Since 1967, when the first intracardiac repair was performed in this centre, until 1991, 840 symptomatic subjects with tetralogy of Fallot have undergone corrective surgery. Cardiac catheterization ...and angiocardiography were carried out in all patients. Cardinal findings on the clinical status of these subjects are outlined. A substantial number of patients (244; 29.0%) were > 15 years of age. Historically, a transannular pericardial gusset has been utilized in 578 (68.8%), and in 423 (93.0%) during the past decade. The incidence of residual interventricular septal defects has been 0.68% and occurrence of complete heart block after surgery 0.4%. Death occurred in 86 patients (10.2%) within 30 days of operation and later in 40 subjects (4.8%). Long-term results have been excellent with good haemodynamic status in > 90% of subjects in the follow-up period. Associated features including absent pulmonary valve, absent left pulmonary artery, and previous palliative shunts did not alter the outcome; however, a raised haematocrit (> 0.65) was associated with an increased mortality rate.
We conducted a study on the factors predictive of early mortality (within 30 days of onset of symptoms) in a clinical series of 94 patients at their first stroke. Irrespective of the type of stroke, ...ischemic or hemorrhagic, early mortality proved to correlate with clinical parameters, such as coma at onset, presence of paralysis, changes in ocular motility, and neuroradiological parameters (lesion size on the CT scan) indicative of stroke severity.
A scoring system to predict early mortality and morbidity in CABG, distinguishing low and high risk patients.
563 patients (1998) served as development dataset, 969 patients as validation set. ...Univariate and logistic regression analysis was used to identify risk factors.
Gender, hypertension, pulmonary disease, reoperation, age, operative status and left-ventricular function were predictive variables for early mortality. The area under the ROC curve was 0.81. We identified a low risk, mortality of 1.8% and a high-risk group, mortality of 13.4%. Diabetes, hypertension, kidney and lung disease, reoperation, operative status and left ventricular function were predictive variables for morbidity. The area under the ROC curve was 0.73. We identified a low risk, morbidity of 17%, and a high-risk group, morbidity of 41%.
This scoring system is a simple system identifying a low and high-risk group for morbidity and early mortality.
The purposes of this study were to investigate the sequential changes of PMN elastase during evolving myocardial infarction, and also to ascertain whether or not ulinastatin (UL), a clinically useful ...protease inhibitor, would affect the extent of ischemic myocardial injury. The levels of plasma PMN elastase (as α1-proteinase inhibitor-elastase complex) were measured once in 13 normal controls, and at intervals in 30 acute myocardial infarction (AMI)patients given UL and 30 AMI controls on conventional therapy, and compared between the groups. The levels in control group on conventional therapy were significantly higher from 6 to 72 hours after the onset than those in normal controls. Maximum PMN elastase levels in non-survivors (n=7) were significantly higher than in survivors (n=23) at the 6-month follow-up (288.4±75.8 vs. 188.1±56.9μg/1, p<0.01). The maximum level of PMN elastase in patients given UL was significantly lower than that in the control group (162.2±96.2 vs 207.3±70.1μg/1, p<0.05), and the peak CK-MB in patients given UL was significantly lower than that in controls (252.3±150.9 vs 360.1±239.6 IU/1, p<0.05). Early mortality (seen at 6-month follow-up) in patients administered UL was significantly lower than that of the treated control (3.3% vs 23.3%, p<0.05). Analysis of changes in PMN elastase levels suggested that UL would be clinically beneficial for reduction of ischemic myocardial injury.
The clinical efficacy of intravenous fibrinolytic treatment using a moderate dose of urokinase (UK) on acute myocardial infarction (AMI) has not been well evaluated in randomized trials. In order to ...assess the efficacy of UK, a prospective randomized study was undertaken, aimed mainly at evaluating coronary myocardial blood flow in the infarcted myocardium using Tl-201 myocardial scintigraphy. 166 patients (131 male and 35 female, mean age 61.1 years) with AMI classified in Killip I or II who were admitted to the CCU within 24 hours of the onset of symptoms were devided into two groups; 76 patients treated with UK (UK group) and 90 patients treated with conventional therapy without UK (control group). Intravenous UK 72, 000 IU was injected over 10 minutes and UK 528, 000 IU was subsequently given by drip infusion over the following 12 (n=36) or 24 hours (n=40). There was no significant difference between the two groups with regard to the patients'background. Tl-201 uptake of infarcted myocardium in the UK group (n=17) significantly increased in the first week compared with that on the day of admission (p<0.005) and a further significant increase was observed in the fourth week (p<0.05). In the control group (n=10) Tl-201 uptake did not change in the first week and then increased significantly in the fourth week (p<0.05). Coronary angiography and left ventriculography (43 cases in the UK group and 32 cases in the control group) performed in the convalescent stage of AMI showed: 1) similar prevalence of patency of the infarct related artery (UK group: 72.1%, control group: 75.0%), 2) more prominent collateral circulation in the UK group (62.9% vs 41.4%), 3) significantly better perfusion of infarcted myocardium by coronary antegrade flow and/or collateral flow in the UK group (70.0% vs 46.9%, p<0.05), 4) a trend towards reduction of severe asynergy in the infarcted regional wall of the left ventricle in the UK group (16.3% vs 34.4%). The mortality rate of patients with first AMI in the UK group (n=66) was significantly lower than that in the control group (n=68) (4.5% vs 14.7%, p<0.05), and a similar trend was also found in patients with prior infarction (UK: n=10, 0% vs control: n=22, 1 3.6%). Cardiac rupture diagnosed on autopsy was less frequent in the UK group (n=2) than in the control group (n=7). In conclusion, systemic fibrinolytic treatment by a moderate dose infusion of UK has some beneficial effects on AMI due to an improvement of microcirculation in the border zone.
Surgical repair for abdominal aortic aneurysm has become more frequent and the mortality associated with elective surgery has been reduced, but the overall mortality for ruptured aneurysm remains ...unacceptably high. The dilemma for the vascular surgeon is whether to operate early and electively on asymptomatic small aneurysms, less than 5 cm in diameter, or to delay surgery, adopting a wait-and-see attitude. The purpose of this retrospective study was to review a recent 5-year experience of elective aneurysm surgery, with special emphasis on the perioperative outcome of surgical repair of asymptomatic small aneurysms, in order to evaluate whether early mortality and morbidity justify an aggressive approach.
The report concerns a series of 141 consecutive patients who underwent aneurysm repair for small (n = 65, group I) and large aneurysms (n = 76, group II). For each group, the age, sex, risk factors and associated diseases, operative and aortic cross-clamping times, estimated blood loss, blood transfusion volume, type of operation and graft, perioperative morbidity and mortality, and causes of death were recorded and compared.
The majority of patients were males. The mean age of the patients was lower in group I than in group II. No statistically significant difference was found from the comparison of the risk factors and associated diseases in groups I and II. The mean operating time was 82 minutes in group I, 98 minutes in group II, and the aortic cross-clamping time was also shorter in group I (37 min versus 52 min), whereas blood loss was greater, with a statistically significant difference (P < 0.05). The operative mortality rate was higher in group II than in group I (1.3% versus 0%, P = NS).
Elective small aneurysm repair is recommended in good-risk patients for the following reasons: (i) the operative mortality and morbidity rates are lower in small than in large aneurysm patients, and (ii) the small aneurysm repair is technically easier and safer to perform. In addition, there are two other considerations that are more difficult to quantify, but may support an aggressive approach: the cost-benefit ratio is better with early diagnosis and elective surgery, before an emergency operation is required, and personal choice and psychological reasons can induce patients to prefer early elective repair to periodic monitoring by ultrasound or computed tomography scans.
Between October 1979 and January 1993, 85 Chinese neonates in Hong Kong underwent surgical repair for coarctation of the aorta. Their mean (s.e.) age and body weight at operation was 15.6(8.5) days ...and 3.06(0.56) kg, respectively. Simple coarctation was present in 17 babies, while 36 had additional ventricular septal defect and 31 had associated major complex intracardiac lesions. Subclavian flap aortoplasty was performed in 56 babies, resection with end-to-end anastomosis in 18 and aortoplasty with the use of a GORETEX patch in 11. The overall early mortality rate was 16.5%. To identify risk factors for early operative mortality, various clinical variables, surgical options, associated heart lesions and dimensions of the aortic arch at different sites for each patient were reviewed. Univariate analysis identified statistically significant differences between the survivors and non-survivors for the following factors: preoperative body-weight, arterial pH and base excess, serum urea and creatinine levels. Stepwise logistic regression further distinguished serum creatinine levels and the period of operation as two significant risk factors. Contrary to previous reports, the dimensions of the aortic arch and type of surgery did not affect early operative mortality. Among the 71 hospital survivors followed for 38.2(38) months, residual or recurrent coarctation of the aorta was detected in 12(17%). The different surgical operations were not related to the incidence of late complication. The size of the distal transverse arch, however, was different (P=0.05) in those who did and did not develop aortic sequela. Successful balloon angioplasty was subsequently performed in 11 patients. In an era of echocardiography with prenatal diagnosis and therapeutic catheterization, early recognition of the disease with prompt prostaglandin infusion should prevent collapse of the baby, thus avoiding renal impairment and sever metabolic acidosis. Balloon angioplasty would offer a simple effective treatment of patients who developed aortic re-coarctation.
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