Citations

Background— B-type natriuretic peptide (BNP) activation observed in cardiac diseases is a predictor of poor outcome; however, in organic mitral regurgitation (MR), BNP determinants and prognostic value are unknown. Methods and Results— We prospectively enrolled 124 patients with chronic organic MR (aged 63±15 years, 60% males) in whom we measured BNP level and simultaneously quantified MR degree, left ventricular (LV) remodeling, and left atrial (LA) volumes and analyzed long-term outcome. Baseline BNP level (54±67 pg/mL, median 31 pg/mL) was associated univariately with multiple clinical and echocardiographic characteristics, but in multivariate analysis, independent determinants of BNP, beyond age and sex (both P ≤0.01), were LV end-systolic volume index, LA volume, atrial fibrillation, and symptoms (all P <0.02). Conversely, MR degree was not independently associated with BNP. During follow-up, patients with high versus low BNP (≥31 versus <31 pg/mL) displayed lower survival rates (at 5 years, 72±10% versus 95±5%, P =0.03) and higher rates of the combined end point of death and heart failure (at 5 years, 42±10% versus 16±7%, P =0.03). In multivariate analysis, with adjustment for age, sex, functional class, MR severity, and ejection fraction, BNP was independently predictive of mortality (hazard ratio per 10 pg/mL, 1.23 [95% CI 1.07 to 1.48], P =0.004) and of death or heart failure (hazard ratio per 10 pg/mL, 1.09 [95% CI 1.001 to 1.19], P =0.04). Conclusions— BNP activation in organic MR reflects primarily ventricular and atrial consequences rather than degree of MR. Higher BNP level in patients with organic MR independently predicts adverse events under conservative management. Therefore, BNP activation in organic MR is an emerging biomarker of severity of MR consequences and of poor clinical outcome, and its assessment should be considered in the clinical evaluation and risk stratification of patients with MR.

AbstractWe have reviewed 108 cases of bacterial endocarditis treated surgically since 1968. The mean age of the patients was 47.7±15.6 years (± SD) (range, 14–79 yr). Seventy‐seven percent were male. The most common causative organisms were staphylococci (46%), streptococci viridans group (25%), and other streptococci (20%). Forty‐five percent, 25%, and 13% of patients had native aortic valve, native mitral valve, or native double valve (AV/MV) involvement, respectively. Eighteen patients had prosthetic valve endocarditis. No patient underwent surgery for tricuspid valve endocarditis. Seventy‐three patients were considered to have active endocarditis (AE) (positive blood or tissue cultures and/or annular abscesses). The 35 remaining patients had healed endocarditis (HE). Preoperative complications in patients with either AE or HE were stroke (11%, 11%), renal failure (33%, 3%;p<0.001), pulmonary edema (83%, 34%;p<0.001), anemia (36%, 8%;p<0.01), and inotrope dependence (22%, 6%;p<0.05). Hospital mortality for native valve AE was 19.6% (11/56), and for healed endocarditis, 5.7% (2/35). Independent predictors of hospital mortality were inotrope dependence (p<0.001), annular abscess (p<0.01), pulmonary edema (p<0.01), and staphylococcal infection (p<0.05). The 5‐year actuarial survival for operative survivors was 68.4±7.5% (AE) and 78.3±9.2% (HE). We conclude that the operative mortality for patients with continuing sepsis is high and that surgery should be undertaken early in staphylococcal endocarditis. If surgery is successful, then the long‐term prognosis is good.

AbstractThe experiences of 206 patients who underwent palliative operations for advanced gastric carcinoma have been reviewed to evaluate the effect of treatment. Gastroenterostomy for obstruction alleviates vomiting for most patients, but significant palliation followed operation in only 1/3 of cases. The procedure was accomplished with an acceptable mortality rate, and the average period of postoperative hospitalization was 13 days. The results of palliative partial gastrectomy for patients having obstructive symptoms preoperatively were only slightly better than those following gastroenterostomy. Approximately 1/3 of the patients lived in relative comfort for more than a year. The poor progress of 6 patients who received total gastrectomy supports the opinion that total gastrectomy is not a satisfactory palliative operation. Palliative esophagogastrectomy for patients with dysphagia gave results similar to, or possibly better than, palliative resections for distal lesions. Although the results following the use of prostheses for inoperable malignant stricturing of the esophagogastric junction were disappointing, the procedure had significant advantages when compared with the marked limitations and disadvantages of jejunostomy and the transient relief afforded by transesophageal dilatation. Review of the records of patients who had had a feeding jejunostomy confirmed the general opinion that this procedure seldom is indicated in the management of advanced gastric carcinoma.

AbstractOperation for gastric carcinoma should be undertaken in the presence of known or probable carcinoma of the stomach, in the absence of clear contraindications. These contraindications include serious disease elsewhere (such as cardiac insufficiency, advanced pulmonary disease, and pronounced renal failure), definite objective evidence of distant metastases, and evidence of local extension beyond the point of resectability. To deny a patient the potential benefits of exploratory laparotomy is to eliminate the chance of cure. After thorough exploration of the abdomen, curative resection of gastric cancer involves radical subtotal gastrectomy for lesions restricted to the distal 2/3 of the stomach, and total gastrectomy with splenectomy for lesions in the upper 1/3. When there is local extension of the cancer, resection of adjacent organs should be performed if it appears that the growth can be completely removed. When curative resection is not possible, palliative resection or gastroenterostomy is often indicated to relieve symptoms.

AbstractThree hundred and eighty‐four consecutive patients with primary hyperparathyroidism (HPT) were surgically treated at a single institution during the 2 year period 1983 through 1984. Two patients were found to have benign familial hypocalciuric hypercalcemia and a single patient had parathyroid carcinoma. In the remaining 379 patients, the cure rate was 99.5%, the operative mortality 0.3%, persistent vocal cord paralysis 0.8%, and permanent hypocalcemia 0.3%. This data supports a liberal policy regarding cervical exploration in patients with HPT and questions any policy of observation without surgical intervention.

AbstractWith few exceptions, proctocolectomy is the treatment of choice for patients with chronic ulcerative colitis. The method by which patients are offered control of bowel function postoperatively, however, is more controversial. Traditionally, proctocolectomy is accompanied by a conventional Brooke ileostomy and control of enteric effluent provided by an external appliance. Today, several alternatives are available, such as Kock's continent ileostomy and the ileoanal anastomosis. The results of both are generally good. The functional outcome of these procedures is, however, not always uniform and not all patients are candidates for such alternatives. Conventional ileostomy, therefore, remains the standard surgical approach; Brooke ileostomy is the one procedure which is applicable to any patient regardless of age, body habitus, type of disease, or other medical problems. It is the aim of this article to summarize important principles of surgical technique and of stomal care, to detail the functional results and physiologic consequences of standard ileostomy, and to document the impact of ileostomy on quality of life. Finally, the current and future role of ileostomy in the era of surgical alternatives will be discussed.

AbstractAn account is given of the evolution of proctocolectomy with construction of a pelvic ileal pouch and an ileoanal anastomosis, which has probably become the most popular elective operation at the present time for ulcerative colitis. The technique favored by the author for this procedure is described and the results obtained in 422 cases at the Mayo Clinic are analyzed, with 188 of them analyzed in detail. Outstanding issues regarding technical methods and outcome are discussed.