Green Lane Research Articles

Allergic Bronchopulmonary Aspergillosis in the Asthma Clinic: A Prospective Evaluation of CT in the Diagnostic Algorithm

Allergic bronchopulmonary aspergillosis (ABPA) occurs in cases of atopic asthma and may result in important lung disease. Early diagnosis is essential as this disease is responsive to steroids. However, while asthma is common, ABPA is infrequently diagnosed. CT allows precision in the diagnosis of central bronchiectasis (which is virtually pathognomonic of ABPA) and may enable earlier diagnosis. A prospective evaluation of 255 patients with asthma for ABPA, using skin prick testing (SPT) for Aspergillus fumigatus (AF) as a screening tool and incorporating CT into the diagnostic algorithm. Asthma clinic, Green Lane Hospital, Auckland, New Zealand. Patients with asthma. ABPA was diagnosed using "essential" criteria (ie, asthma, SPT positivity to AF, elevated serum total IgE, elevated serum AF-specific IgE, and pulmonary infiltrates seen on chest radiography or central bronchiectasis seen on CT scan) and "minimal essential" criteria (ie, asthma, SPT positivity, and central bronchiectasis). Two hundred fifty-five consecutive patients with asthma who consented to SPT were studied: 218 of 255 patients (86.8%) were atopic; and 47 of 255 patients (21.6%) were AF-positive, of whom 35 accepted further evaluation including CT scanning. A secure diagnosis of ABPA, satisfying all essential criteria, was evident in 9 of 35 patients (25.7%), a proportion that increased to 13 of 35 patients (37.1%) by using the minimal essential diagnostic criteria. SPT positivity to AF was present in approximately 20% of patients in the asthma clinic. A diagnosis of ABPA is disclosed by CT in 25 to 40% of SPT-positive patients, depending on the selection of diagnostic criteria. These findings support the use of SPT as a screening tool in the asthma clinic and indicate that a routine CT scan is warranted in SPT-positive patients.

Physical and Pharmacological Neuroprotection in Cardiac Surgery

Stroke and neurocognitive deficits may follow cardiac surgery and have been linked to perioperative cerebral embolism. Alteration of cardiopulmonary bypass (CPB) or surgical technique to reduce embolism is, therefore, a rational neuroprotective strategy. Pharmacological cerebral protection has been advocated as an ideal "back-stop" to such "physical" interventions. A series of relevant studies conducted at Green Lane Hospital, Auckland, New Zeatand is described. Doppler ultra sound was used to monitor cerebral embolism during left heart valve surgery. Subsequently, salvaged CPB circuits were used to investigate several unexpected sources of emboli. The efficacy of a novel left heart deairing technique was audited using the Doppler de vice. Finally, a randomized double-blind trial of lidocaine in cerebral protection during cardiac surgery was con ducted. Most cerebral emboli were recorded after aortic declamping. However, cerebral emboli counts increased during stable CPB when the hard shell venous reservoir (HSVR) was operated at lower blood volumes and when air was seen in the venous return line. In vitro 2 HSVRs were found to generate bubbles when operated at blood volumes in excess of the manufacturer's recom mended minimum. Air in the venous return line was found to readily transit the CPB circuit and vacuum- assisted venous drainage markedly exacerbated this phenomenon. The novel deairing technique was mark edly superiorto conventional methods. Lidocaine admin istered in a standard antiarrhythmic dose for 48 hours from induction of anesthesia reduced the incidence of neuropsychological deficits at 10 days and 10 weeks postoperatively.

Linear features and butterflies: the importance of green lanes

Green lanes are unmetalled tracks between fields of variable width, which may be sunk below or raised above field level, and bounded on both sides by ‘grass’ banks, hedgerows or dry-stone walls. In the UK they have no unique planning status and have been overlooked as discrete landscape elements. Green lanes were surveyed for butterflies in 1997 on lowland arable farmland on the Trafford/north Cheshire border (Warburton) and on upland grassland in the Yorkshire Dales (Ribble Valley). At the lowland site the green lanes were bounded by vegetation and were compared with grass banks and single hedgerow field boundaries; at the upland farm, the green lanes were bounded by dry-stone walls and were compared with grass banks and single dry-stone walls. Data from earlier work on a largely arable farm (Manydown) in Hampshire in 1987 and 1988 were re-analysed to make comparisons between a green lane, the rides and glades of two coppiced woodlands, and the grass banks and single hedgerows surrounding arable fields. Green lanes, whether bounded by vegetation or stone were superior to other common farmland biotopes with the exception of woodland, in terms of both butterfly abundance and species richness. Multiple regression of the Warburton data indicated the importance of green lanes, adjacent habitat type, and nectar sources for species richness and butterfly abundance. The interior of green lanes had lower windspeeds, and more bramble nectar sources than hedgerows or grass banks. By their nature they occupy a larger area of uncropped land, and are subject to a reduced disturbance regime and reduced inputs of agrochemicals and fertilisers. Their value as biodiversity reservoirs in intensively managed land is likely to be high.

Cardiac surgery in octogenarians--The Green Lane Hospital Experience 1995-1998.

An increasing number of patients aged 80 years and over are being considered and accepted for cardiac surgery. To review the experience of surgery in this elderly group of patients at our institution. Hospital records of octogenarians undergoing surgery between January 1995 and September 1998 were reviewed and follow-up was obtained by general practitioner (GP) and patient questionnaires. Thirty-seven patients underwent cardiac surgery. The mean age was 82.8+/-1.4 years (range 80.8 to 86.2 years). Twenty-three (62%) were male. All were independent pre-operatively with severe symptoms and minor co-existing morbidity. All operations were urgent except two (emergency). Twenty patients (54%) had isolated coronary surgery, six (16%) aortic valve replacement alone, and 11 (30%) combined surgery. There were four (11%) early deaths and five (14%) peri-operative neurological events. The mean duration of post-operative intensive care stay was 2.4+/-3.9 days (range 0.05 to 16, median 1.0) and post-operative hospital stay 14.0+/-13.9 days (range 0 to 79, median 11). At the time of follow-up (mean duration 20.0+/-11.2 months) two further patients had died (non-cardiac). Twenty-six of the 31 survivors were living at home (23 independently), one with relatives, and four in residential care. Their cardiac symptoms were well controlled. The GPs of all hospital survivors, and all surviving patients themselves, felt that cardiac surgery had been beneficial. Cardiac surgery in the very elderly has been reserved for those with severe disease or symptoms and little co-morbidity. Early mortality is higher than for the general population undergoing cardiac surgery, but post-operative resource use is acceptable and the intermediate-term outcome for survivors is good.

Postimplantation leaflet cellularity of valve allografts: are donor cells beneficial or detrimental?

Background. The theory that “viable” valve grafts have superior durability because the donor cell population of the leaflets survives implantation and functions normally, thus maintaining leaflet integrity, is still not definitively proven. The postulate has been investigated for grafts produced and used at Green Lane Hospital by examining a series of 155 removed at reoperation following up to 21.3 years of implantation. Methods. Leaflet cellularity at explantation was assessed histologically. An additional 55 cases were also assessed by tissue culture. Cell origin for six positive cultures was determined by comparison of DNA of the culture with that of the recipient’s blood cells. Results. Grafts known to be nonviable at implantation lacked leaflet fibroblasts but sometimes showed ongrowth of fibrous tissue derived from the recipient’s aorta. Grafts potentially viable at implantation showed three main patterns of fibroblastic growth: (1) relatively sparse, scattered cells; (2) focal hyperplastic growth with intervening acellular tissue that was prone to rupture; and (3) widely disseminated, vigorous growth causing abnormal thickening. The first pattern was associated with recipient cells, and both the second and third patterns were associated with nonrecipient cells. Conclusions. Donor cells surviving implantation do not maintain a normal leaflet architecture and may lead to failure by producing loss of leaflet flexibility.

Long lesion length assessment

Catheterization and Cardiovascular DiagnosisVolume 45, Issue 3 p. 299-300 Pearls Long lesion length assessment S. R. Dixon BHB, MBCHB, Corresponding Author S. R. Dixon BHB, MBCHB SDixon@ahsl.co.nz Department of Cardiology, Green Lane Hospital, Auckland, New ZealandDepartment of Cardiology, Green Lane Hospital, Green Lane West, Auckland 1003, New ZealandSearch for more papers by this authorJ. A. Ormiston MBCHB, FRACP, FRACR, J. A. Ormiston MBCHB, FRACP, FRACR Department of Cardiology, Green Lane Hospital, Auckland, New ZealandSearch for more papers by this authorM. W. I. Webster MBCHB, FRACP, M. W. I. Webster MBCHB, FRACP Department of Cardiology, Green Lane Hospital, Auckland, New ZealandSearch for more papers by this author S. R. Dixon BHB, MBCHB, Corresponding Author S. R. Dixon BHB, MBCHB SDixon@ahsl.co.nz Department of Cardiology, Green Lane Hospital, Auckland, New ZealandDepartment of Cardiology, Green Lane Hospital, Green Lane West, Auckland 1003, New ZealandSearch for more papers by this authorJ. A. Ormiston MBCHB, FRACP, FRACR, J. A. Ormiston MBCHB, FRACP, FRACR Department of Cardiology, Green Lane Hospital, Auckland, New ZealandSearch for more papers by this authorM. W. I. Webster MBCHB, FRACP, M. W. I. Webster MBCHB, FRACP Department of Cardiology, Green Lane Hospital, Auckland, New ZealandSearch for more papers by this author First published: 12 December 1998 https://doi.org/10.1002/(SICI)1097-0304(199811)45:3<299::AID-CCD17>3.0.CO;2-4Citations: 1AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume45, Issue3November 1998Pages 299-300 SCAI Member Sign in RelatedInformation

Apolipoprotein(a) phenotypes as genetic markers of coronary atherosclerosis severity

We investigated Lp(a) levels and apo(a) polymorphism in relation to the severity of coronary artery disease, expressed both by the number of coronary arteries stenosed and three different coronary scoring systems. In a sample of 267 patients with coronary artery disease, a Mono-, Bi- or Multi-vessel coronary stenosis was documented by angiography. Twenty-five apo(a) isoforms were detected by a high resolution phenotyping method. Lp(a) levels did not show any differences among subgroups of patients. Both the percentage of apo(a) isoforms of low molecular weight (<655 kDa) ( P=0.00015) and the percentage of subjects with at least one apo(a) isoform of low molecular weight ( P=0.00027) were significantly correlated with increasing number of coronary vessels stenosed. In multivariate analysis, only apo(a) isoforms of low molecular weight were predictors of coronary atherosclerosis severity, when we used as the dependent variable both the `1-2-multi-vessels' categorization ( P=0.000067) and the Gensini ( P=0.008767), or Green Lane ( P=0.000001) or Dahlen ( P=0.000102) coronary scoring system. Our data show that apo(a) isoforms of low molecular weight are associated with a greater severity of coronary atherosclerosis. If these data are confirmed by prospective studies, apo(a) phenotypes might be used as genetic markers of a greater severity of coronary atherosclerotic lesions.

Plunging ranula: Clinical observations

The plunging ranula is a relatively uncommon phenomenon which represents a mucus escape reaction occurring from disruption of the sublingual salivary gland. We present a series of 20 patients managed at Green Lane Hospital (Auckland, New Zealand) over a 9-year period. A retrospective review of 13 patients with this condition was undertaken, and a prospective study was conducted on 7 patients. Information was collected on age, sex, ethnic origin, history of onset, predisposing factors, treatment, and outcome of treatment. The patients were all young adults with a median age of 31 years. The sex distribution was relatively equal, with 11 men and 9 women. All patients were Maori or Pacific Island Polynesians. Six patients gave a clear history of preceding trauma to the neck or oral cavity. Two recurrences were seen, both in patients who had had the sublingual gland excised via a cervical approach. Five patients sustained lingual nerve damage during surgery. Full function recovered in four patients, but the complication was still present in the fifth patient at 2 years, after which he was lost to follow-up. Plunging ranulas appear to occur with greater incidence in the Maori and Pacific Island Polynesian populations. The precise etiology of their predisposition is unknown, although local trauma or inherent mylohyoid dehiscences may play important roles. Removal of the sublingual gland via either a cervical or intraoral approach is important in the management of this condition. Excision of the pseudocyst is probably unnecessary and places surrounding structures at risk of damage, but a biopsy of the pseudocyst wall is important to confirm the diagnosis.

Surgical correction of hypertrophic obstructive cardiomyopathy: seventeen-year Green Lane experience.

Between 1977 and 1994, 42 patients were treated surgically for hypertrophic obstructive cardiomyopathy (HOCM). Patients have been followed up between 2 months to 17 years, mean of 107 months. There were 26 (62%) males and 16 (38%) females. There was only one pediatric case. There was no correlating factor among the ethnic groups (Maori, European, Indian, Asian, etc.). Family history was noted in 12% of the cases. Seventy-one percent of patients had aortic/left ventricular (LV) combined approach while 29% had aortic approach alone at the time of surgery. Five patients underwent other procedures, along with coronary artery bypass grafting in 3, mitral valve replacement in 1, and aortic valve replacement in 1. Persistent postoperative arrhythmias were found in 7 cases, atrial fibrillation (AF) in 3, and left bundle branch block in 4.

Coronary revascularisation in young adults.

To evaluate the long-term outcome of coronary artery bypass surgery (CABG) in patients < 40 years old and to determine factors predictive of adverse outcomes. Retrospective review of data on 220 patients who underwent isolated CABG at Green Lane Hospital, New Zealand from 1970 to 1992. The actuarial survival after surgery was 91, 74 and 50% at 5, 10 and 15 years, respectively. Recurrence of ischaemic symptoms occurred at a median time of 72 months, and only 20% of patients remained asymptomatic 10 years after CABG. Univariate analysis of potentially adverse surgical factors showed that patients who had prolonged bypass time (> or = 100 min, P < 0.007) had increased late mortality. There were two distinct operative eras with respect to the use of IMA conduits (4% pre 1985, 87% post 1984) The relationship between IMA conduits use and survival was significant on time independent analysis (P < 0.02), but was not using the log-rank test. Preoperative clinical characteristics associated with increased late mortality were impaired left ventricular function (end-systolic volume (ESV) > or = 80 ml, P = 0.008; ejection fraction < 40%, P = 0.0005), and lack of aspirin use either pre- or post-operatively (P < 0.0001). Multivariate analysis indicated that reduced ejection fraction (P = 0.04) and prolonged bypass time (P = 0.05) was associated with an increased risk of late death. Aspirin therapy (P = 0.001) was associated with decreased late mortality. Cumulative events rate of reintervention and mortality was reduced in female patients (P = 0.0009). At review, 45% of patients had total cholesterol > 6.5 mmol/l. To avoid the early recurrence of symptoms, the need for reintervention and late mortality, young patients should receive IMA conduits, cardioplegia as myocardial protection, aspirin and therapy to modify/ameliorate their risk factors including dyslipidaemia, diabetes and left ventricular dysfunction.

Tirofiban: a breakthrough in treating unstable angina

Adding the glycoprotein IIb/IIIa receptor antagonist tirofiban # to standard treatment for patients with unstable angina pectoris and non-Q-wave myocardial infarction (MI) can significantly reduce ischaemic complications, note researchers from the PRISM * and PRISM-plus * studies. The results of these studies were presented at the 46th Annual Scientific Sessions of the American College of Cardiology [ Anaheim, US; March 1997 ]. Study investigator Dr Harvey White from Green Lane Hospital, Auckland, New Zealand, described the findings as a true ‘ breakthrough ’ in the management of this condition.

CNS distribution of free‐radical inactivating enzymes in amyotrophic lateral sclerosis

Annals of NeurologyVolume 40, Issue 4 p. 689-690 Letter CNS distribution of free-radical inactivating enzymes in amyotrophic lateral sclerosis J. D. Mitchell, J. D. Mitchell Department of Neurology Royal Preston Hospital Sharoe Green Lane Fulwood, Preston, PR2 9HT, UK and Centre for Taxicology University of Central Lancashire Preston, UKSearch for more papers by this authorP. S. Fitzmaurice, P. S. Fitzmaurice Department of Neurology Royal Preston Hospital Sharoe Green Lane Fulwood, Preston, PR2 9HT, UK and Centre for Taxicology University of Central Lancashire Preston, UKSearch for more papers by this authorJ. M. Knight, J. M. Knight Department of Neurology Royal Preston Hospital Sharoe Green Lane Fulwood, Preston, PR2 9HT, UK and Centre for Taxicology University of Central Lancashire Preston, UKSearch for more papers by this authorI. C. Shaw, I. C. Shaw Department of Neurology Royal Preston Hospital Sharoe Green Lane Fulwood, Preston, PR2 9HT, UK and Centre for Taxicology University of Central Lancashire Preston, UKSearch for more papers by this author J. D. Mitchell, J. D. Mitchell Department of Neurology Royal Preston Hospital Sharoe Green Lane Fulwood, Preston, PR2 9HT, UK and Centre for Taxicology University of Central Lancashire Preston, UKSearch for more papers by this authorP. S. Fitzmaurice, P. S. Fitzmaurice Department of Neurology Royal Preston Hospital Sharoe Green Lane Fulwood, Preston, PR2 9HT, UK and Centre for Taxicology University of Central Lancashire Preston, UKSearch for more papers by this authorJ. M. Knight, J. M. Knight Department of Neurology Royal Preston Hospital Sharoe Green Lane Fulwood, Preston, PR2 9HT, UK and Centre for Taxicology University of Central Lancashire Preston, UKSearch for more papers by this authorI. C. Shaw, I. C. Shaw Department of Neurology Royal Preston Hospital Sharoe Green Lane Fulwood, Preston, PR2 9HT, UK and Centre for Taxicology University of Central Lancashire Preston, UKSearch for more papers by this author First published: October 1996 https://doi.org/10.1002/ana.410400425AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume40, Issue4October 1996Pages 689-690 RelatedInformation

Delirium and Dementia; Are They Distinct?

Journal of the American Geriatrics SocietyVolume 44, Issue 8 p. 1001-1002 Delirium and Dementia; Are They Distinct? A.J.D. Macdonald MD, FRCPsych, Corresponding Author A.J.D. Macdonald MD, FRCPsych Hither Green Hospital, London, and †Bexley Hospital, Bexley, Kent, UK.(Guys Campus), Hither Green Hospital, Hither Green Lane, London SE13 6RU, UK.Search for more papers by this authorA. Treloar MRCP, MRPCPsych, MRCGP, A. Treloar MRCP, MRPCPsych, MRCGP Hither Green Hospital, London, and †Bexley Hospital, Bexley, Kent, UK.Search for more papers by this author A.J.D. Macdonald MD, FRCPsych, Corresponding Author A.J.D. Macdonald MD, FRCPsych Hither Green Hospital, London, and †Bexley Hospital, Bexley, Kent, UK.(Guys Campus), Hither Green Hospital, Hither Green Lane, London SE13 6RU, UK.Search for more papers by this authorA. Treloar MRCP, MRPCPsych, MRCGP, A. Treloar MRCP, MRPCPsych, MRCGP Hither Green Hospital, London, and †Bexley Hospital, Bexley, Kent, UK.Search for more papers by this author First published: August 1996 https://doi.org/10.1111/j.1532-5415.1996.tb01880.xCitations: 21Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume44, Issue8August 1996Pages 1001-1002 RelatedInformation

Dr. Hugh C. Cullen green lane hospital Auckland, New Zealand Predictors of hospital stay after cardiac surgery

Dr. Hugh C. Cullen green lane hospital Auckland, New Zealand Predictors of hospital stay after cardiac surgery

Common DNA Polymorphisms at the Lipoprotein Lipase Gene

DNA variants of the lipoprotein lipase gene are associated with changes in lipid metabolism similar to those in diabetes and may relate to the development of atherosclerotic lesions, particularly premature lesions. To determine whether lipoprotein lipase gene variants are relevant to ongoing atherogenesis, we explored relationships between two common lipoprotein lipase gene polymorphic markers, Pvu II at intron 6 and HindIII at intron 8; the severity of coronary artery disease (CAD); and lipid variables in 475 white patients 65 years of age or younger. We assessed CAD severity as the number of significantly stenosed (> 50% luminal obstruction) major coronary arteries at angiography and by the Green Lane coronary score. We found a significant association between the Pvu II polymorphism and the number of significantly diseased vessels (P = .0099) and coronary score (P = .028), with the Pvu II(-) alleles associated with less severe disease. The HindIII polymorphism was not associated with severity but had an additive effect with the Pvu II polymorphism. There was a close relationship between the Pvu II(+/+) genotype and the presence of diabetes (P = .0025), with an OR of 3.12 (95% CI, 1.30 to 7.49) compared with the Pvu II(-/-) genotype. The interaction between these polymorphisms and CAD severity (rather than occurrence) was independent of the levels of triglycerides and HDL cholesterol and of other lipid variables. There was also a dosage-dependent relationship between the Pvu II polymorphism and levels of triglyceride. The Pvu II(-) allele was associated with low levels and variances of triglycerides. We conclude that the lipoprotein lipase Pvu II polymorphism is significantly associated with CAD severity and with type II diabetes in CAD patients, independent of changes in circulating lipid levels. These findings may be relevant to mechanisms mediating atherogenesis.

Risk factors in heart transplantation. A statistical study of New Zealand cases.

The first heart transplantation in New Zealand was performed on December 2, 1987. This study covers all forty-five transplantations that were performed in New Zealand at Green Lane Hospital from that time through January 1994. Eleven patients from that group have died. The 30 day and 1, 2 and 4 year survival rates were found to be 91.1, 86.7, 80.0 and 75.6%, respectively. The mean waiting period of the patients for heart transplantation was 61.9 days. Only pulmonary vascular resistance was a statistically significant risk factor for early death after cardiac transplantation. Ischemic time was not a significant risk factor in this study.

Genotype distribution of angiotensin-converting enzyme polymorphism in Australian healthy and coronary populations and relevance to myocardial infarction and coronary artery disease.

Angiotensin-converting enzyme is a key component of the renin-angiotensin system that plays an important role in cardiovascular regulation. An association between the angiotensin-converting enzyme insertion/deletion (I/D) polymorphism and increased coronary risk has been found in some studies but not in others. To explore this further in an Australian white population, we compared the ACE genotype distribution in 550 patients aged 37 to 65 years with coronary artery disease documented by angiography with the genotype distribution in 404 healthy school children aged 6 to 13 years. We also explored associations in the patients between the angiotensin-converting enzyme I/D polymorphism and a history of myocardial infarction and coronary artery disease severity assessed by the number of major coronary arteries with more than 50% luminal obstructions and by the Green Lane coronary score. The frequencies of the angiotensin-converting enzyme genotype in the coronary artery disease patients were 0.236 for I/I, 0.395 for I/D, and 0.369 for D/D genotypes. This distribution with an excess of the D/D genotype was significantly different (chi 2 = 23.69, P < .0001) from that in the school children, in whom the genotype distribution was in Hardy-Weinberg equilibrium (I/I, 0.21; I/D, 0.54; D/D, 0.25). There was also a significant excess of D/D genotype among patients with a history of myocardial infarction (chi 2 = 9.42, P = .009), and there was the same D/D excess in the subgroup of children (n = 60) with two or more grandparents who had had coronary artery disease. We found no associations between the angiotensin-converting enzyme polymorphism and the number of significantly stenosed coronary arteries (chi 2 = 2.069, P = .91). We conclude that the D/D genotype is a significant predictor for coronary artery disease events in the Australian white population but is not a marker for angiographically assessed coronary artery disease severity. The angiotensin-converting enzyme genotype-associated increased risk for coronary events may be mediated more by angiotensin II-induced coronary vasoconstriction than by an increase in injury-related smooth muscle cell proliferation in the coronary vasculature.

Late Outcome After Coronary Artery Bypass Graft Surgery in Patients &lt;40 Years Old

Randomized trials confirm the long-term efficacy of coronary artery bypass graft surgery (CABG), although there are no randomized data in patients < 40 years old. Because these patients have been reported to have an early recurrence of symptoms, the long-term postoperative outcome was examined. The long-term outcome of patients (n = 221) < 40 years old undergoing CABG at Green Lane Hospital, New Zealand, from 1970 to 1992 was determined. The 30-day mortality rate was 1.8% for initial and 9.5% for redo CABG. The median times to angina or myocardial infarction (recurrent ischemic event), further intervention, and death were 6.0, 9.6, and 14.2 years, respectively. Factors associated with increased late mortality on univariate analysis included end-systolic volume (ESV) > or = 80 mL (P = .004; 10-year mortality 19% versus 39% ESV > or = 80 mL), no internal mammary conduit (P = .01), no lipid-modifying therapy (P = .005), and no postoperative aspirin use (P = .0002); the latter was also associated with increased recurrent ischemic events (P = .04) or increased reintervention (P = .02). On stepwise logistic regression analysis, factors associated with increased late mortality were increasing ESV (P = .004), no internal mammary artery conduit (P = .009), diabetes (P = .04), and no postoperative aspirin (P = .02); the latter was also associated with increased recurrent ischemic events (P = .02). Hypercholesterolemia (> or = 6.5 mmol/L) was present in 65% of patients at presentation and 45% at follow-up. To attempt to prevent recurrent ischemia or late death, patients < 40 years old who require CABG should receive internal mammary conduits, aspirin, lipid-modifying therapy, therapy to inhibit ventricular dilatation, and strict diabetes management.

Determinants of severity of left ventricular dysfunction in Australian men and women with coronary disease aged 65 years or less.

The degree of left ventricular (LV) impairment is an important determinant of long term outcome in patients with coronary artery disease (CAD). We aimed to determine variables predictive of the severity of LV dysfunction in men and women aged 65 years or less with CAD, and to quantitate their contributions. We documented atherogenic variables and extent of LV impairment and CAD severity at angiography in 521 consecutively studied men and women aged 65 years or less (381 males and 140 females). We assessed severity from an LV impairment score (Green Lane) and the ejection fraction. We related severity to quantitative and categorical variables which included the severity of angina (no angina, stable and unstable angina). The LV impairment score correlated closely (negatively) with the ejection fraction (r = -0.783, p = 0.0001). There were eight variables independently predictive of the severity of LV impairment assessed by the LV score. The variables in descending order of relative importance in predicting the LV scores were past history of myocardial infarction (MI), number of significantly diseased vessels (> 50% luminal obstruction), life-time smoking dose, log-triglycerides, total cholesterol to HDL-C ratio, hypertension, age and Body Mass Index (BMI). They were all positive relationships. Together they correctly classified the LV scores of 52.6% of the patients. Gender was not an independent contributor to the LV score when other variables were controlled. When the contributions to the variance in LV scores of past history of MI (15.4%) and number of significantly diseased vessels (2.6%) were controlled, life-time smoking dose independently explained 2.1% (p < 0.01) of the variance. The LV impairment score was 55% higher in heavy smokers than in non-smokers (p = 0.01). When we compared patients with stable and unstable angina, LV scores are higher and ejection fraction lower in the unstable angina patients consistent with them having a greater degree of LV dysfunction. We conclude that variables other than a history of MI and CAD severity contribute significantly to the variance of the degree in LV impairment in CAD patients among which the life-time smoking dose, triglycerides, TC/HDL-C, hypertension and increased BMI are all relevant to prevention, and that patients with unstable vs stable angina usually have more impaired LV function.

Viability studies of human valves prepared for use as allografts

The preimplantation viability status of pulmonary and aortic valves prepared for use as allografts by the methods in current use at Green Lane Hospital, Auckland was determined by autoradiography and culture. The valves were obtained from cadaver donors, disinfected in antibiotic solution and stored by cryopreservation. A group of 45 banked valves considered unsuitable for clinical use was assayed initially and very few were found to have viable fibroblasts in their leaflets. A series of 29 valves collected at postmortem examination then was assayed sequentially after each phase of the preparation procedure. Valves obtained within 24 hours of donor death usually retained considerable viability. However, in all but a minority of cases this declined markedly after antibiotic treatment and further still after cryopreservation, so that most valves were nonviable when thawed.