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Byline: Shigeki Morita, Pablo Zubiate, Gregory Louis Kay, Joseph M. Ruggio, Guo-Wen Sun, David W. Winsor, Jerome Harold Kay Abstract: Ejection fraction is a major determinant of morbidity and mortality for patients with ischemic heart disease. Patients with an ejection fraction of 0.40 or less are generally recognized as having a poorer prognosis than those patients with an ejection fraction of 0.50 or better and remain a heterogeneous group. It would be useful if patients with a favorable surgical prognosis could be identified preoperatively. Fifty-five patients who underwent coronary artery bypass grafting and had an ejection fraction less than 0.40 (mean of 0.23 [+ or -] 0.07 standard deviation) were studied by catheter measurement of pulmonary arterial pressure and radionuclide left ventriculography. Heart rate, systemic blood pressure, pulmonary artery pressures, cardiac output, and ejection fraction were measured, at rest, after nitroglycerin was given intravenously and with supine bicycle exercise. Forty-seven patients who had follow-up longer than 4 years were divided into two groups according to their life status (alive or dead) 4 years after operation. Measured variables of exercise stress tests and clinical characteristics were entered into factor analysis to obtain a cardiac function factor score for predicting the life status after 4 years. The cardiac function factor score was highly loaded by stroke index (rest, nitroglycerin), cardiac index (exercise), systemic vascular resistance index (exercise), and history of congestive heart failure. The cardiac function factor provided a predictive value superior to that of any individual variable. By dividing the patients into two groups by cardiac function factor score, the actuarial 5-year survival was 72% versus 17% for good and poor prognosis groups, respectively (p < 0.0001). Preoperative exercise stress testing data integrated by factor analysis provide a predictive tool for patients with a low ejection fraction. Author Affiliation: Heart Institute, Good Samaritan Hospital, Los Angeles, Calif., USA Article History: Received 28 April 1994; Accepted 10 March 1995 Article Note: (footnote) Supported in part by Los Angeles Thoracic and Cardiovascular Foundation.

Recently, a new technique for myocardial protection that does not rely on hypothermia has been reported. in this method, the heart is continuously perfused with normothermic hyperkalemic blood cardioplegia during [...]

A simplified method of performing coronary artery surgery without the use of blood is described. Not only is the use of blood substantially decreased by this method (71 per cent of our patients did not require blood), but the time of cardiopulmonary bypass is decreased since the proximal anastomoses are performed before bypass. This method has allowed us to operate upon critically ill patients in congestive failure, with marked left ventricular impairment and an ejection fraction of 0.10 to 0.20 (normal 0.70). The mortality rate in 33 such patients was 9 per cent (three deaths).

Despite what was considered adequate pharmacological treatment, the conditon of six patients with severe mitral valve prolapse but with trivial or no mitral regurgitation deteriorated. These patients had marked weakness, chest pain, dyspnea, and arrhythmias. Because these patients found their condition to be intolerable, the prolapsed mitral valve was repaired. Electrocardiography, treadmill stress testing, and left ventriculography performed following operation showed complete repair of the valve and significant improvement over the preoperative findings in all six patients. Repair of the floppy mitral valve did not eradicate all abnormalities; however, it did significantly improve the chest pain, weakness, dyspnea, and arrhythmias in all six patients. Five patients no longer require any medication. The prolapsed mitral valve contributed significantly to the symptoms and arrhythmias, but it could not have been the sole cause for these patients’ signs and symptoms. With complete correction of the prolapse in all six patients, few of the signs and symptoms of the disease persisted. Repair of severe mitral valve prolapse without mitral regurgitation is recommended only for those patients who continue to be severely symptomatic from chest pain, dyspnea, or ventricular arrhythmias after an extensive trial of adequate medical therapy.

Pure mitral insufficiency associated with secundum atrial septal defect is not an unusual finding. Thirteen patients with significant mitral insufficiency and an associated secundum defect were operated upon. Two of these patients also had severe tricuspid insufficiency. The mitral valve was repaired in 12 patients and replaced in one. The tricuspid valve was repaired in the two patients with associated tricuspid insufficiency. There were two early deaths due to mediastinitis and one late death due to a cerebral embolus in the only patient who had valve replacement; this patient died 3 years after the operation. It is concluded that mitral and tricuspid valve repair should be performed for patients with significant mitral and tricuspid insufficiency associated with atrial septal defect of the secundum variety. Replacement of the valves should be avoided if possible.

Seventy-nine patients underwent repeat myocardial revascularization between March 1971 and January 1977. The initial procedure was performed at the St. Vincent Medical Center, Los Angeles, in 70 (2.0 percent) of 3,526 patients undergoing surgery for coronary arterial disease and in nine more patients was performed at other hospitals; the second operation followed the first procedure at an interval of from three weeks to 78 months. Five deaths (6 percent) occurred while patients were hospitalized, and six deaths (8 percent) occurred later. Two of the six later deaths were from noncardiac causes. Complications were not different from those that occurred during primary procedures. Thirty-six (60 percent) of 60 patients undergoing repeat surgery since 1973 did not receive any transfusions of blood during or after surgery. Of 48 patients followed-up for periods ranging from 12 to 70 months after the second operation, angina was completely relieved in 18 patients (38 percent), improved in 16 patients (33 percent), unchanged in 11 patients (23 percent), and worse in three patients (6 percent).

Six patients with a large aneurysm of the ascending aorta involving the root of the aorta and severe aortic valve insufficiency owing to marked annular dilatation were treated by replacement of the ascending aorta and aortic valve with a composite unit. It was also necessary to transpose the origin of the coronary arteries with the use of saphenous vein grafts. In 3 patients, the aneurysm was due to a chronic dissection. In one patient, the aneurysm extended beyond the arch of the aorta. There were no operative deaths. One patient died suddenly of pulmonary emboli 11 months after surgery. The remaining 5 patients are doing well, 5 months to 4 years postoperatively.

Case reports from a group of 15 patients with Candida endocarditis seen and treated at the Los Angeles-University of Southern California Medical Center between 1960 and 1974, together with a survey of other reported cases, serve to re-emphasize the importance of early diagnosis of this disease and lead to certain conclusions regarding its treatment. With medical or surgical treatment alone, the mortality for Candida endocarditis is 82 percent. With surgery and medical treatment combined, the mortality is 20 percent. It is important to institute medical treatment as soon as diagnosis of Candida endocarditis is made and surgery must be performed as soon as possible, preferably within 24 to 48 hours or, at most, a few days after diagnosis. Medical treatment must be continued for a prolonged period after the patient has left the hospital. Close observation of the patient after discharge is important.

From 1970 to 1978, 61 patients were operated upon for mitral insufficiency secondary to coronary artery disease. These patients were between 44 and 71 years of age and all were in Class III or IV of the New York Heart Association Classification. The left ventricular end-diastolic pressure was 15 mm Hg or more in 32 of the 39 patients in whom it was measured. Twenty-four of 31 patients in whom right heart catheterization was performed had a systolic pulmonary artery pressure of 50 mm Hg or greater. All 61 patients had myocardial revascularization, 52 had repair of the mitral valve, and nine had mitral valve replacement. There were five hospital deaths in these 61 patients. Among the nine patients with a preoperative ejection fraction of 0.1 to 0.2, there were two hospital deaths; among the 20 patients with a preoperative ejection fraction of 0.25 to 0.40, there were two hospital deaths; and among the 32 patients with a preoperative ejection fraction of 0.45 to 0.70, there was only 1 hospital death. For those patients with repair and revascularization, the survivability was 81% at 7 years. In the patients with repair and myocardial revascularization, the incidence of peripheral embolization was 0.5% per patient-year.

The second known successful operation for carcinoid valvular heart disease is reported. The patient underwent tricuspid valve replacement and pulmonary valvotomy and has no symptoms of heart disease more than 1 year after operation.