Functional status after operation for Ebstein anomaly: the Mayo Clinic experience

OBJECTIVES

The objective of this study was to review the long-term functional outcome of patients with Ebstein anomaly who had cardiac operation at our institution.

BACKGROUND

Ebstein anomaly is a spectrum of tricuspid valvular and right ventricular dysplasia. Many patients will require operation in an attempt to improve quality of life.

METHODS

From April 1, 1972, to January 1, 2006, 539 patients with Ebstein anomaly underwent 604 cardiac operations at the Mayo Clinic in Rochester, Minnesota. Patient records were reviewed, and all patients known to still be alive were mailed a medical questionnaire or contacted by telephone.

RESULTS

At the initial operation at our institution, the mean age of the patients was 24 years (range 8 days to 79 years) and 53% were female patients. Survival at 5, 10, 15, and 20 years was 94%, 90%, 86%, and 76%, respectively. Survival free of late reoperation was 86%, 74%, 62%, and 46% at 5, 10, 15, and 20 years, respectively. Surveys were returned by 285 of 448 (64%) patients known to be alive at the time of this study. Two hundred thirty-seven (83%) patients were in New York Heart Association functional class I or II, and 34% were taking no cardiac medication. One hundred three patients (36%) reported an incident of atrial fibrillation or flutter, 5 patients (2%) reported having had endocarditis, and 1 patient (<1%) reported having a stroke. There were 275 pregnancies among 82 women. The recurrence of congenital heart disease was reported in 9 of 232 (3.9%) liveborn children.

CONCLUSIONS

Patients have good long-term survival and functional outcomes after undergoing surgery for Ebstein anomaly. Atrial arrhythmias are common both before and after surgery. Many patients have had one or more successful pregnancies with a low-recurrence risk of congenital heart disease.

Surgical management of obstructive hypertrophic cardiomyopathy: the gold standard

While medication is the first line of therapy in obstructive hypertrophic cardiomyopathy, patients who have symptoms refractory to medical treatment or asymptomatic patients with high resting gradients (>or=30 mmHg) may require septal myectomy. Surgical septal myectomy can be performed safely, with excellent survival, relief from symptoms and low morbidity. Alcohol septal ablation is an alternative to surgical treatment, but late outcomes are uncertain. Although both methods of septal reduction relieve left ventricular outflow tract gradients and improve functional status, the need for permanent pacing appears higher with alcohol ablation compared with surgical myectomy. As our understanding of obstructive hypertrophic cardiomyopathy continues to grow, the indications for intervention will evolve. In our practice, septal myectomy remains the gold standard for treatment of obstructive hypertrophic cardiomyopathy.

Disentangling effects of nuclear structure in heavy element formation

Forming the same heavy compound nucleus with different isotopes of the projectile and target elements allows nuclear structure effects in the entrance channel (resulting in static deformation) and in the dinuclear system to be disentangled. Using three isotopes of Ti and W, forming 232Cm, with measurement spanning the capture barrier energies, alignment of the heavy prolate deformed nucleus is shown to be the main reason for the broadening of the mass distribution of the quasifission fragments as the beam energy is reduced. The complex, consistently evolving mass-angle correlations that are observed carry more information than the integrated mass or angular distributions, and should severely test models of quasifission.

Timing of operation in asymptomatic severe aortic stenosis

Calcific aortic stenosis is now the main cause of aortic stenosis in the majority of patients, due to declining incidence of rheumatic fever. Risk factors such as hyperlipidemia play an important role in the progression of aortic stenosis. According to the most recent American College of Cardiology/American Heart Association guidelines, peak velocity greater than 4 m/sec, a mean gradient of more than 40 mmHg and a valve area of less than 1.0 cm(2) is considered hemodynamically severe aortic stenosis. Aortic valve surgery promptly should be done in symptomatic patients due to dismal prognosis without operation. Features such as high aortic valve calcium and positive exercise test identify asymptomatic patients who would benefit from early aortic valve surgery. Due to improvement in surgical techniques and better prosthesis, aortic valve surgery can now be offered at low risk to a selected group of asymptomatic patients with severe aortic stenosis. Currently percutaneous aortic valves are used in very high-risk patients with severe symptomatic aortic stenosis. Their role may expand in the future, depending on the improvements in design and operator experience. Whether advances in molecular cardiology lead to novel therapies in preventing calcific aortic stenosis in the future remains to be seen.

Intraoperative Diagnosis of Isolated Cardiac Sarcoid

Cardiac sarcoid is a rare and frequently fatal disease. We report a case of isolated cardiac sarcoid diagnosed during elective cardiac surgery. Although this patient presented with a history that was consistent with sarcoid heart disease, diagnosis is challenging when there is no other organ involvement with sarcoid. The patient was successfully treated with steroids and 8 years later remains clinically free of sarcoidosis.

Safety of same-day coronary angiography in patients undergoing elective valvular heart surgery

OBJECTIVE

To maximize patient convenience, we developed a protocol for coronary angiography the same day as elective valvular surgery.

PATIENTS AND METHODS

We analyzed the medical records from a single surgical service of 226 consecutive patients who had undergone cardiac catheterization on the day of elective valvular repair or replacement between August 1, 2000, and August 30, 2004. The rates of renal failure (creatinine >2.0 mg/dL and 2 times the preoperative level), hemodialysis, continuous renal replacement therapy, and mortality were evaluated.

RESULTS

Patients undergoing same-day angiography had a mean age of 65.6 plus-or-minus 12.1 years, and 33% were female. Of the study patients, 11.1% were diabetic, with a mean ejection fraction of 61% plus-or-minus 10%, and 28.3% had coronary artery disease severe enough to require bypass grafting. One patient died within 30 days of surgery; the overall mortality was 0.4%. Postoperatively, serum creatinine levels increased an average of 0.1 mg/dL (P<.001) in patients undergoing same-day coronary angiography. Four patients had transient renal failure (1.8%), 2 of whom required temporary hemodialysis.

CONCLUSION

In properly selected patients, same-day coronary angiography is safe and has little impact on renal function. This protocol offers a simple way to reduce the number of hospital visits required by patients undergoing elective valvular surgery.

Systolic anterior motion after mitral valve repair: Is surgical intervention necessary?

OBJECTIVE

The natural history and management of patients with systolic anterior motion after mitral valve repair are uncertain.

METHODS

We performed a retrospective chart review and survey follow-up of all patients in whom systolic anterior motion developed intraoperatively after mitral valve repair.

RESULTS

From January 1993 to December 2002, mitral valve repair was performed in 2076 patients, and in 174 cases (8.4%) systolic anterior motion was identified on intraoperative echocardiography. These patients form the study group. Initially, patients were managed with a combination of beta-blockade, vasoconstriction with phenylephrine, and/or intravascular volume expansion. Four patients had revision of repair because of persistent systolic anterior motion, and 3 additional patients had revision of repair because of mitral regurgitation from other causes. The median follow-up of the remaining 167 patients was 5.4 years (range 0-13.2 years). There were 2 late reoperations, but none were caused by systolic anterior motion or left ventricular outflow tract obstruction. Ninety percent of patients were in New York Heart Association class I, 7% were in class II, and 3% were in class III or IV. Echocardiograms were available for review in 93 patients at a median interval of 5.4 years (range 0.2-12.2 years); 13 patients had systolic anterior motion, and 4 patients had systolic anterior motion with left ventricular outflow tract obstruction.

CONCLUSIONS

In this experience, most cases of systolic anterior motion resolved with conservative measures including beta-blockade, vasoconstriction, and fluid administration. Persistent systolic anterior motion with left ventricular outflow tract obstruction was documented in 2.3% of patients who had early systolic anterior motion, but late reoperation was not required. Furthermore, the clinical outcomes of patients with systolic anterior motion are comparable to the current norms for mitral valve repair. Ninety percent of patients were in New York Heart Association class I, 7% were in class II, and 3% were in class III or IV.

Effect of perioperative antioxidant therapy on suboptimal islet transplantation in rats

Islet transplantation success is limited by the posttransplant inflammatory response, and we are investigating the ability of antioxidants to neutralize this islet damage. We have shown that pyruvate can enhance the engraftment and functionality of a suboptimal islet mass in rats. The present study further investigated the effects of pyruvate, as well as the antioxidants vitamin E and vitamin C. In study A, 350 syngeneic islets were transplanted into the liver of chemically diabetic rats. Antioxidant treatment, or vehicle, was administered during the perioperative period and an intraperitoneal glucose tolerance test (IPGTT) was performed 2 months posttransplant. In study B, 500 syngeneic islets were transplanted under the kidney capsule of chemically diabetic rats. Antioxidant treatment was administered during the perioperative period. Islet-bearing kidney grafts were harvested 24, 48, and 96 hours posttransplant for histological study. Results revealed that pyruvate was the only significantly effective treatment in enhancing the engraftment and functionality of a suboptimal islet mass. Respectively, 56% and 80% of pyruvate-treated rats became normoglycemic after islet transplantation in study A and study B and had a normal insulin response to IPGTT. Histology results from the islet-bearing kidneys were inconclusive as to whether or not pyruvate has an antiapoptotic effect. We conclude that pyruvate, but not vitamin E or vitamin C, aids in the engraftment and functionality of a suboptimal islet mass with as much effectiveness as a full mass in this study. Further investigation into the mechanism of pyruvate protection is still warranted.

Progress in cancer screening over a decade: results of cancer screening from the 1987, 1992, and 1998 National Health Interview Surveys

BACKGROUND

Screening to detect cancer early, an increasingly important cancer control activity, cannot be effective unless it is widely used.

METHODS

Use of Pap smears, mammography, fecal occult blood tests (FOBTs), sigmoidoscopy, and digital rectal examination (DRE) was evaluated in the 1987, 1992, and 1998 National Health Interview Surveys. Levels and trends in screening use were examined by sex, age, and racial/ethnic group. The effects of income, educational level, and health care coverage were examined within age groups. Logistic regression analyses of 1998 data were used to develop a parsimonious, policy-relevant model.

RESULTS

Use of all screening modalities increased over the period examined; for mammography and DRE, the increase was more rapid in the first half of the decade; for the Pap test and sigmoidoscopy, the increase was more rapid in the second half of the decade. Levels of colorectal cancer screening (both sigmoidoscopy and FOBTs) in 1998 were less than the level that prevailed a decade earlier for mammography. Patterns of change for all screening modalities differed between age, sex, and racial/ethnic groups, but prevalence of use during the study, within recommended time intervals, was consistently lower among groups with lower income and less education. Logistic regression analyses indicated that insurance coverage and, to a greater extent, usual source of care had strong independent associations with screening usage when age, sex, racial/ethnic group, and educational level were taken into account.

CONCLUSIONS

While cancer screening is generally increasing in the United States, usage is relatively low for colorectal cancer screening and among groups that lack health insurance or a usual source of care.

Bowel surveillance patterns after a diagnosis of colorectal cancer in Medicare beneficiaries

BACKGROUND

Postoperative colon surveillance has been recommended for patients with a diagnosis of local/regional colorectal cancer. The extent to which these recommendations are followed in practice is poorly characterized. Patterns of surveillance after surgery for colorectal cancer were determined by using a large population-based database.

METHODS

This is a retrospective cohort study with cancer registry data linked to Medicare claims. Identified were 52,283 patients treated for local/regional colorectal cancer between 1986 and 1996, and surveillance patterns through 1998 were determined. Surveillance patterns were analyzed by using survival analysis and by computing the proportion of surviving patients who underwent procedures during 4 time periods after treatment: 2 to 14 months, 15 to 50 months, 51 to 86 months and more than 87 months.

RESULTS

Median times to first through fifth surveillance events were 20, 14, 15, 15, and 15 months, respectively. For 17% of the cohort there was no surveillance event. Younger patients were more likely to undergo surveillance. Surveillance patterns were not affected by stage. The proportions of the cohort that underwent no surveillance during the 4 respective time periods were 54%, 52%, 60%, and 69%. The percentages of patients who underwent surveillance annually or more frequently in the latter 3 time periods, respectively, were 19%, 10%, and 5%, or 11% overall, treating the data for the 3 events as a whole. Over the period from 1986 to 1998, the proportion of patients who had no surveillance procedures gradually decreased, whereas the proportion of those who underwent procedures annually or more frequently remained relatively constant.

CONCLUSIONS

During the period from 1986 to 1998 there was low utilization of postdiagnosis colon surveillance in a substantial proportion of elderly patients with a diagnosis of local/regional colorectal cancer. Over time there was a trend toward increasing receipt of any surveillance procedures. The percentages of patients undergoing surveillance annually or more frequently did not change between earlier and later periods.

The effects of environmental tobacco smoke on children: Information and implications for PNPs

Although much information is available about the harmful effects of smoking and exposure to environmental tobacco smoke (ETS), many children are in contact with ETS in their home every day. Health effects related to ETS vary from minor nasal irritation to an increased susceptibility to sudden infant death syndrome. ETS can also cause future health problems as exposed children become adults. Assessment of ETS exposure is an essential component of a patient's health history, and parents should be educated about the harmful effects of ETS and how to protect young children from it. Strategies for prevention of ETS exposure must be pursued to ensure improved health outcomes for all children.

The burden of illness of cancer: economic cost and quality of life

Cancer is a major public health issue and represents a significant burden of disease. In this chapter, we analyze the main measures of burden of disease as relate to cancer. Specifically, we review incidence and mortality, years of life lost from cancer, and cancer prevalence. We also discuss the economic burden of cancer, including cost of illness, phase-specific and long-term costs, and indirect costs. We then examine the impact of cancer on health-related quality of life as measured in global terms (disability-adjusted life years and quality-adjusted life years) and using evaluation-oriented applications of health-related quality of life scales. Throughout, we note the relative strengths and weaknesses of the various approaches to measuring the burden of cancer as well as the methodologic challenges that persist in burden-of-illness research. We conclude with a discussion of the research agenda to improve our understanding of the burden of cancer and of illness more generally.

Parathyromatosis: a cause for recurrent hyperparathyroidism

OBJECTIVE

To report a case of parathyromatosis as a cause for recurrent hyperparathyroidism.

METHODS

We present the case history, laboratory results, operative interventions, and pathologic findings in a 36-year-old woman. Relevant reports from the literature are reviewed.

RESULTS

Our patient, who had been undergoing long-term hemodialysis because of renal failure, presented with secondary hyperparathyroidism and progressive bone pain. After an uneventful subtotal parathyroidectomy (removal of 3-1/2 glands), her symptoms resolved in conjunction with normalization of parathyroid hormone levels. Subsequently, however, recurrent hyperparathyroidism and severe bone pain necessitated second and third neck explorations, during which parathyromatosis was discovered. A total thyroidectomy was performed because of the bilateral nature of the disease. Postoperatively, the patient's bone pain resolved substantially, although her parathyroid hormone levels remained high.

CONCLUSION

Parathyromatosis is a rare cause of recurrent hyperparathyroidism after parathyroidectomy. It consists of hyperfunctioning parathyroid tissues scattered throughout the neck, due either to intraoperative tissue spillage and subsequent implantation or to hyperplasia of parathyroid rests from embryologic development. This is one of the few case reports of parathyromatosis and the first case report of a mixed form of the disease, consisting of features of both subcapsular parathyroid rests and extracapsular implantation.

Dynamic radioisotope bone imaging as a noninvasive indicator of canine tibial blood flow

The relative values of dynamic and static bone imaging with hydroxymethylenediphosphonate technetium 99m (99mTc HDP) as an indicator of bone blood flow was investigated in the tibia of mature dogs. The dynamic bone scan consisted of 60 1-s images formed after the intravenous injection of 99mTc HDP, and the static bone scan was a 45-min uptake image. Blood flow to the tibia was determined by using radioactively labeled microspheres. Studies were carried out in control dogs, in dogs in which blood flow was increased in one leg with ATP, and in dogs in which blood flow was decreased in one leg with norepinephrine. A significant (p less than 0.001) linear relationship between the dynamic scan values and bone blood flow was found at a wide range of blood flow rates. When blood flow increased by more than 50%, the effects of "diffusion limitation" were seen in the static scans: increase in tracer uptake was disproportionately small for a significant increase in blood flow. There is no method currently available for estimating bone blood flow by a noninvasive technique. The method described here may be useful for providing a semiquantitative measure of bone blood flow. This improved versatility of bone imaging may have a role in the management of osteomyelitis or complicated fractures, or in assessing the viability of vascularized bone grafts.

Design, synthesis, and evaluation of novel A2A adenosine receptor agonists

We have been interested in the design, synthesis, and evaluation of novel adenosine A2A agonists. Through the use of comparative molecular field analysis (CoMFA) we have generated a training model that includes 78 structurally diverse A2A agonists and correlated their affinity for isolated rat brain receptors with differences in their structural and electrostatic properties. We validated this model by predicting the activity of a test set that included 24 additional A2A agonists. Our CoMFA model, which incorporates the physiochemical property of dipole and selects against A1 receptor activity, generated a correlated final model (r2 = 0.891) that provides for enhanced A2A selectivity and predictability. Synthesis, pharmacological evaluation, and modeling of four novel ligands further validate the utility and predictive power (r2 = 0.626) of the CoMFA model.