Hugh Scully | University of Toronto (original) (raw)

Papers by Hugh Scully

The Journal of Thoracic and Cardiovascular Surgery, Jun 1, 1995

Tricuspid valve replacement is not a common operation. The purpose of this study was to examine t... more Tricuspid valve replacement is not a common operation. The purpose of this study was to examine the early and late results in 60 patients who underwent 28 (417%) bioprosthetic and 32 (53%) mechanical tricuspid valve replacements. All operations took place between January 1978 and June 1993 during which period a total of 4741 patients underwent valve replacement operation. Mean patient age was 5 0-15 (18 to 75) years. Forty-one patients (68%) were female and 19 patients (32%) were male. Forty-nine patients (82%) were in New York Heart Association class III or IV before operation. Forty-five patients (75%) were undergoing repeat cardiac valve operation. Seventeen patients (28%) had complex congenital cardiac problems. Operation was urgent in 15 patients (25%). The hospital mortality rate was 27% (16 patients). All patients with hospital death were in New York Heart Association class III or IV, ,were having repeat operations, or had complex congenital disease. Low output syndrome was observed in 21 patients (35%). Reoperation because of bleeding was required in seven patients (12%). Thirteen patients (22%) required permanent (epicardial lead) pacemaker implantation. Mean follow-up is 75-45 months (maximum 173 months) and 100% complete for the 44 patients who left the hospital. There have been 14 deaths (32%). Nine of these patients (64%) had mechanical valves and five (36%) had bioprostheses. Of the 11 cardiac deaths, three were valve related (bioprostheses). Three patients (10%) required reoperation because of tricuspid valve prosthetic failure (1 thrombosed mechanical valve, 2 failed porcine valves). Of the remaining 30 patients, 20 (67%) are in New York Heart Association class I or II. Seventeen patients have mechanical valves and 13 have bioprostheses. Twenty-six

Journal of Cardiac Surgery, 1988

Abstract Aortic valve replacement with stentless porcine valve should provide superior hemodynami... more Abstract Aortic valve replacement with stentless porcine valve should provide superior hemodynamic results to stented porcine valve because the obstruction caused by the stent and the sewing ring is eliminated. In addition, the coronary sinuses of the recipient may allow for better dissipation of the mechanical stress to which the leaflets are subjected during diastole, thus enhancing durability of the heterograft.

The Journal of Thoracic and Cardiovascular Surgery, 1973

PubMed, Nov 1, 1991

Between 1982 and 1989, 119 patients had repair of thoracic aortic pathology. Thirty-seven had rep... more Between 1982 and 1989, 119 patients had repair of thoracic aortic pathology. Thirty-seven had repair of ascending aortic aneurysms, with an 11% hospital mortality. Forty-one patients had urgent repair of acute type A aortic dissections, with a 32% hospital mortality. The independent predictors of mortality were the use of crystalloid cardioplegia, aortic dissection, and the use of an intraluminal prosthesis or the inclusion surgical technique. Better grafts and the resection technique has reduced mortality since 1986. Seventeen patients had their primary pathology in the aortic arch, with a 47% hospital mortality. The urgency of the procedure and crystalloid cardioplegia predicted an unsuccessful outcome. Seventeen patients had descending aortic aneurysms repaired, with an 18% mortality. The urgency of surgery was the predictor of mortality. Seven patients had a descending thoracic aortic disruption repaired, with one death (14%). Better graft materials, surgical techniques, and methods of myocardial protection have contributed to the improved results of thoracic aortic surgery in recent years.

Canadian Journal of Cardiology, Sep 1, 2012

As the professional society representing cardiac surgeons in Canada, the Canadian Society of Card... more As the professional society representing cardiac surgeons in Canada, the Canadian Society of Cardiac Surgeons (CSCS) recognizes the importance of maintaining a stable cardiac surgical workforce. The current reactive approach to health human resource management in cardiac surgery is inadequate and may result in significant misalignment of cardiac surgeon supply and demand. The availability of forecasting models and high quality, consistent data on productivity, workload, utilization, and demand is a prerequisite for our profession's capacity to predict and plan for changes in health human resources. The CSCS recognizes that improved workforce management is a key component to providing optimal cardiac surgical care for Canadians in

The Journal of Thoracic and Cardiovascular Surgery, Aug 1, 1998

To assess the potential benefits of the hemodynamic superiority of stentless valves, we conducted... more To assess the potential benefits of the hemodynamic superiority of stentless valves, we conducted a case-match study among patients who underwent aortic valve replacement with two types of porcine bioprostheses: the Toronto SPV and the stented Hancock II bioprosthesis. Methods: Preoperative clinical variables predictive of death after aortic valve replacement were determined by a stepwise logistic regression analysis in a series of 908 consecutive patients who received porcine aortic bioprostheses during a 14-year interval. Advanced age, New York Heart Association functional class IV, left ventricular ejection fraction of less than 30%, and coronary artery disease were independent predictors of death. On the basis of these four variables, 198 pairs of patients who survived aortic valve replacement with stentless and stented porcine valves were matched. The follow-up, truncated to the shortest interval for each matched pair, was 43 ؎ 24 months for both groups. Results: At 8 years the actuarial survival was 91% ؎ 4% for the Toronto SPV group and 69% ؎ 8% for the Hancock II group (p ‫؍‬ 0.006); the freedom from cardiac-related death was 95% ؎ 4% for the Toronto SPV and 81% ؎ 8% for the Hancock II (p ‫؍‬ 0.01); the freedom from any valve-related complication was 81% ؎ 5% for the Toronto SPV and 50% ؎ 10% for the Hancock II (p ‫؍‬ 0.008). A Cox proportional hazard model demonstrated a significant reduction in cardiac mortality rates and valve-related morbidity in patients who received the Toronto SPV bioprosthesis. Conclusions: Although it is possible that confounding factors may have played a role in the clinical outcomes of this case-control study, the study suggests that aortic valve replacement with a stentless porcine valve enhances survival. This is believed to be due to the hemodynamic superiority of these valves.

The Annals of Thoracic Surgery, Feb 1, 2009

Background. Elderly patients older than the age of 75 constitute 13% of the population that under... more Background. Elderly patients older than the age of 75 constitute 13% of the population that undergoes cardiac surgery at our institution and represent the fastest growing population in Ontario. We have witnessed an increasing proportion of elderly patients being referred for repeat surgical intervention for valvular heart disease. We determined the perioperative and long-term outcomes in elderly patients undergoing redo cardiac valve surgery. Methods. A retrospective review of our institutional database identified 112 patients aged 75 years or older (mean age, 78 ؎ 3 years; range, 75 to 89 years) who underwent redo valve surgery between 1990 and 2004. All patients presented with a previous surgical intervention on the valve of interest. The mean follow-up was 5 ؎ 4 years and was 100% complete. Results. Eighty-eight patients (79%) had isolated valve surgery at their primary operation whereas 24 patients (21%) had concomitant coronary artery bypass grafting at the time of their initial valve surgery. At reoperation, 74 patients (66%) underwent single valve surgery (40 aortic valve, 34 mitral valve), 33 patients (29.5%) required double valve surgery, and 5 patients (4.5%) had triple valve surgery. Thirty-three patients (29.5%) required concomitant coronary artery bypass grafting, among whom 14 patients had a previous coronary artery bypass graft surgery. There were 12 operative (10.7%) and 47 late deaths (42%). Cardiovascular events were the cause of death in 32 patients (54% of all deaths). Overall survival at 5 years was 67% ؎ 5%. The freedom from valve-related mortality and morbidity was 86% ؎ 4% at 5 years. Mean intensive care eunit stay was 3.7 ؎ 4.5 days, and postoperative hospital stay was 15 ؎ 12 days. Conclusions. Redo valvular surgery in an elderly cohort can be performed with acceptable morbidity and mortality. Although 5-year survival is lower than that observed with a younger patient population, it is still likely higher than expected survival without surgical intervention. Despite increased resource utilization, elderly patients should be offered redo surgical intervention for valvular heart disease.

The Annals of Thoracic Surgery, Jun 1, 1988

Lung transplantation has become a successful method in the therapy for end-stage pulmonary diseas... more Lung transplantation has become a successful method in the therapy for end-stage pulmonary disease. While single-lung transplantation provides benefit to patients with pulmonary fibrosis, bilateral lung transplants are required for septic or emphysematous lung disease. We describe the technique employed in 6 patients to transplant en bloc both lungs with the recipient heart left in place. The lungs are connected by a left atrial cuff, main pulmonary artery, and trachea. The completed implantation has a tracheal anastomosis securely wrapped in omentum, a left atrial anastomosis posterior to the heart, and a pulmonary artery anastomosis anteriorly. Airway ischemia resulted in the death of 1 patient. This procedure allows complete excision of all diseased pulmonary tissue, retention of the recipient's own heart, and separate excision of the donor heart for use in another recipient, thereby markedly increasing the supply of donor lungs for transplantation.

The Annals of Thoracic Surgery, Apr 1, 1979

Survey of Anesthesiology, Dec 1, 1987

The Journal of Thoracic and Cardiovascular Surgery, Aug 1, 1973

The Annals of Thoracic Surgery, Apr 1, 1998

Background. Deep sternal wound infection (DSWI) is a serious complication of cardiac operations p... more Background. Deep sternal wound infection (DSWI) is a serious complication of cardiac operations performed by median sternotomy. We attempted to define the predictors of DSWI and to describe the outcomes of two treatment strategies used at our institution. Methods. Retrospective review was performed using prospectively gathered data on 12,267 consecutive cardiac surgical patients from 1990 to 1995. Chart review was performed on all patients in whom DSWI developed, and follow-up was obtained on 100% of these patients. Results. Deep sternal wound infections developed in 92 patients (incidence 0.75%). Multivariable predictors for development of DSWI in all patients were (odds ratios and 95% confidence intervals in parentheses) (1) diabetes mellitus (2.6; 1.7 to 4.0) and (2) male sex (2.2; 1.3 to 3.9). In patients receiving coronary artery bypass grafting alone, independent predictors were (1) bilateral internal thoracic artery grafts (3.2; 1.1 to 8.9), (2) diabetes (2.7; 1.6 to 4.3), and (3) male sex (1.8; 0.9 to 3.7). For all other patients, predictors were (1) age more than 74 years (3.3; 1.1 to 10.1), (2) male sex (3.0; 1.1 to 8.1), and (3) diabetes (2.3; 0.9 to 5.8). Bilateral internal thoracic artery grafts increased the risk of DSWI in all subgroups of coronary artery bypass graft patients, particularly in diabetics who had a 14.3% incidence of DSWI after bilateral internal thoracic artery grafting. Patients with DSWIs received either sternal debridement with primary closure (n ‫؍‬ 45) or sternectomy with flap reconstruction (n ‫؍‬ 46). The 6-month freedom from adverse event rate (ie, readmission, reoperation, or death) was 76% for both groups of patients. Conclusions. Male sex and diabetes are predictors of DSWI in all cardiac surgical patients. Bilateral internal thoracic artery grafting may be contraindicated in diabetic patients.

The Journal of Clinical Endocrinology and Metabolism, Nov 1, 1989

Anesthesia, surgery, and hypothermia are conventionally considered the major stress factors in th... more Anesthesia, surgery, and hypothermia are conventionally considered the major stress factors in the metabolic and hormonal responses to cardiac surgery. We compared these responses in 14 nondiabetics during and for 24 h after coronary artery bypass surgery; 8 received cardioplegic solutions (C+), and 6 did not (C-). The mean intraoperative glucose load in C+ was 106 g compared to 32 g in C-; postoperatively both groups received 50 g. Marked hyperglycemia (31.8 +/- 4.8 mmol/L) occurred during hypothermia in C+, but dropped to 18.9 mmol/L before surgery ended and to 11.2 +/- 1.1 mmol/L by 2 h postop. In contrast, C- showed constant mild hyperglycemia of 8.3-9.8 mmol/L throughout, significantly less than C+ until 1 h postop. Insulin was suppressed by 55% only during hypothermia, peaking with rewarming in C+ at 2,849 +/- 911 vs. 639 +/- 251 pmol/L in C- (P less than 0.05); as with glycemia, values were comparable after 2 h postop. The pancreatic beta-cell thus responded to hyperglycemia during restoration of normothermia, resulting in a rapid decline in glycemia. This occurred despite elevations in antiinsulin factors in both groups; GH was 14 +/- 4 micrograms/L, cortisol was 607 +/- 38.6 nmol/L, norepinephrine was 11.5 +/- 3.7 nmol/L, epinephrine was 13,863 +/- 3,875 pmol/L, and FFA were 0.36 +/- 0.05 g/L. Early postop, a secondary rise in stress hormones occurred in both groups. Maximal cortisol values were at 4 h (1,186 +/- 140 nmol/L) and peaks of norepinephrine (6.50 +/- 1.66 nmol/L), epinephrine (7,969 +/- 3,602 pmol/L), and FFA (0.27 +/- 0.03 g/L) occurred. The only significant glucagon elevation was at 24 h (C+, 464 +/- 53 ng/L; C-, 350 +/- 241 ng/L; P less than 0.02), Thus, 1) many metabolic responses during coronary artery bypass surgery are influenced by the glucose-containing cardioplegic solution; 2) hypothermia suppresses insulin secretion, but it responds thereafter despite marked elevations of catecholamines, and is associated with decreasing glycemia despite elevated antiinsulin factors; 3) a lesser but highly significant stress response corresponds to awakening from anesthesia; and 4) glucagon plays a minor role in intraoperative hyperglycemia; the rise at 24 h is unexplained.

HealthcarePapers, Dec 15, 1999

Rosser and Kasperski build upon and consolidate several earlier reports to put forward a &quo... more Rosser and Kasperski build upon and consolidate several earlier reports to put forward a "bottom-up" model for the integration of health services for Ontario that establishes the family physician as the focal point of entry to the healthcare system. The essential features of this model are as follows: 1. Each person in the province should choose a family physician and formalize a partnership with this physician. 2. Each family physician should be in some form of group practice or practice network ranging in size from 7 to 30 physicians. 3. Urgent care would be provided by the members of the physician group on a 24-hour-a-day/7-days-per-week basis. 4. The family physician would be responsible for maintaining a comprehensive record for each patient through the use of information technology. 5. All providers in the system with whom a patient had contact would be required to forward copies of all reports and associated information from that contact to the family physician. 6. The group model will be characterized by collaboration, with the use of nurse practitioners and family-practice nurses to provide preventative and chronic care, the use of midwives to augment the provision of obstetrical, prenatal and postnatal care, and community access and hospital-in-the-home services. 7. Family physicians would be supported by a geographically defined group of specialists providing secondary care, such as psychiatrists, pediatricians and obstetricians, who would also coordinate tertiary care. 8. Every family physician should be an active staff member of his or her local hospital. 9. At some level of aggregation a family physician would be responsible for facilitating/implementing quality-improvement programs for community physicians. 10. Family physicians would be supported through a blended funding model.

Healthcare quarterly, Sep 15, 2000

Later this year, the Canadian Medical Association will publish a background discussion paper on C... more Later this year, the Canadian Medical Association will publish a background discussion paper on Canada's specialty care delivery system entitled, "An Overview of Specialty Care in Canada: Issue Identification and Policy Challenges." This article draws on the information contained within this discussion paper.

The Annals of Thoracic Surgery, Jul 1, 2004

We report the case of a 70-year-old woman with significant intermediate coronary artery stenosis ... more We report the case of a 70-year-old woman with significant intermediate coronary artery stenosis who underwent a series of stent procedures, ultimately leading to compromise of the origin of the circumflex artery. Intraoperatively, identification of an obtuse marginal coronary artery was impossible due to a thick layer of epicardial fat, calcification of the posterior atrioventricular groove, and an adherent, thickened pericardium. Therefore, a saphenous vein graft to the posterior vein of the left ventricle was constructed with ligation of the vein cephalad. This uncommon approach to surgical revascularization effectively relieved the patient's angina and may be of use in other difficult cases.

PubMed, Sep 1, 1985

To develop strategies for the management of high-risk patients, contemporary risk factors for ope... more To develop strategies for the management of high-risk patients, contemporary risk factors for operative mortality and postoperative ventricular dysfunction were identified in 214 patients undergoing mitral valve surgery in 1982 and 1983. Thirty-eight preoperative and perioperative variables were prospectively collected and analyzed by univariate and multivariate statistics. The overall mortality was 4.6% and the incidence of postoperative low-output syndrome (LOS) was 18.7%. Forty-seven patients with coronary artery disease (CAD) had a higher mortality and incidence of LOS (as evidenced by the need for inotropic drugs or counterpulsation to maintain blood pressure) (those with CAD 15% mortality, 40% LOS; those without CAD 2% mortality, 13% LOS; p less than .05). The presence of unstable angina and ischemic mitral regurgitation further increased the risk. Age was also a predictor of outcome. Patients who died or had LOS were older (those who died, 65 +/- 7 years, those with LOS, 58 +/- 11 years) than patients who survived and did not have postoperative dysfunction (those who survived, 53 +/- 11; those with no LOS, 53 +/- 11; p less than .01). Mitral regurgitation was associated with a higher (p less than .05) mortality and incidence of LOS (mortality 10.5%, LOS 36%; n = 76) than was mitral stenosis (mortality 0%, LOS 4%; n = 74) or mixed lesions (mortality 3%, LOS 15%; n = 64). In patients without CAD, mitral regurgitation remained a significant predictor of mortality and ventricular dysfunction.(ABSTRACT TRUNCATED AT 250 WORDS)

The Journal of Thoracic and Cardiovascular Surgery, 1985

patients were treated with debridement, primary wound closure, and mediastinal antibiotic irrigat... more patients were treated with debridement, primary wound closure, and mediastinal antibiotic irrigation (Group I). Between January of 1982 and December of 1983, 22 patients were treated with debridement, open "clean" packing, and delayed woundclosure by the techniqueof pectoral muscle flap mobilization, which preserves the thoracoacromial pedicles and the pectoral humeral attachments (Group II). The purpose of this study was to compare the results of the treatment of deep sternal infectiom after cardiac operatiom with these two techniques. The perioperative hemodynamic, operation, functional, and pathologicl profilesof both groups of patients werethe same. Thecosmeticandfunctionalresults werethe same in both groups as were shoulder girdle and torso mobility. We conclude that either technique is equally effective in the managementof patients in whomthe serious complication of deep sternal infection with mediastinitis develops after cardiac operation, and we now recommend debridement and pectoral muscle flap closure in one stage.

Survey of Anesthesiology, 1984