 +/- 1 and 0.4 +/- 0.1; reoperation, 94 +/- 2 and 0.6 +/- 0.2; valve failure, 82 +/- 4 and 1.6 +/- 0.2; and composite valve-related morbidity and mortality, 46 +/- 4 and 8.8 +/- 0.2. Overall survival was 72 +/- 2% at 5 years and 55 +/- 3% at 10 years; valve-related complications accounted for 22% of the late deaths. Although no instance of structural valve failure could be identified, 25% of valve-related complications resulted from valve failure, of which 67% were fatal. By 10 years, 54% of patients had experienced at least one form of major valve-related complication, 16% of which proved fatal. The Björk-Shiley standard aortic valve has late valve-related complications similar to other existing mechanical prostheses that have been subjected to long-term analysis.
- [Show abstract] [Hide abstract] ABSTRACT: Although ventricular resection guided by endocardial mapping has been a successful treatment for drug-refractory ventricular arrhythmias, 20 to 30 percent of patients still have postoperative sustained ventricular tachycardia or sudden death. To improve the outcome of the procedure, we implanted an automatic cardioverter-defibrillator in conjunction with endocardial resection in 28 patients, all of whom had had previous myocardial infarctions and between one and five cardiac arrests. There were three perioperative deaths. During follow-up of 8 to 51 months (mean, 25), 4 of the 25 survivors had recurrences of hypotensive ventricular tachycardia, which in all instances were automatically terminated by the implanted device. One patient, whose automatic cardioverter-defibrillator was not functional, died suddenly. We conclude that patients undergoing mapping-directed endocardial resection can be provided with additional protection against recurrent ventricular tachyarrhythmias or sudden death by implantation of an automatic cardioverter-defibrillator.
- [Show abstract] [Hide abstract] ABSTRACT: To identify possible risk factors for the occurrence of stroke during coronary artery bypass grafting (CABG), the cases of 3,279 consecutive patients having isolated CABG from 1974 to 1983 were reviewed. During this period, the risk of death fell from 3.9% to 2.6%. The stroke rate, however, fell initially but then rose from 0.57% in 1979 to 2.4% in 1983. Adjustment of these data for age clearly demonstrated that the risk of stroke has increased largely because of an increase in the mean age of patients undergoing CABG procedures. A case-control study involving all 56 stroke victims and 112 control patients was used to identify those risk factors significantly associated with the development of stroke in univariate analysis: increased age (63 versus 57 years in stroke patients and controls, respectively; p less than 0.0001); preexisting cerebrovascular disease (20% versus 8%; p less than 0.03); severe atherosclerosis of the ascending aorta (14% versus 3%; p less than 0.005); protracted cardiopulmonary bypass time (122 minutes versus 105 minutes; p less than 0.005); and severe perioperative hypotension (23% versus 4%; p less than 0.0001). Other variables not found to correlate with postoperative stroke included previous myocardial infarction, hypertension, diabetes mellitus, lower extremity vascular disease, preoperative left ventricular function, and intraoperative perfusion techniques. Elderly patients who have preexisting cerebrovascular disease or severe atherosclerosis of the ascending aorta or who require extensive revascularization procedures have a significantly increased risk of postoperative stroke.
- [Show abstract] [Hide abstract] ABSTRACT: Between January 1974 and December 1983, 3279 patients have undergone isolated coronary artery bypass (CAB) grafting at the Johns Hopkins Hospital. There were 639 women in this group. Women represented 18 to 22% of the patients having isolated CAB grafting throughout the 10-year period, except in 1976 when only 13% of the CAB patients were women. Mean age-at-operation for women has increased from 53.9 to 61.1 years since 1974, and was higher than the mean operative age of men during each of the 10 years. Although the oldest woman undergoing CAB grafting in 1974 was 64 years old, the eldest in 1983 was 84 years old. Except for an older mean age-at-operation for women and a higher incidence of unstable angina prior to surgery, the only other significant difference in the clinical status of female versus male CAB patients, detected by a case control analysis, was the smaller body surface area of women compared to men. Although operative mortality was significantly greater for women during most of this review period, mortality was similar during 1983 (2.6% for men versus 2.4% for women), in spite of a significantly higher incidence of unstable angina in the female group (54% for women versus 35% for men). The improved survival noted following coronary bypass grafting in women, which occurred in spite of the advancing age of the female group, supports an aggressive approach to surgical intervention in women with severe coronary artery disease.
- [Show abstract] [Hide abstract] ABSTRACT: Le cardioverter-défibrillateur automatique implantable a été implanté chez 276 patients porteurs de tachycardies malignes tenaces avec une survie jusqu’è 50 mois (moyenne = 9.75 mois). Les results de cet appareil sont encourageants. Les risques et les complications associées sont acceptables et ressemblent è ceux des pacemakers. L'accélération des tachycardies ventriculaires ou l'induction de fibrillation ventriculaire sont traitées par le recyclage de l'appareil. Le défibrillateur a réduit la mortalité de ces patients è 2% durant la première année. The automatic implantable cardioverter-defibrillator has been implanted in 276 patients with ventricular tachyarrhythmias refractory to therapy with a follow-up period up to 50 months (average 9.75 months). The functional performance of the device has so far been most encouraging. The risks and complications associated with its use are acceptable and quite similar to those observed in patients with implanted pacemakers. Acceleration of ventricular tachycardia to a faster rhythm or to ventricular fibrillation is dealt with successfully through recycling. Actuarial analysis indicates that the device has a significant impact on the survival rate of the implantees, reducing the one-year mortality rate attributed to arrhythmias to only 2%.
- [Show abstract] [Hide abstract] ABSTRACT: Il existe différentes options d'appareillage et de techniques chirurgicales pour l'implantation du défibrillateur automatique. Le système peut mime être utilisé mialgré difficultés posées par la présence d'aulres appareils implantés ou par la morphologie du patient. La sensibilité ainsi que l'énergie délivrée peuvent être ajustées selon les besoins des patients. La survie de la pile est suivie de façon non-invasive, ce qui permet Ie remplacement non-urgent de l'appareil. There are a number of equipment options and surgical techniques available for automatic implantable cardioverter-defibrillator implantation. The system can be successfully used even in problem cases where restrictions may be imposed because of physical build or the presence of other implanted devices. The sensing requirements and energy output of the units can be tailored to the exact needs of the particular patient. Battery life and device function are easily monitored penodically following implantation, maiking possible elective replacement of the pulse generator when the batteries become depleted.
- [Show abstract] [Hide abstract] ABSTRACT: Depuis février 1980, le défibrillateur automatique a été implanté chez 77 patients ayant survécus à plusieurs arrêts cardiaques. La voie souscostale a été utilisée chez 28 patients, et la tharocotomie chez 20 patients. Dans 29 cas, une sternotomie médiane a été utilisée en raison d'autres interventions chirurgicales cardiaques antérieures. Bien que la voie sous costale paraîsse la plus bénigne, toutes ces téchniques sont éfficaces. La méthode préferée est déterminée par l'aspect clinique. Les statistiques démontrent une survie nettement améliorée chez tous ces patients à haut risque. Since February 1980, the automatic defibrillator was implanted in 77 survivors of multiple cardiac arrest. The subxiphoid technique was used in 28 patients and the thoracotomy technique was used in 20 patients with previous cardiac surgery. Median sternotomy was used in 29 patients undergoing open heart procedures as well as defibrillator implantation. While the subxiphoid is the most benign procedure employed, all are safe and well tolerated. The method used is determined by the clinical picture. Survival studies indicate improved survival in this high risk population.
Sinai HospitalBaltimore, Maryland, United States