Early Death Group Research Articles

Acute myocardial infarction due to left main coronary artery occlusion. Therapeutic strategy.

Acute myocardial infarction due to left main coronary artery occlusion remains catastrophic and mostly fatal due to severe cardiogenic shock and arrhythmia. We studied 13 patients undergoing coronary artery bypass grafting for acute myocardial infarction due to left main coronary artery occlusion to clarify the optimal management of these difficult patients. In-hospital mortality was 46.2% (6/13). Revascularization was achieved by catheter intervention followed by bypass surgery in 7, and bypass surgery alone in 6. Two bypass surgery patients without catheter intervention had collateral flow to the left coronary artery, with the right coronary artery dominant. The time from onset to recanalization in the survival group was significantly shorter than in the early death group. Emergency intervention to preserve left ventricular function or right coronary artery dominant and collateral blood flow to left coronary arteries is important for improving the prognosis of patients with acute myocardial infarction due to left main coronary artery occlusion. If residual left main coronary artery stenosis is significant or other proximal coronary stenosis exists after catheter intervention, early coronary bypass surgery may improve long-term survival.

Importance of blood pressure control in hemodialysis patient survival

Importance of blood pressure control in hemodialysis patient survival.BackgroundIn the general population, hypertension is the leading cause of cardiovascular mortality. In dialysis patients, however, the relationship between blood pressure (BP) and mortality is controversial. We analyzed this relationship in hemodialysis (HD) patients.MethodsThe study population included 405 patients who had survived at least two years on HD. The observation period was initiated at the beginning of the third year. Predialysis BP measurements of all the dialysis treatments performed during the second year of HD was collected as the baseline data. Mean systolic BP (SBP) and mean diastolic BP (DBP) were calculated. Demographic and comorbidity data were collected at the start of the observation period (beginning of third year of HD). Mortality was analyzed at the end of the follow-up (death or December 31, 1998; total mortality), during the first two years of follow-up (years 3 and 4 of HD; early mortality) and after the second year of follow-up (≥5 years of HD; late mortality).ResultsIn the multivariate analysis, SBP and DBP were significantly associated with death. The adjusted total mortalities were U shaped. When early mortality was analyzed, only low BP (DBP <74.5 mm Hg) was significantly associated with mortality. When late mortality was analyzed, only high BP (SBP> 160 mm Hg) was significantly associated with mortality. In the early deaths, a cardiac cause was significantly less frequent, while withdrawal and malignancy were more frequent than in late deaths.ConclusionsThis study confirms that hypertension is a risk factor for mortality in HD patients, and shows the importance of the length of the follow-up time to demonstrate this relationship. The low frequency of a cardiac cause in the early death group suggests that the association between hypotension and mortality in HD patients is not related to cardiovascular causes, and only reflects the association between hypotension and other severe medical conditions. Importance of blood pressure control in hemodialysis patient survival. In the general population, hypertension is the leading cause of cardiovascular mortality. In dialysis patients, however, the relationship between blood pressure (BP) and mortality is controversial. We analyzed this relationship in hemodialysis (HD) patients. The study population included 405 patients who had survived at least two years on HD. The observation period was initiated at the beginning of the third year. Predialysis BP measurements of all the dialysis treatments performed during the second year of HD was collected as the baseline data. Mean systolic BP (SBP) and mean diastolic BP (DBP) were calculated. Demographic and comorbidity data were collected at the start of the observation period (beginning of third year of HD). Mortality was analyzed at the end of the follow-up (death or December 31, 1998; total mortality), during the first two years of follow-up (years 3 and 4 of HD; early mortality) and after the second year of follow-up (≥5 years of HD; late mortality). In the multivariate analysis, SBP and DBP were significantly associated with death. The adjusted total mortalities were U shaped. When early mortality was analyzed, only low BP (DBP <74.5 mm Hg) was significantly associated with mortality. When late mortality was analyzed, only high BP (SBP> 160 mm Hg) was significantly associated with mortality. In the early deaths, a cardiac cause was significantly less frequent, while withdrawal and malignancy were more frequent than in late deaths. This study confirms that hypertension is a risk factor for mortality in HD patients, and shows the importance of the length of the follow-up time to demonstrate this relationship. The low frequency of a cardiac cause in the early death group suggests that the association between hypotension and mortality in HD patients is not related to cardiovascular causes, and only reflects the association between hypotension and other severe medical conditions.

Importance of blood pressure control in hemodialysis patient survival

In the general population, hypertension is the leading cause of cardiovascular mortality. In dialysis patients, however, the relationship between blood pressure (BP) and mortality is controversial. We analyzed this relationship in hemodialysis (HD) patients. The study population included 405 patients who had survived at least two years on HD. The observation period was initiated at the beginning of the third year. Predialysis BP measurements of all the dialysis treatments performed during the second year of HD was collected as the baseline data. Mean systolic BP (SBP) and mean diastolic BP (DBP) were calculated. Demographic and comorbidity data were collected at the start of the observation period (beginning of third year of HD). Mortality was analyzed at the end of the follow-up (death or December 31, 1998; total mortality), during the first two years of follow-up (years 3 and 4 of HD; early mortality) and after the second year of follow-up (> or = 5 years of HD; late mortality). In the multivariate analysis, SBP and DBP were significantly associated with death. The adjusted total mortalities were U shaped. When early mortality was analyzed, only low BP (DBP <74.5 mm Hg) was significantly associated with mortality. When late mortality was analyzed, only high BP (SBP> 160 mm Hg) was significantly associated with mortality. In the early deaths, a cardiac cause was significantly less frequent, while withdrawal and malignancy were more frequent than in late deaths. This study confirms that hypertension is a risk factor for mortality in HD patients, and shows the importance of the length of the follow-up time to demonstrate this relationship. The low frequency of a cardiac cause in the early death group suggests that the association between hypotension and mortality in HD patients is not related to cardiovascular causes, and only reflects the association between hypotension and other severe medical conditions.

Baseline variables associated with early death and extended survival on dialysis

Patients who die during the first three months on dialysis are not systematically included in the American and European statistics. In contrast, only a few patients survive more than 10 years on this modality of renal replacement therapy. The factors determining these two extreme forms of outcome are poorly understood. We tested the hypothesis that a few variables, easily obtainable at the initiation of dialysis, would identify those individuals at high and low risk of early death. We retrospectively studied 23 patients who died within 90 days of initiating dialysis and 20 patients who survived more than 10 years. These patients were admitted for dialysis to a Brazilian center between July 1, 1976 and February 28, 1997. The baseline variables assessed which were thought to influence survival, were: age, sex, race, body weight, etiology of renal disease, blood pressure, comorbid conditions, hematocrit and serum electrolytes, albumin, creatinine, urea, and urea/creatinine ratio. Univariate analysis showed that patients who died early were older (56.2 ± 15.6 vs. 42.1 ± 10.4 years, p < 0.01), had lower serum creatinine (10.6 ± 2.9 vs. 13.7 ± 3.7 mg/dL, p < 0.01) and albumin (3.3 ± 0.9 vs. 4.0 ± 0.5 g/dL) and a higher urea/creatinine ratio (18.4 ± 5.8 vs. 13.5 ± 4.8, p < 0.01) compared with subjects surviving more than 10 years. Early death patients also had more cases of diabetes (35% vs. 0%, p < 0.01) and less chronic glomerulonephritis (9% vs. 35%, p < 0.05). Multivariate analysis showed that age (p < 0.01, CI 1.02 to 1.15, odds ratio 1.1) and urea/creatinine ratio (p < 0.01, CI 1.03 to 1.38, odds ratio 1.2) were positively and independently related to outcome. In the early death group, malnutrition was an important cause of death (17% of all deaths). Compared to baseline data, long-term survivors, at the last follow up, presented reduced systolic blood pressure and increased hematocrit and unchanged body weight, serum albumin and urea/creatinine ratio. These results, based on easily accessible initial variables, suggest that early death on dialysis is influenced by age and by indices related to the nutritional condition of the patients. They also highlight the importance of a potentially correctable risk factor in a population with an elevated prevalence of premature death.

Relation between perinatal factors and outcome of very low birth weight infants.

In order to better understand the effect of obstetric management on the prognosis of very low birth weight (VLBW) fetuses, we retrospectively studied perinatal factors and the outcome of two hundred twenty-eight VLBW infants without major anomaly excluding cases of multiple pregnancy. The frequency of malpresentation were significantly high in the early neonatal death group (p < 0.05) and in the cerebral palsy/mental retardation (CP/MR) group (p < 0.01). A stepwise regression analysis for the CP/MR detected dependent variables as malpresentation, use of tocolytic agents (beta(2)-stimulant plus MgSO4) and pH < 7.20 in cord artery. Delivery method was not a dependent variable for the early neonatal death or the CP/MR. We analyzed a relation between fetal presentation-delivery method, and the prognosis. Among four groups (cephalic-vaginal, cephalic-cesarean, breech-vaginal, breech-cesarean), the cephalic-vaginal group had the lowest incidence of the poor prognosis (death and major handicap) where the breech-vaginal had the highest incidence. Breech groups (vaginal plus cesarean) had significantly high incidence of the poor prognosis when compared with that of cephalic groups (vaginal plus cesarean) (p < 0.05). Significant difference of the prognosis between the cephalic-vaginal group and the cephalic-cesarean group was not observed. These findings suggest that the delivery method is not a risk factor, but the malpresentation itself may be a risk factor for the poor prognosis of VLBW infants.

Early postoperative change of plasma levels of amino acids in neonates with perforative peritonitis and its prognostic significance

As a possible prognostic index, plasma levels of amino acids were serially measured for 1 week in 22 neonates with perforative peritonitis including gastric rupture and necrotizing enterocolitis and 28 neonatal surgical patients without infection as a control, who were subjected to total parenteral nutrition with hypertonic glucose and amino acids formulated for neonates. Plasma levels of branched chain amino acids significantly increased on the first day after operation in peritonitis group, whereas plasma levels of phenylalanine and histidine increased on the third postoperative day and tyrosine increased seventh postoperative day. In the peritonitis group, 5 neonates died within 2 weeks after operation (early death group) because of cardiopulmonary failure and 5 neonates died with hyperbilirubinemia from 1 month to 6 months after operation (late death group). The early death group showed increased levels of total amino acids compared with those in the late death group and survivors. The late death group also showed higher levels of total amino acids than survivors. Plasma levels of tyrosine increased in the early and late death groups compared with survivors. These results indicated that serial measurements of plasma amino acids early after operation showed the existence of liver dysfunction in addition to the derangement of amino acid metabolism in the liver and muscle caused by septic insult, which predicted the prognosis of perforative peritonitis in neonates.

Disseminated intravascular coagulation (DIC) and pre-DIC due to severe infection in the elderly

Because of pre-thrombotic state frequently present in the elderly, sepsis easily progresses to pre-DIC and DIC, sometimes with a fatal outcome. We assessed 31 elderly patients who developed pre-DIC and DIC due to severe infection. They were divided into two groups, early death group: 14 elderly patients with poor prognosis died within 14 days, and long survival group: 17 patients with good prognosis lived 15 days or more. Controls consisted of 31 elderly thrombotic disease cases and 25 healthy elderly cases. The DIC score was significantly higher in the early death group than in the long survival group, and there was a correlation between DIC score and survival. Moreover, many of the early death group were long-termed bed-ridden patients, serum BUN and Cre levels were significantly increased in the early death group compared to the long survival group. While plasma TAT, PIC and D-dimer levels were increased in thrombotic disease group compared to the healthy control group, TAT and D-dimer were also increased in the pre-DIC and DIC state than in the thrombotic state. In the early death group, D-dimer was higher than in the long survival group. We suggest that early diagnosis by molecular marker is important in the DIC stage, and a high D-dimer level may be a poor prognostic factor.

食道癌５年以上生存例の検討

Fifteen patients who survived for at least 5 years (long-term survivor group) and 24 patients who died of recurrence within 5 years after surgery (early death group) of the esophageal cancer in our department during the period 1964 and August 1984 were examined. We compared age, sex, location of lesion, X-ray type, longitudinal diameter of tumor, depth of invasion, lymph node metastasis, histological stage, blood vessel invasion, lymphatic invasion, therapeutic effect of preoperative radiation, and presence or absence of postoperative adjuvant therapy of two groups in order to study the factors affecting the postoperative prognosis of esophageal cancer. The results were as follows: 1) The incidence of lymph node metastasis in the long-term survivor group was lower (P=0. 003) than in the early death group and the number of patients in whom preoperative radiation was therapeutically effective was greater (P=0. 040) in the long-term survivor group than in the early death group. 2) The number of female patients was higher in the long-term survivor group, and the number of patients without blood vessel invasion, v (-), tended to be greater in the long-term survivor group. 3) There were 8 patients who survived for more than 10 years among the 15 long-term survivors, and longest survival period was 21 years. 4) Cumulative survival rate of 5 and 10 years were 37. 8% and 31. 0%, respectively, for 38 patients with curative resection.

Restoration of ATP contents in the transplanted liver closely relates to graft viability in dogs.

Searching for a marker of graft viability, adenosine triphosphate (ATP) content in the graft tissue was measured sequentially during orthotopic liver transplantation (OLT) in 24 adult mongrel dogs. According to the survival period, 12 recipients were divided into two groups: group I - early-death group (n = 6), death within 3 days after OLT and group II - survival group (n = 6), survived more than 7 days after OLT (average 12 days). Serum biochemical findings showed no differences between the two groups except that the prothrombin time on the first postoperative day in group I was significantly longer (p less than 0.05). The ATP content ratio (% of initial value) was significantly higher in group II, compared to that of group I (p less than 0.05), 94 versus 53% at 10 min after perfusion, 31 versus 17% at just before recirculation, respectively. The ATP content ratio recovered significantly to more than 80% at 10 min after recirculation in group II but only to less than 50% in group I. These results suggest that restoration of ATP content in the liver after graft recirculation reflects the viability of the graft and can serve as an appropriate prognostic marker in cases of OLT.

Significance of cardiac weight in patients having coronary artery bypass grafting for angina pectoris

Cardiac weight at necropsy in 211 patients who had coronary artery bypass grafting (CABG) for angina pectoris, and its relation to early (<60 days) and late (>60 days) death after CABG was sought. The 121 patients dying early had a lower mean heart weight than did the 90 patients dying late (444 ± 94 vs 498 ± 107 g; p :0.001). The mean heart weight of the 85 men dying early was less than that of the 75 men dying late (472 vs 506 g; p <0.05), and the mean heart weight of the 36 women dying early was less than that of the 15 women dying late (377 vs 459 g; p <0.005). Most patients with hearts of normal weight were in the early death group: of the 17 women with hearts of normal weight (⩽350 g), 16 (94%) died early (p <0.01), and of the 34 men with hearts of normal weight (⩽400 g), 21 (62%) died early (difference not significant). Conversely, most patients in the late death group had hearts of increased weight: of the 15 women dying late, 14 (93%) had hearts of increased weight, and of the 75 men dying late, 62 (83%) had hearts of increased weight. The mean cardiac weight of the 125 patients with left ventricular scars was larger than that of the 86 patients without scars (492 vs 432 g; p <0.01), and these differences were observed within each sex and in both early (463 vs 425 g) and late (520 vs 448 g) death groups. This study suggests that patients with normal or near normal sized hearts have a higher early mortality after CABG than do persons with hearts of increased weight.

Surgical repair of acquired ventricular septal defect: Determinants of early and late outcome

Between January 1970 and June 1985, 60 patients underwent surgical repair of postinfarction ventricular septal defect. The preoperative cineangiograms of all patients were reviewed to measure left ventricular ejection fraction and to quantitatively assess right ventricular function by measuring the percentage reduction in right ventricular midcavity diameter. There were 23 early deaths (within 30 days) and 14 late deaths occurring between 1 and 92 months after operation. Of the 23 long-term survivors, 87% are in New York Heart Association Class I or II. The early mortality was significantly higher for inferior infarction (58%) than for anterior infarction (25%). Early mortality was also influenced by the time interval between infarction and operation (under 1 week 41%, over 4 weeks 22%). Early survival was favored by good preoperative right ventricular function; the percentage reduction in right ventricular midcavity diameter was 16.5% +/- 9.5% (mean +/- standard deviation) for the early death group and 26.7% +/- 10.6% for the early survival group. However, the early outcome was not influenced by left ventricular function before operation. Conversely, long-term survival was favored by preserved preoperative left ventricular function; left ventricular ejection fraction was 26.2% +/- 9.3% for the late death group and 35% +/- 8.5% for the late survival group. Long-term survival was not, however, affected by right ventricular function before operation. The results of surgical closure of postinfarction ventricular septal defect have improved between two successive time frames in this series, which is the largest to date.

Prediction of early death after therapeutic hepatic arterial embolisation.

A consecutive series of 14 patients with hepatic malignant disease treated by palliative hepatic arterial embolisation was reviewed. Twelve patients had hepatic pain from their tumour and two were suffering from the carcinoid syndrome. Six patients died within four weeks of the procedure (group 1) and eight survived for at least 10 weeks (group 2). Factors were sought that might permit prediction of a high risk of early death (group 1). The pre-embolisation angiograms reviewed by a "blind" observer showed no differences in vascularity or tumour size between the groups and no difference in the extent of arterial occlusion after embolisation. The portal vein was patent in all patients. No significant difference was seen between the groups in the pre-embolisation biochemical values, with the exception of lower serum albumin concentrations and higher alkaline phosphatase activities in group 1. All those who died early had serum alkaline phosphatase activities of 45 KAU or above, while six of the eight who survived longer had activities below this value (p less than 0.02). These findings suggest that serum alkaline phosphatase activity of 45 KAU or more (normal range 3-13) might alone be a useful predictor of early death. Stepwise discriminant analysis using a weighted combination of serum alkaline phosphatase activity and albumin concentration predicted the outcome in all but one of the patients studied (p less than 0.002).

Irreversible morphological changes contributing to depressed cardiac function after surgery for chronic aortic regurgitation.

The timing of surgery in chronic aortic regurgitation remains a difficult problem. To identify variables predictive of postoperative haemodynamic improvement, changes in left ventricular mass, volume, morphology, and histochemistry were analysed in 67 patients undergoing surgery for chronic aortic regurgitation. Patients were divided into two groups: those in whom the left ventricular echo diameters returned to normal after operation (51 patients, group A), and those with postoperative dilatation (16 patients, group B). A preoperative biopsy was obtained in all patients; postoperative tissue samples were available in 13 patients (five from group A, eight from group B). Data were correlated with the postoperative clinical, haemodynamic state over a follow-up period of three years. Regression of hypertrophy was usually incomplete. Echocardiographic and angiographic data could not define the type and degree of dysfunction which was irreversible. Massive fibre hypertrophy (mean 34.1 micrometers), moderately or severely increased interstitial fibrous tissue, reduced levels of the myofibrillar and mitochondrial enzymes adenosine triphosphates and succinate dehydrogenase in pre- and post-operative tissue samples correlated with persistent dilation, cardiac failure, and early death (group B). Irreversible morphological and functional changes contributed to a depressed cardiac function after operation. Preoperative ventricular biopsies are thus of prognostic importance in volume overload.

Late results after repair of tetralogy of Fallot

Three hundred eleven patients up to 17 years of age underwent repair of tetralogy of Fallot from 1964 through 1970. Age of early death group versus early survivor group was 6.1 versus 7.5 years (p = 0.03), and the right ventricular–to–left ventricular (RVILV) pressure ratio was higher for the early death group—0.663 versus 0.569 (p < 0.01). Use of an outflow tract patch was associated with only a minimally higher early mortality rate (p = 0.07). Of early survivors, late results were ideal in 80 per cent, fair in 10 per cent, and poor in 3 per cent; the late mortality rate was 4 per cent. Five per cent had residual hemodynamic defects. The mean cardiothoracic (CT) ratio was 0.485 for the group with ideal results and 0.567 for those with poor results. The RV/LV pressure ratio after repair was considerably higher in the group with poor results (0.74 versus 0.56). These studies give support for (1) the need to achieve as complete a repair of pulmonary stenosis as possible, even if pulmonary insufficiency results and an outflow tract patch is required, and (2) continued avoidance of the insertion of a substitute pulmonary valve during repair of tetralogy in the typical patient until the long-term fate of such valves is known.