RESUMEN
OBJECTIVE: This study was conducted to compare the composites of valve-related complications, namely reoperation, morbidity (defined as permanent neurologic or other functional impairment), and mortality, between bioprostheses and mechanical prostheses for aortic valve replacement. METHODS: Between 1982 and 1998, 2195 bioprostheses were implanted in 2179 patients and 980 mechanical prostheses were implanted in 883 patients. Total follow-up was 16,442 years and 5740 years for bioprostheses and mechanical prostheses, respectively. Eight variables were considered as predictors of risk for the composites of valve-related complications. RESULTS: Linearized rates for valve-related reoperation were 1.3%/patient-year and 0.3%/patient-year for bioprostheses and mechanical prostheses (P < .001), respectively. All age groups were differentiated, except >70 years. Valve-related morbidity was differentiated for all age groups and overall, for bioprostheses and mechanical protheses, was 0.4 %/patient-year and 2.1%/patient-year, respectively (P < .001). Overall valve-related mortality was 1.0%/patient-year for bioprostheses and 0.7%/patient-year for mechanical prostheses (P = .018). Age and valve-type were predictive risk factors for reoperation and morbidity, whereas age alone was predictive of mortality. Actual freedom from valve-related reoperation favored mechanical prostheses for all age groups, except 61-70 years and >70 years. Actual freedom from valve-related morbidity favored bioprostheses in all age groups, except < or =40 years. Actual freedom from valve-related mortality was undifferentiated in patients 51-60, 61-70, and >70 years. CONCLUSION: No differences were observed in valve-related reoperation and mortality in patients >60 years. Comparative evaluation gives high priority for bioprostheses in patients >60 years based on improved morbidity profile. This evaluation extends this center's recommendation for bioprostheses in aortic valve replacement to include patients >60 years.
Asunto(s)
Válvula Aórtica/cirugía , Bioprótesis/efectos adversos , Prótesis Valvulares Cardíacas/efectos adversos , Adolescente , Adulto , Anciano , Supervivencia sin Enfermedad , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Diseño de Prótesis , Factores de TiempoRESUMEN
BACKGROUND: Clinical performance of bioprostheses (BP) with presence of atrial fibrillation and/or paced rhythm and mechanical prostheses (MP) in aortic valve replacement was considered a study of importance. METHODS: Aortic valve replacement (AVR) was performed in 163 replacements with porcine bioprostheses (Carpentier-Edwards supra-annular) with atrial fibrillation/paced rhythm identified at latest follow-up. Mechanical population was 886 procedures (St. Jude Medical = 436; CarboMedics = 450). Concomitant coronary artery bypass (CAB) was conducted in 40.5 % (66) of BP; 27.0 % (239) of MP. MP patients were all (100 %) on Coumadin and BP patients 35.6 % on acetylsalicylic acid (ASA), 37.4 % Coumadin, 7.4 % Coumadin + ASA, and 19.6 % on no therapy. RESULTS: Major thromboembolism (TE) and hemorrhage (ATH) occurred in 2.4 %/pt-yr (32) for BP and 5.3 %/pt-yr (157) for MP ( p < 0.0001); (TE major 1.6 %/pt-yr [21] for BP and 2.1 %/pt-yr [62] for MP [ p = 0.24]; ATH = 0.8 %/pt-yr [11] for BP and 3.2 %/pt-yr [95] for MP) ( p < 0.0001). There were no predictors of overall TE, TE major, ATH, overall TE + ATH, and TE major + ATH. Age and CAB were predictors of survival. Overall BP survival at 8 years was 97.5 +/- 1.5 %; and for MP 66.4 +/- 4.8 % ( p < 0.01). Actuarial freedom from overall thromboembolism and hemorrhage was 54.5 +/- 10.8 % for MP; 85.9 +/- 3.1 % for BP ( p = 0.0000). For major thromboembolism and hemorrhage, actuarial freedom was 63.4 +/- 11.8 % for MP; 91.4 +/- 2.5 % for BP ( p = 0.0003). CONCLUSIONS: Patients with atrial fibrillation/paced rhythm having AVR with bioprostheses with 45 % on Coumadin have greater freedom from thromboembolism and hemorrhage than after AVR with mechanical prostheses on Coumadin.
Asunto(s)
Fibrilación Atrial/epidemiología , Bioprótesis , Enfermedades de las Válvulas Cardíacas/epidemiología , Prótesis Valvulares Cardíacas , Adolescente , Adulto , Anciano , Bioprótesis/efectos adversos , Enfermedades de las Válvulas Cardíacas/cirugía , Prótesis Valvulares Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Persona de Mediana Edad , Tromboembolia/etiologíaRESUMEN
OBJECTIVE: Predominant concerns of patients undergoing valve replacement surgery are risks of death, stroke, antithrombotic bleeding, and reoperation related to the replacement prosthesis. The purpose of this study was to compare valve-related reoperation, morbidity (permanent impairment), and mortality between bioprostheses and mechanical prostheses for mitral valve replacement. METHODS: Between 1982 and 1998, a total of 959 bioprostheses were implanted in 943 patients, and a total of 961 mechanical prostheses were implanted in 839 patients. Total follow-ups were 5730 years for bioprostheses and 5271 years for mechanical prostheses. Eight variables were considered as predictors of risk for the composites of valve-related complications. RESULTS: The linearized occurrence rates for valve-related reoperation were 3.7 events/100 patient-years for bioprostheses and 0.5 events/100 patient-years for mechanical prostheses ( P < .001), with all age groups differentiated except older than 70 years. Valve-related morbidity was undifferentiated for bioprostheses and mechanical prostheses. Valve-related mortalities were 1.7 events/100 patient-years for bioprostheses and 0.7 events/100 patient-years for mechanical prostheses ( P < .001). Predictors of valve-related reoperation were age and valve type. The only predictor of valve-related morbidity was age, whereas age and valve type were predictors for valve-related mortality. Actual freedom from valve-related reoperation favored mechanical prostheses in all age groups except older than 70 years (91.7% +/- 2.0% for bioprostheses at 15 years and 96.7% +/- 1.5% at 12 years for mechanical prostheses). Actual freedom from valve-related morbidity was not different between bioprostheses and mechanical prostheses. Actual freedom from valve-related mortality favored mechanical prostheses in all groups except older than 70 years. CONCLUSION: Comparative evaluation gives high priority in mitral valve replacement for mechanical prostheses relative to bioprostheses for freedom from valve-related reoperation and valve-related mortality but not valve-related morbidity. Freedom from valve-related reoperation and valve-related mortality favors mechanical prostheses for all age groups except older than 70 years. Valve-related morbidity, due to neurologic or functional impairments, does not differentiate between bioprostheses and mechanical prostheses.
Asunto(s)
Bioprótesis/efectos adversos , Prótesis Valvulares Cardíacas/efectos adversos , Válvula Mitral/cirugía , Adulto , Anciano , Supervivencia sin Enfermedad , Femenino , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/epidemiología , Reoperación/estadística & datos numéricos , Factores de TiempoRESUMEN
OBJECTIVE: The predominant complication of bioprostheses is structural valve deterioration and the consequences of re-operation. Prosthesis choice for aortic valve replacement surgery (bioprostheses and mechanical prostheses), is influenced by valve-related complications (mortality and morbidity) of the prosthesis type chosen. The purpose of the study is to determine the mortality and risk assessment of that mortality for aortic bioprosthetic failure. METHODS: From 1975 to 1999, 3356 patients received a heterograft bioprosthesis in 3530 operations. The procedures were performed with concomitant coronary artery bypass (CAB) in 1388 procedures and without in 2142 procedures. Three hundred twenty-two re-operations for structural valve deterioration were performed in 312 patients with 22 fatalities (6.8%). Of the 322 re-replacements, 36 had CAB and 286 had isolated replacement; the mortality was 8.3% (3) and 6.6% (19), respectively. Eleven predictive factors inclusive of age, concomitant CAB, urgency status, New York Heart Association (NYHA) at Re-op and year of Re-op (year periods) were considered. RESULTS: The mortality for 1979-1986 was 6.1% (2/33); 1987-1992, 7.7% (8/104); and 1993-2000, 6.5% (12/185) (pNS). The mortality by urgency status for elective/urgent was 6.4% (19/299); and emergent, 13.0% (3/23) (pNS). The mortality for NYHA I/II was 2.0% (1/50), III 4.2% (8/191) and IV 16.0% (13/81) (P=0.00063), for gender was male 4.6% and female 13.3% (P=0.011), for age at implant 'No' (no re-operation) 51.6+/-12.2 years and 'Yes' (yes re-operation) 59.9+/-7.3 years (P=0.00004), for age at explant 'No' 62.6+/-12.7 years and 'Yes' 70.6+/-6.5 years (P=0.00001), and for age at explant <60 years 0.0% (0/110), 60-70 years 8.5% (10/117) and >70 years 12.6% (12/95) (P=0.0011). The predictive risk factor assessment by multivariate regression analysis revealed only NYHA III Odds Ratio 1.7 and IV 7.8 P=0.0082. For the period 1993-2000 of re-operations only gender was significant; age at implant, age at explant, CAB pre-Re-op, CAB concomitant with Re-op, urgency at Re-op, ejection fraction, valve lesion and NYHA at Re-op were not significant. CONCLUSIONS: Bioprosthetic aortic re-operative mortality can be lowered by re-operation in low rather than medium to severe NYHA functional class. The routine evaluation of patients can achieve earlier low risk re-operative surgery.
Asunto(s)
Válvula Aórtica/cirugía , Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas/métodos , Prótesis Valvulares Cardíacas , Adulto , Distribución por Edad , Anciano , Colombia Británica/epidemiología , Femenino , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Humanos , Masculino , Persona de Mediana Edad , Análisis Multivariante , Falla de Prótesis , Reoperación/métodos , Reoperación/mortalidad , Medición de Riesgo/métodos , Factores de RiesgoRESUMEN
BACKGROUND: The predominant complication of bioprostheses is structural valve deterioration and the consequences of reoperation. The purpose of the study was to determine the mortality and risk assessment of that mortality for mitral bioprosthetic failure. METHODS AND RESULTS: From 1975 to 1999, 1 973 patients received a heterograft bioprosthesis in 2 152 operations. The procedures were performed with concomitant coronary artery bypass (CAB) in 694 operations and without in 1 458 operations. There were 481 reoperations for structural valve deterioration performed in 463 patients with 34 fatalities (7.1%). Of the 481 re-replacements, 67 had CAB and 414 had isolated replacement; the mortality was 11.9% (8) and 6.3% (26), respectively. Eleven predictive factors inclusive of age, concomitant CAB, urgency status, New York Heart Association (NYHA; reoperation), and year of reoperation (year periods) were considered. The mortality from 1975 to 1986 was 9.8% (6/61), from 1987 to 1992 it was 10.8% (20/185), and from 1993 to 2000 it was 3.4% (8/235) (I versus III P=0.0458, II versus III P=0.0047). The mortality by urgency status was elective/urgent 6.0% (26/436) and emergent 17.8% (8/45) (P=0.00879). The mortality was NYHA I/II 0.00% (0/37), III 5.1% (14/273), and IV 11.7% (20/171) (P=0.0069). The predictive risk factors by multivariate regression analysis were age at implant, odds ratio (OR) 0.84 (P=0.0113); age at explant, OR 1.2 (P=0.0089); urgency, OR 2.8 (P=0.0264); NYHA, OR 2.5 (P=0.015); 1975-1986 versus 1993-2000 of reoperations, OR 5.8 (P=0.0062); and 1987-19 92 versus 1993-2000, OR 4.0 (P=0.0023). For the period 1993 to 2000 of reoperations, only age at implant and age at explant were significant; NYHA class, urgency status, and concomitant CAB were not significant. CONCLUSIONS: Bioprosthetic mitral reoperative mortality can be lowered by reoperations on an elective/urgent basis in low to medium NYHA functional class. The routine evaluation of patients can achieve earlier low risk reoperative surgery.
Asunto(s)
Bioprótesis/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Prótesis Valvulares Cardíacas/efectos adversos , Válvula Mitral/cirugía , Adulto , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Reoperación/mortalidad , Medición de RiesgoRESUMEN
BACKGROUND: The Carpentier-Edwards supraannular porcine bioprosthesis experience for more than 18 years has been evaluated by actuarial and actual analysis to determine the clinical performance in aortic valve replacement. METHODS: From 1981 to 1998, 1,823 patients (mean age 68.5 years, range 20 to 90 years) underwent 1,846 procedures. Previous coronary artery bypass was performed in 3.1% (56) and previous valve repair/replacement in 6.0% (110). Concomitant coronary artery bypass grafting was performed in 41.5% (756). RESULTS: The overall valve-related complication rate was 4.5%/patient-year (567 patients) with a fatality rate of 0.9%/patient-year (110 patients). The patient survival, at 15 years, was 33.0%+/-3.7% for the 61 to 70 years age group and 13.5%+/-2.4% for the older than 70 years group. At 15 years, the overall actual, cumulative freedom from reoperation was 83.2%+/-1.4%, valve-related mortality was 88.0%+/-1.2%, and valve-related residual morbidity was 92.0%+/-0.8%. The actual freedom from structural valve deterioration at 15 years was 84.2%+/-2.8% for the 61 to 70 years group and 97.1%+/-0.9% for the older than 70 years group. CONCLUSIONS: The Carpentier-Edwards porcine bioprosthesis provides excellent freedom from structural valve deterioration, and overall freedom from valve-related morbidity, mortality, and reoperation for aortic valve replacement for up to 15 years. The prosthesis is recommended for patients older than 70 years and for patients 61 to 70 years, especially when extended survival is not anticipated.
Asunto(s)
Válvula Aórtica/cirugía , Bioprótesis , Prótesis Valvulares Cardíacas , Complicaciones Posoperatorias/mortalidad , Análisis Actuarial , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Masculino , Persona de Mediana Edad , Diseño de Prótesis , Reoperación , Análisis de SupervivenciaRESUMEN
BACKGROUND AND AIM OF THE STUDY: The surgical management of tricuspid valve endocarditis, especially in patients with positive serology for HIV and hepatitis C, is complicated by the inappropriateness of reconstruction and the late complications of mechanical prostheses and bioprostheses. Late results of mitral homograft replacement of the tricuspid valve have been satisfactory, but evidence of moderate and severe regurgitation appears in some patients. This report presents a novel approach to implantation of a mitral homograft in the tricuspid position. METHODS: Five patients with complications of native tricuspid valve endocarditis underwent mitral homograft replacement of the tricuspid valve, the homograft being implanted with the anterior leaflet orientated to the septum, the papillary muscles exteriorized and sutured to the right ventricular wall, the posteromedial muscle anteriorly, and the anterolateral muscle inferiorly. The annular attachment was reinforced with a rigid mitral annuloplasty ring in the anti-anatomical relationship. RESULTS: There was no early mortality. Among three patients available for echocardiographic assessment during the first year, regurgitation was absent in two cases, and trivial in one case. The latter patient died of a drug overdose after nine months. Two patients required insertion of atrioventricular pacemakers for complete heart block. CONCLUSION: This novel extension to the technique of mitral homograft replacement of the tricuspid valve for uncontrollable native endocarditis in drug abusers makes the procedure more technically feasible, and should be considered a procedure of choice.
Asunto(s)
Válvula Mitral/trasplante , Válvula Tricúspide/cirugía , Adulto , Procedimientos Quirúrgicos Cardíacos/métodos , Portador Sano , Criopreservación , Endocarditis/cirugía , Femenino , Seropositividad para VIH , Hepatitis C , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Reoperación , Factores de Riesgo , Abuso de Sustancias por Vía Intravenosa , Trasplante Homólogo , Insuficiencia de la Válvula Tricúspide/diagnóstico por imagen , Insuficiencia de la Válvula Tricúspide/etiología , UltrasonografíaRESUMEN
BACKGROUND AND AIM OF THE STUDY: The bileaflet St. Jude Medical mechanical prosthesis has been implanted for over 20 years. The purpose of this study was to evaluate the clinical performance of the bileaflet CarboMedics (CM) prosthesis, which was introduced in 1986. METHODS: The CM prosthesis was implanted in 1,258 patients (709 males, 549 females; mean age 60.9 +/- 12.3 years) between 1989 and 1997. The prosthesis distribution was aortic valve replacement (AVR) 613; mitral valve replacement (MVR) 447; and multiple replacement (MR) 231. Coronary artery bypass (CAB) was performed in 334 (26.6%) patients; previous procedures had been performed in 346 (27.5%). The age distribution was <60 years (n = 527), 61-70 years (n = 424) and >70 years (n = 307). Risk factors assessed were age or age groups, gender, CAB, previous surgery, rhythm, valve position, status and NYHA functional class. The total follow up was 4,765.0 patient-years (pt-yr), and was 98.4% complete. RESULTS: The early mortality rate was 5.6% (AVR 4.8%, MVR 3.7%, MR 11.5%). The late mortality rate was 3.7%/pt-yr (n = 174), and valve-related mortality 1.1%/pt-yr (n = 50). The total thromboembolism (TE) rate was 4.1%/pt-yr (n = 195) (p = NS by valve position); the major TE rate was 1.9%/pt-yr and fatal TE rate 0.31%/pt-yr (n = 15). The valve thrombosis rate was 0.31%/pt-yr (n = 15; 11 MVR, four MR). The fatal thrombosis rate was 0.06%/pt-yr (n = 3; two MVR, one MR). The hemorrhage rate was 2.7%/pt-yr (n = 128) and fatal hemorrhage rate 0.4%/pt-yr (n = 20). The reoperation rate was 1.0%/pt-yr (n = 46), fatal 0.1%/pt-yr (n = 5). The actuarial freedom from overall TE at eight years was 77.3 +/- 2.8%; major TE 88.5 +/- 1.6%, and hemorrhage 76.4 +/- 3.2% (all p = NS by valve position). There were no independent predictors of overall TE and TE exclusion of early events. The only predictor for TE major was status (emergency > urgent > elective). The actuarial freedom from valve-related mortality at eight years was 91.4 +/- 1.8% (p = NS by position) (actual freedom 93.0 +/- 1.3%). The actuarial freedom from valve-related reoperation was 91.1 +/- 2.4% (p <0.05; AVR > MVR and MR, MVR > MR) (actual freedom 92.2 +/- 2.7%). Overall survival rate at eight years was 68.2 +/- 2.3% (p <0.05; AVR > MVR and MR, MVR > MR). CONCLUSION: The clinical performance of the CarboMedics mechanical prosthesis is satisfactory when implanted in the mitral, aortic and multiple positions.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Anciano , Válvula Aórtica/cirugía , Puente de Arteria Coronaria , Femenino , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Hemorragia/etiología , Humanos , Masculino , Persona de Mediana Edad , Válvula Mitral/cirugía , Complicaciones Posoperatorias , Diseño de Prótesis , Reoperación , Factores de Riesgo , Tromboembolia/etiología , Factores de Tiempo , Resultado del TratamientoRESUMEN
BACKGROUND AND AIM OF THE STUDY: The clinical performance of porcine bioprostheses for valve replacement has been evaluated for over three decades by actuarial analysis as the standard for reporting time-related results. Actual or cumulative incidence analysis provides a complementary method to determine the manifestations of valve-related complications due primarily to structural valve deterioration. Valve-related mortality and reoperation of porcine bioprostheses for aortic and mitral valve replacement was compared by actuarial and actual methodology. METHODS: The Carpentier-Edwards porcine bioprostheses were implanted between 1975 and 1995 as 2,237 aortic valve replacements (AVR) and 1,582 mitral valve replacements (MVR). Coronary artery bypass was performed in 36.4% of AVR, and 30.6% of MVR. Fatal valve-related complications occurred in 7.6% of AVR and 11.3% of MVR. The cumulative follow up was 14,810 patient-years (mean 6.6 years) for AVR and 9,718 patient-years (mean 6.1 years) for MVR. RESULTS: Patient survival, and actuarial and actual freedom from valve-related mortality and valve-related reoperation was reported at 15 years. For AVR, survival in the 61-70 years age group was 30.9%, freedom from valve-related mortality was 79.3% and 86.9% respectively, and freedom from valve-related reoperation 79.0% and 88.1% respectively. For AVR, survival in the >70 years age group was 18.1%, freedom from valve-related mortality 72.8% and 84.9% respectively, and freedom from reoperation 86.3% and 96.1% respectively. For MVR, survival in the 61-70 years age group was 16.1% at 15 years, freedom from valve-related mortality was 59.5% and 79.5% respectively, and freedom from valve-related reoperation 32.6% and 71.0% respectively. For MVR, survival in the >70 years age group was 2.8% at 15 years, valve-related mortality was 26.1% and 82.0% respectively, and freedom from valve-related reoperation 83.4% and 93.3% respectively. CONCLUSION: The actual freedom from valve-related mortality and valve-related reoperation (primarily from structural valve deterioration), provides further evidence to consider porcine bioprostheses for AVR in patients aged >60 years, and for MVR in patients aged >70 years. The freedom from valve-related mortality supports the use of porcine bioprostheses for MVR in patients aged 61-70 years. Patient survival is influenced to the greatest extent by factors other than valve-related mortality.
Asunto(s)
Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Prótesis Valvulares Cardíacas , Análisis Actuarial , Adulto , Factores de Edad , Anciano , Animales , Válvula Aórtica , Estudios de Seguimiento , Humanos , Persona de Mediana Edad , Válvula Mitral , Reoperación/estadística & datos numéricos , Análisis de Supervivencia , Porcinos , Factores de TiempoRESUMEN
OBJECTIVES: The purpose of this study was to determine the origin of the pulmonary venous systolic flow pulse using wave-intensity analysis to separate forward- and backward-going waves. BACKGROUND: The mechanism of the pulmonary venous systolic flow pulse is unclear and could be a "suction effect" due to a fall in atrial pressure (backward-going wave) or a "pushing effect" due to forward-propagation of right ventricular (RV) pressure (forward-going wave). METHODS: In eight patients during coronary surgery, pulmonary venous flow (flow probe), velocity (microsensor) and pressure (micromanometer) were recorded. We calculated wave intensity (dP x dU) as change in pulmonary venous pressure (dP) times change in velocity (dU) at 5 ms intervals. When dP x dU > 0 there is a net forward-going wave and when dP x dU < 0 there is a net backward-going wave. RESULTS: Systolic pulmonary venous flow was biphasic. When flow accelerated in early systole (S1), pulmonary venous pressure was falling, and, therefore, dP x dU was negative, -0.6 +/- 0.2 (x +/- SE) W/m2, indicating a net backward-going wave. When flow accelerated in late systole (S2), pressure was rising, and, therefore, dP x dU was positive, 0.3 +/- 0.1 W/m2, indicating a net forward-going wave. CONCLUSIONS: Pulmonary venous flow acceleration in S1 was attributed to a net backward-going wave secondary to a fall in atrial pressure. However, flow acceleration in S2 was attributed to a net forward-going wave, consistent with propagation of the RV systolic pressure pulse across the lungs. Pulmonary vein systolic flow pattern, therefore, appears to be determined by right- as well as left-sided cardiac events.
Asunto(s)
Función del Atrio Izquierdo/fisiología , Presión Sanguínea/fisiología , Venas Pulmonares/fisiología , Flujo Pulsátil/fisiología , Anciano , Velocidad del Flujo Sanguíneo/fisiología , Puente de Arteria Coronaria , Enfermedad Coronaria/fisiopatología , Enfermedad Coronaria/cirugía , Femenino , Humanos , Masculino , Persona de Mediana Edad , Monitoreo Intraoperatorio/métodos , Monitoreo Intraoperatorio/estadística & datos numéricos , Análisis de Regresión , Sístole/fisiologíaRESUMEN
BACKGROUND: The clinical performance of porcine bioprostheses for valve replacement surgery has been evaluated for over three decades by actuarial analysis as the standard for reporting time-related results. The incidence of structural valve deterioration (SVD) is used for the selection of prostheses for various subsets of patients. Actual or cumulative incidence analysis may provide a superior method to determine durability of bioprostheses. OBJECTIVE: To compare actuarial versus actual methodology in determining the durability of porcine bioprostheses for aortic (AVR) and mitral valve replacement (MVR). PATIENTS AND METHODS: Carpentier-Edwards porcine bioprostheses were implanted between 1975 and 1995 in 2237 AVR and 1582 MVR. The mean age for AVR patients was 65.4+/-12 years and for MVR patients 61.7+/-12 years. The cumulative follow-up for AVR was 14,810 years (mean 6.6+/-4.7) and for MVR 9718 years (mean 6. 1+/-4.5). RESULTS: For AVR the actual freedom from SVD was 87.4+/-2. 0% and 95.6+/-1.8% in those aged 61 to 70 years and more than 70 years, respectively; the actuarial freedom was 75.9+/-4.2% and 82. 3+/-7.9%, respectively. For MVR the actual freedom from SVD was 69. 4+/-2.5% and 92.9+/-1.9% for those aged 61 to 70 years and more than 70 years, respectively; the actuarial freedom was 25.5+/-5.7% and 79. 5+/-6.0%, respectively. Predictors of freedom from SVD for AVR were identified as advancing age, falling into the age groups 61 to 70 and those older than 70 years, and intermediate valve sizes; predictors for MVR were advancing age and age older than 70 years. CONCLUSIONS: Comparison of methods of durability assessment revealed that actual freedom from SVD supports porcine bioprostheses for AVR in patients more than 60 years of age and for MVR in patients more than 70 years of age. This evaluation with experience to 15 years supports the indications for use of porcine bioprostheses.
Asunto(s)
Bioprótesis , Anciano , Válvula Aórtica , Insuficiencia de la Válvula Aórtica/cirugía , Bioprótesis/normas , Falla de Equipo , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia de la Válvula Mitral/cirugía , Análisis Multivariante , Oportunidad Relativa , Pronóstico , Resultado del TratamientoRESUMEN
OBJECTIVE: The experience with the Carbomedics (CM) and the St. Jude Medical (SJM) bileaflet mechanical prostheses was evaluated to determine thromboembolic and hemorrhagic complications and predictive risk factors. METHODS: From 1989 to 1994, a total of 625 patients had mitral valve replacement (CM, 240; SJM, 385); 32.5% (203), concomitant procedures and 32.8% (205), previous cardiac surgery, primarily valve replacement procedures. RESULTS: The pre-operative variables did not distinguish the populations, except for previous surgery CM 37.9% and SJM 29.6% (P < 0.05). The pre-operative variables (type of prostheses, cardiac rhythm, coronary artery bypass, NYHA III/IV, advancing age, gender, urgency status and previous surgery) were not predictive of overall thromboembolism (TE), major TE, minor TE, prosthesis thrombosis and hemorrhage (P not significant; P = NS). The linearized rate of total TE events for overall MVR was 5.0%/patient-year (CM 4.4; SJM 5.4). The < or = 30 day major crude rate was 0.44%, while the > 30 day late major event rate was 2.0%/patient-year. Of the total TE events 91% of < or = 30 days and 75%, > 30 days had an INR < 2.5 at or immediately prior to the event. The thrombosis rate (included in TE events) was 0.63%/patient-year (ten events, four managed successfully with thrombolysis, five successfully with reoperation, and one fatality identified at autopsy). The freedom, at 5 years, from major/fatal TE, thrombosis and hemorrhage from anticoagulation was 88.2%, and 89.5% exclusive of early events. CONCLUSIONS: This non-randomized prospective observational evaluation of the CarboMedics and St. Jude Medical prostheses has not revealed any differentiation in performance of the prostheses. The study serves as a single institution experience with the potential for future comparative evaluation.
Asunto(s)
Prótesis Valvulares Cardíacas/efectos adversos , Válvula Mitral/cirugía , Adulto , Anciano , Anciano de 80 o más Años , Trastornos Cerebrovasculares/etiología , Femenino , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/mortalidad , Hemorragia/etiología , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Diseño de Prótesis , Factores de Riesgo , Tromboembolia/etiologíaRESUMEN
BACKGROUND: Performance with regard to structural valve deterioration (SVD) with the Carpentier-Edwards standard (CE-S) and supraannular (CE-SAV) (Baxter Healthcare Corp, Irvine, CA) porcine bioprostheses was evaluated to determine whether progress in reduction of structural failure has been achieved with technological changes. METHODS: The CE-S was implanted during 567 aortic valve replacement (AVR) and 486 mitral valve replacement (MVR) procedures, and the CE-SAV was implanted during 1,670 AVR and 1,096 MVR procedures. The failure mode of early stent dehiscence with the CE-SAV prosthesis, thought to be controlled by manufacturing changes in 1986 and 1987, supported comparison of the CE-SAV with censored cases of stent dehiscence. Stent dehiscence accounted for only 1.2% (1 of 81) and 14.1% (29 of 205) of AVR and MVR CE-SAV failures, respectively. RESULTS: The only difference for AVR for freedom from SVD occurred in the 21- to 40-year age group at 15 years and was 68% for the CE-SAV and 31% for the CE-S (p<0.05). In the 61- to 70-year age group, freedom from SVD at 15 years was 76% for the CE-S and 84% for the CE-SAV; for the 71-year or higher age group, freedom from SVD was 89% and 95%, respectively (p = NS). For MVR freedom from SVD was different only in the 71-year or higher age group and was 90% for the CE-S and 59% for the CE-SAV (p<0.05). Freedom from SVD was reduced but was similar (p = NS) for the other age groups. For AVR the actual freedom from SVD at 15 years for the CE-S and CE-SAV was, respectively, 79% and 72% for the 51- to 60-year age group, 86% and 91% for the 61- to 70-year age group, and 98% and 98% for the 71-year or higher age group. For MVR, these rates were, respectively, 69% and 75% for the 61- to 70-year age group and 96% and 89% for the 71-year and higher age group. CONCLUSIONS: The technologic advancements made in the second-generation CE-SAV bioprosthesis to reduce the incidence of structural failure have not uniformly been successful. The actual freedom from SVD provides evidence for implantation of porcine bioprostheses for AVR in age groups 61 to 70 years and 71 years or higher and for MVR in the age group 71 years or higher.
Asunto(s)
Bioprótesis , Prótesis Valvulares Cardíacas , Adulto , Anciano , Válvula Aórtica , Enfermedades de las Válvulas Cardíacas/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Humanos , Persona de Mediana Edad , Válvula Mitral , Diseño de Prótesis , Estudios Retrospectivos , Stents , Resultado del TratamientoRESUMEN
OBJECTIVE: To determine major thromboembolic and hemorrhagic complications and predictive risk factors associated with aortic valve replacement (AVR), using bileaflet mechanical prostheses (CarboMedics and St. Jude Medical). DESIGN: A case series. SETTING: Cardiac surgical services at the teaching institutions of the University of British Columbia. PATIENTS AND METHODS: Patients 2 age groups who had undergone AVR between 1989 and 1994 were studied. Group 1 comprised 384 patients younger than 65 years. Group 2 comprised 215 patients 65 years of age and older. RESULTS: The linearized rates of major thromboembolism (TE) occurring after AVR were 1.54%/patient-year for group 1 and 3.32%/patient-year for group 2; the rates for major TE occurring more than 30 days after AVR were 1.13%/patient-year for group 1 and 1.55%/patient-year for group 2. The crude rates for major TE occurring within 30 days of AVR were 1.04% for group 1 and 3.72% for group 2. The death rate from major TE in group 1 was 0.31%/patient-year and in group 2 was 0.88%/patient-year. Of the major TE events occurring within 30 days, 100% of patients in both age groups were inadequately anticoagulated at the time of the event, and for events occurring more than 30 days after AVR, 45% in group 1 and 57% in group 2 were inadequately anticoagulated (INR less than 2.0). The overall linearized rates of major hemorrhage were 1.54%/patient-year for group 1 and 2.21%/patient-year for group 2. There were no cases of prosthesis thrombosis in either group. The mean (and standard error) overall freedom from major TE for group 1 patients at 5 years was 95.6% (1.4%) and with exclusion of early events was 96.7% (1.3%); for group 2 patients the rates were 90.0% (3.2%) and 93.7% (3.0%), respectively. The mean (and SE) overall freedom from major and fatal TE and hemorrhage for group 1 patients was 90.1% (2.3%) and with exclusion of early events was 91.2% (2.3%); for group 2 patients the rates were 87.9% (3.1%) and 92.5% (2.9%), respectively. The 5-year rate for freedom from valve-related death for group 1 patients was 96.3% (2.1%) and for group 2 patients was 97.2% (1.2%). CONCLUSION: The thromboembolic and hemorrhagic complications after AVR with bileaflet mechanical prostheses occur more frequently and result in more deaths in patients 65 years of age and older than in patients years younger than 65 years.
Asunto(s)
Válvula Aórtica/cirugía , Implantación de Prótesis de Válvulas Cardíacas , Hemorragia/etiología , Complicaciones Posoperatorias/etiología , Tromboembolia/etiología , Adulto , Anciano , Anciano de 80 o más Años , Insuficiencia de la Válvula Aórtica/mortalidad , Insuficiencia de la Válvula Aórtica/cirugía , Estenosis de la Válvula Aórtica/mortalidad , Estenosis de la Válvula Aórtica/cirugía , Análisis de Falla de Equipo , Femenino , Estudios de Seguimiento , Hemorragia/mortalidad , Hemorragia/cirugía , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/cirugía , Diseño de Prótesis , Reoperación , Factores de Riesgo , Tasa de Supervivencia , Tromboembolia/mortalidad , Tromboembolia/cirugíaRESUMEN
The pulmonary venous systolic flow wave has been attributed both to left heart phenomena, such as left atrial relaxation and descent of the mitral annulus, and to propagation of the pulmonary artery pressure pulse through the pulmonary bed from the right ventricle. In this study we hypothesized that all waves in the pulmonary veins originate in the left heart, and that the gross wave features observed in measurements can be explained simply by wave propagation and reflection. A mathematical model of the pulmonary vein was developed; the pulmonary vein was modeled as a lossless transmission line and the pulmonary bed by a three-element lumped parameter model accounting for viscous losses, compliance, and inertia. We assumed that all pulsations originate in the left atrium (LA), the pressure in the pulmonary bed being constant. The model was validated using pulmonary vein pressure and flow recorded 1 cm proximal to the junction of the vein with the left atrium during aortocoronary bypass surgery. For a pressure drop of 6 mmHg across the pulmonary bed, we found a transit time from the left atrium to the pulmonary bed of tau approximately 150ms, a compliance of the pulmonary bed of C approximately 0.4 ml/mmHg, and an inertance of the pulmonary bed of 1.1 mmHgs2/ml. The pulse wave velocity of the pulmonary vein was estimated to be c approximately 1m/s. Waves, however, travel both towards the left atrium and towards the pulmonary bed. Waves traveling towards the left atrium are attributed to the reflections caused by the mismatch of impedance of line (pulmonary vein) and load (pulmonary bed). Wave intensity analysis was used to identify a period in systole of net wave propagation towards the left atrium for both measurements and model. The linear separation technique was used to split the pressure into one component traveling from the left atrium to the pulmonary bed and a reflected component propagating from the pulmonary bed to the left atrium. The peak of the reflected pressure wave corresponded well with the positive peak in wave intensity in systole. We conclude that the gross features of the pressure and flow waves in the pulmonary vein can be explained in the following manner: the waves originate in the LA and travel towards the pulmonary bed, where reflections give rise to waves traveling back to the LA. Although the gross features of the measured pressure were captured well by the model predicted pressure, there was still some discrepancy between the two. Thus, other factors initiating or influencing waves traveling towards the LA cannot be excluded.
Asunto(s)
Presión Sanguínea/fisiología , Circulación Pulmonar/fisiología , Venas Pulmonares/fisiología , Flujo Pulsátil/fisiología , Fenómenos Biomecánicos , Hemodinámica , Humanos , Modelos CardiovascularesRESUMEN
OBJECTIVE: The experience with the St. Jude Medical (SJM) and CarboMedics (CM) bileaflet mechanical prostheses was evaluated to determine thromboembolic and hemorrhagic complications and predictive risk factors. METHODS: From 1989 to 1994, a total of 246 patients had multiple valve replacement (SJM, 140; CM, 106); concomitant procedures 20.3% (50) [coronary artery bypass 10.6% (26)] and 53.7% (132) previous cardiac surgery, primarily valve replacement procedures. The pre-operative variables [coronary artery disease, previous cardiovascular surgery, concomitant procedures, valve lesion (except mitral stenosis), status, atrial fibrillation, and NYHA III/IV] did not distinguish the prosthesis-type (pNS). RESULTS: The prosthesis-type and the pre-operative variables, including atrial fibrillation, were not predictive of overall thromboembolism (TE). The linearized rate of total TE events for overall multiple replacements (MR) was 5.4%/patient-year (minor, 2.52; major 2.85); the total TE for CM and SJM was 5.4%/patient-year, respectively. The < or = 30 day major TE crude rate was 0.82%, while the > 30 day major event rate was 2.7%/patient-year. Of the total (major and minor) TE events 100% (3) of < or = 30 days and 72% (29), > 30 days had an INR < 2.5 at or immediately prior to the event. The thrombosis rate (included in total TE events) was 0.67%/patient-year (4 events, 100% INR < 2.5). Of the various TE event categories the prosthesis-types (CM and SJM) were not differentiated (pNS). The freedom, at 5 years, from major/fatal TE, thrombosis and hemorrhage from anticoagulation was 89.3 +/- 3.8% for CM and 87.9 +/- 3.7% for SJM and, 91.3 +/- 3.5% and 89.3 +/- 3.7%, respectively, (pNS) exclusive of early events. CONCLUSIONS: The performance of the CarboMedics and St. Jude Medical prostheses in multiple valve replacement surgery in this non-randomized prospective study revealed no significant differences in performance with regard to thromboembolic and hemorrhagic complications.
Asunto(s)
Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Adulto , Anciano , Anciano de 80 o más Años , Femenino , Enfermedades de las Válvulas Cardíacas/cirugía , Humanos , Masculino , Persona de Mediana Edad , Complicaciones Posoperatorias , Estudios Prospectivos , Diseño de Prótesis , Factores de Riesgo , Trombosis/etiología , Resultado del TratamientoRESUMEN
BACKGROUND: The Carpentier-Edwards standard porcine bioprosthesis experience to 21 years has been evaluated to determine the influence of structural valve deterioration by valve position in various age groupings. METHODS: From 1975 to 1988, 1,181 patients had the prosthesis implanted in 1,198 procedures. The mean age of the population was 57.9+/-12.5 years (range, 21 to 85 years). Aortic valve replacement was performed in 564 patients (47.8%); mitral valve replacement, 478 (40.5%); and multiple valve replacement, 132 (11.2%). Concomitant procedures were performed in 337 patients (28.5%), and 140 (11.9%) had previous operations. RESULTS: The early mortality was 8.1% (97), only 0.4% (5) of which were valve-related. The total follow-up was 10,405 years (mean, 8.8+/-5.2 years). The late mortality was 5.7%/patient-year (591), with the valve-related component 1.6%/patient-year (168) with a 13% reoperative mortality (56). The linearized rate of structural valve deterioration was 3.8%/patient-year (395), with overall complications of 7.1%/patient-year (737). The overall survival at 20 years was 17.2%+/-3.1% (p < 0.05; aortic valve replacement greater than mitral valve replacement or multiple valve replacement). The freedom from structural valve deterioration was, at 18 years, 25.8%+/-2.8% overall, AVR 40.6%+/-4.2%, and MVR 8.5%+/-3.4% (p < 0.05, aortic valve replacement greater than mitral valve replacement or multiple valve replacement). The freedom from structural valve deterioration for aortic valve replacement was, at 15 years, for patients older than 70 years, 82.9%+/-9.1%; 61 to 70 years, 73.2%+/-4.7%; 51 to 60 years, 58.8%+/-5.4%; 41 to 50 years, 41.7%+/-8.2%; and 21 to 40 years, 25.5%+/-7.8%. The freedom from structural valve deterioration for mitral valve replacement was, at 15 years, for patients older than 70 years, 89.8%+/-7.6%; 61 to 70 years, 22.8%+/-6.3%; 51 to 60 years, 26.3% +/- 5.7%; 41 to 50 years, 11.7%+/-5.6%; and 21 to 40 years, 7.0%+/-4.7%. CONCLUSIONS: The prosthesis is recommended for aortic valve replacement for patients older than 70 years and for patients 61 to 70 years (when extended longevity is not anticipated) and for mitral valve replacement for patients older than 70 years.
Asunto(s)
Bioprótesis , Prótesis Valvulares Cardíacas , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Válvula Aórtica/cirugía , Bioprótesis/efectos adversos , Puente de Arteria Coronaria , Estudios de Evaluación como Asunto , Femenino , Estudios de Seguimiento , Prótesis Valvulares Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Modelos Lineales , Estudios Longitudinales , Masculino , Persona de Mediana Edad , Válvula Mitral/cirugía , Análisis Multivariante , Diseño de Prótesis , Falla de Prótesis , Reoperación , Factores de Riesgo , Tasa de Supervivencia , Tromboembolia/etiologíaRESUMEN
BACKGROUND: The Carpentier-Edwards supraannular porcine bioprosthesis experience during 15 years has been evaluated to determine the incidence of structural valve deterioration by valve position in various age groupings. METHODS: From 1981 to 1995, 2,943 patients older than 20 years had the prosthesis implanted in 3,024 procedures. The mean age of the population was 65.5+/-11.9 years (range, 21 to 89 years). Aortic valve replacement was performed in 1,657 patients (54.8%); mitral valve replacement, 1,092 (36.1%); multiple valve replacement, 253 (8.3%); pulmonary valve replacement, 2 (0.1%); and tricuspid valve replacement, 20 (0.7%). Concomitant procedures were performed in 1,332 patients (45.3%), and 352 (12.0%) had previous procedures. RESULTS: The early mortality was 8.9% (270), only 0.4% (11) valve-related. The total follow-up was 17,471 years (mean, 5.9+/-4.1 years). The late mortality was 5.2%/ patient-year (901) with the valve-related component 1.0%/patient-year (171). The reoperation rate was 2.1%/ patient-year (369) with 4.3% mortality (16). The linearized rate of structural valve deterioration was 2.0%/patient-year (341), and overall complications, 5.9%/patient-year (1,019). The overall survival, at 15 years, was 31.1%+/2.8% (p < 0.05; aortic valve replacement greater than mitral valve replacement or multiple valve replacement). The freedom from structural valve deterioration for aortic valve replacement was, at 12 years, for patients older than 70 years, 95.3%+/-2.7%; 61 to 70 years, 92.9%+/-2.1%; 51 to 60 years, 70.1%+/-5.3%; 41 to 50 years, 60.0%+/-8.8%; and 21 to 40 years, 75.7%+/-7.3%. The freedom from structural valve deterioration for mitral valve replacement was, at 12 years, for patients older than 70 years, 66.1%+/-9.7%; 61 to 70 years, 53.1%+/-4.7%; 51 to 60 years, 52.6%+/-5.5%; 41 to 50 years, 39.3%+/-6.9%; and 21 to 40 years, 42.1%+/-9.4%. CONCLUSIONS: The prosthesis is recommended for aortic valve replacement for patients older than 70 years and for patients 61 to 70 years (when extended longevity is not anticipated) and for mitral valve replacement for patients older than 70 years (when extended longevity is not anticipated).
Asunto(s)
Bioprótesis , Implantación de Prótesis de Válvulas Cardíacas , Prótesis Valvulares Cardíacas , Adulto , Factores de Edad , Anciano , Anciano de 80 o más Años , Válvula Aórtica/cirugía , Bioprótesis/efectos adversos , Puente de Arteria Coronaria , Estudios de Evaluación como Asunto , Femenino , Estudios de Seguimiento , Prótesis Valvulares Cardíacas/efectos adversos , Implantación de Prótesis de Válvulas Cardíacas/efectos adversos , Humanos , Incidencia , Modelos Lineales , Masculino , Persona de Mediana Edad , Válvula Mitral/cirugía , Análisis Multivariante , Diseño de Prótesis , Falla de Prótesis , Arteria Pulmonar/cirugía , Reoperación , Tasa de Supervivencia , Tromboembolia/etiología , Válvula Tricúspide/cirugíaRESUMEN
BACKGROUND: The St. Jude Medical (SJM) mechanical prosthesis has been the predominant mechanical prosthesis worldwide since its introduction in 1977. The CarboMedics (CM) mechanical prosthesis, also a bileaflet pyrolite carbon prosthesis, was introduced in 1986 and was approved by the Food and Drug Administration of the United States in 1993. The experience of the two prostheses was evaluated in a parallel, nonrandomized study commencing with the CM investigational study in 1989. METHODS AND RESULTS: The clinical performance of the two prostheses was evaluated in accordance with the Guidelines for Reporting Morbidity and Mortality After Cardiac Valvular Operations. The CM prosthesis was implanted in 239 mitral valve replacements (MVR) and 106 multiple valve replacements (MR), and the SJM prosthesis was implanted in 379 MVR and 137 MR. The CM and SJM populations were not distinguished within MVR and MR for mean age, previous surgery, concomitant surgery, mean follow-up, and late mortality (P=NS). The linearized occurrence rate for the combined experience for major thromboembolic and hemorrhage events >30 days was 3.4% of patients per year for MVR (inclusive of cerebral thromboembolism reversible, major; systemic; thrombosis; and fatal; and major systemic hemorrhage) and for MR was 3.9% of patients per year (P=NS between prostheses by position). The major crude event rate for < or =30 days was 1.3% for MVR and 1.2% for MR (P=NS between prostheses by position). The inadequacy of anticoagulation (as determined by international normalized ratio 2.5) for all thromboembolic events (major and minor) < or =30 days was 93%, and that for >30 days was 75%. The freedom from major thromboembolism for MVR at 3 years was 92.7+/-1.9% for CM and 94.0+/-1.5% for SJM; for MR, it was 94.2+/-3.0% for CM and 93.5+/-2.5% for SJM (P=NS). The freedom from major thromboembolism exclusive of early events for MVR at 3 years was 94.4+/-1.8% for CM and 94.8+/-1.4% for SJM, and for MR, it was 94.2+/-3.0% for CM and 95.0+/-2.2% for SJM (P=NS). The freedom from major thromboembolism and hemorrhage for prostheses (CM and SJM) by valve positions (MVR and MR) was also indistinguishable (P=NS). CONCLUSIONS: There are no distinguishing performance characteristics with regard to thromboembolic and hemorrhagic events between the CM and the SJM mechanical prostheses in MVR and MR. There was an identified need for improvement in the early and late anticoagulant management. A randomized trial with optimization of anticoagulant management between the CM and SJM mechanical prostheses is recommended.
Asunto(s)
Anticoagulantes/uso terapéutico , Implantación de Prótesis de Válvulas Cardíacas , Válvula Mitral/cirugía , Pérdida de Sangre Quirúrgica/prevención & control , Humanos , Persona de Mediana Edad , Tromboembolia/prevención & controlRESUMEN
OBJECTIVES: This study sought to investigate whether right atrial pressure could be used to estimate pericardial pressure during positive end-expiratory pressure (PEEP). BACKGROUND: Because of elevated intrathoracic pressure during PEEP, pulmonary capillary wedge pressure may not accurately reflect left ventricular preload. An estimate of pericardial pressure during PEEP would allow assessment of transmural filling pressure. METHODS: In eight patients, at the start of cardiac surgery, pericardial and pleural pressures were recorded by balloon transducers placed over the anterolateral left ventricular wall. We also recorded intravascular pressures and left ventricular short-axis area by transesophageal echocardiography. RESULTS: A stepwise increase in PEEP from 0 to 15 cm H2O caused a linear increase in pleural pressure from 0.3 +/- 0.6 (mean +/- SEM) to 6.1 +/- 0.8 mm Hg (p < 0.01). Pericardial pressure increased from 2.3 +/- 0.5 to 5.9 +/- 0.6 mm Hg (p < 0.01). The correlation between right atrial (Pra) and pericardial pressure (Pperic) was good: Pra = 0.85 x Pperic + 1.8, r = 0.77. The correlation between changes in right atrial pressure and in pericardial pressure was better: delta Pra = 0.96 x delta Pperic -0.2, r = 0.97. Pulmonary capillary wedge pressure increased with PEEP (p < 0.05), whereas left ventricular area decreased (p < 0.05). However, there was a progressive reduction in transmural pressure, calculated as wedge pressure minus pericardial pressure (p < 0.05), and in transmural pressure, estimated as wedge pressure minus right atrial pressure (p < 0.05). The estimated transmural filling pressure correlated (r = 0.86) with end-diastolic area. CONCLUSIONS: The present observations suggest that right atrial pressure may be used to estimate changes in pericardial pressure with PEEP and that pulmonary capillary wedge pressure minus right atrial pressure is a potentially clinically useful approximation of transmural filling pressure.