1
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Choi CH, Singh S, Cheung AT, Vanneman M, Madhok J. Prolonged Postoperative Euglycemic Diabetic Ketoacidosis in a Lung Transplant Recipient With Preoperative SGLT2 Inhibitor Use. J Cardiothorac Vasc Anesth 2024:S1053-0770(24)00171-X. [PMID: 38637210 DOI: 10.1053/j.jvca.2024.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 04/20/2024]
Affiliation(s)
- Christine H Choi
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
| | - Shivani Singh
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Albert T Cheung
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Matthew Vanneman
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jai Madhok
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University School of Medicine, Stanford, CA
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Aggarwal A, Mortensen P, Hao J, Kaczmarczyk Ł, Cheung AT, Ghofaily LA, Gorman RC, Desai ND, Bavaria JE, Pouch AM. Strain estimation in aortic roots from 4D echocardiographic images using medial modeling and deformable registration. Med Image Anal 2023; 87:102804. [PMID: 37060701 DOI: 10.1016/j.media.2023.102804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/30/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023]
Abstract
Even though the central role of mechanics in the cardiovascular system is widely recognized, estimating mechanical deformation and strains in-vivo remains an ongoing practical challenge. Herein, we present a semi-automated framework to estimate strains from four-dimensional (4D) echocardiographic images and apply it to the aortic roots of patients with normal trileaflet aortic valves (TAV) and congenital bicuspid aortic valves (BAV). The method is based on fully nonlinear shell-based kinematics, which divides the strains into in-plane (shear and dilatational) and out-of-plane components. The results indicate that, even for size-matched non-aneurysmal aortic roots, BAV patients experience larger regional shear strains in their aortic roots. This elevated strains might be a contributing factor to the higher risk of aneurysm development in BAV patients. The proposed framework is openly available and applicable to any tubular structures.
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3
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Steffner KR, Cheung AT. Preservation of Spinal Cord Function. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00023-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Pouch AM, Patel PA, Desai ND, Yushkevich N, Goodwin M, Lai EK, Cheung AT, Moeller P, Weiss SJ, Gorman JH, Bavaria JE, Gorman RC. Dynamic Volumetric Assessment of the Aortic Root: The Influence of Bicuspid Aortic Valve Competence. Ann Thorac Surg 2021; 112:1317-1324. [PMID: 32987018 PMCID: PMC7990744 DOI: 10.1016/j.athoracsur.2020.07.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 07/13/2020] [Accepted: 07/20/2020] [Indexed: 11/20/2022]
Abstract
BACKGROUND Aortic root evaluation is conventionally based on 2-dimensional measurements at a single phase of the cardiac cycle. This work presents an image analysis method for assessing dynamic 3-dimensional changes in the aortic root of minimally calcified bicuspid aortic valves (BAVs) with and without moderate to severe aortic regurgitation. METHODS The aortic root was segmented over the full cardiac cycle in 3-dimensional transesophageal echocardiographic images acquired from 19 patients with minimally calcified BAVs and from 16 patients with physiologically normal tricuspid aortic valves (TAVs). The size and dynamics of the aortic root were assessed using the following image-derived measurements: absolute mean root volume and mean area at the level of the ventriculoaortic junction, sinuses of Valsalva, and sinotubular junction, as well as normalized root volume change and normalized area change of the ventriculoaortic junction, sinuses of Valsalva, and sinotubular junction over the cardiac cycle. RESULTS Normalized volume change over the cardiac cycle was significantly greater in BAV roots with moderate to severe regurgitation than in normal TAV roots and in BAV roots with no or mild regurgitation. Aortic root dynamics were most significantly different at the mid-level of the sinuses of Valsalva in BAVs with moderate to severe regurgitation than in competent TAVs and BAVs. CONCLUSIONS Echocardiographic reconstruction of the aortic root demonstrates significant differences in dynamics of BAV roots with moderate to severe regurgitation relative to physiologically normal TAVs and competent BAVs. This finding may have implications for risk of future dilatation, dissection, or rupture, which warrant further investigation.
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Affiliation(s)
- Alison M Pouch
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Bioengineering, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nimesh D Desai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Natalie Yushkevich
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Goodwin
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric K Lai
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Albert T Cheung
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, California
| | - Patrick Moeller
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Stuart J Weiss
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph H Gorman
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph E Bavaria
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert C Gorman
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Luo YH, Li WHC, Cheung AT, Ho LLK, Xia W, He XL, Zhang JP, Chung JOK. Relationships between resilience and quality of life in parents of children with cancer. J Health Psychol 2021; 27:1048-1056. [PMID: 33522296 DOI: 10.1177/1359105321990806] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
CLINICALTRIALS.GOV ID NCT03631485.
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Affiliation(s)
- Y H Luo
- University of Hong Kong, Hong Kong
| | - W H C Li
- University of Hong Kong, Hong Kong
| | | | - L L K Ho
- University of Hong Kong, Hong Kong
| | - W Xia
- University of Hong Kong, Hong Kong
| | - X L He
- People's Hospital of Hunan Province, China
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Aly AH, Aly AH, Lai EK, Yushkevich N, Stoffers RH, Gorman JH, Cheung AT, Gorman JH, Gorman RC, Yushkevich PA, Pouch AM. In Vivo Image-Based 4D Modeling of Competent and Regurgitant Mitral Valve Dynamics. Exp Mech 2021; 61:159-169. [PMID: 33776070 PMCID: PMC7988343 DOI: 10.1007/s11340-020-00656-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 08/05/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND In vivo characterization of mitral valve dynamics relies on image analysis algorithms that accurately reconstruct valve morphology and motion from clinical images. The goal of such algorithms is to provide patient-specific descriptions of both competent and regurgitant mitral valves, which can be used as input to biomechanical analyses and provide insights into the pathophysiology of diseases like ischemic mitral regurgitation (IMR). OBJECTIVE The goal is to generate accurate image-based representations of valve dynamics that visually and quantitatively capture normal and pathological valve function. METHODS We present a novel framework for 4D segmentation and geometric modeling of the mitral valve in real-time 3D echocardiography (rt-3DE), an imaging modality used for pre-operative surgical planning of mitral interventions. The framework integrates groupwise multi-atlas label fusion and template-based medial modeling with Kalman filtering to generate quantitatively descriptive and temporally consistent models of valve dynamics. RESULTS The algorithm is evaluated on rt-3DE data series from 28 patients: 14 with normal mitral valve morphology and 14 with severe IMR. In these 28 data series that total 613 individual 3DE images, each 3D mitral valve segmentation is validated against manual tracing, and temporal consistency between segmentations is demonstrated. CONCLUSIONS Automated 4D image analysis allows for reliable non-invasive modeling of the mitral valve over the cardiac cycle for comparison of annular and leaflet dynamics in pathological and normal mitral valves. Future studies can apply this algorithm to cardiovascular mechanics applications, including patient-specific strain estimation, fluid dynamics simulation, inverse finite element analysis, and risk stratification for surgical treatment.
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Affiliation(s)
- A H Aly
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - A H Aly
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - E K Lai
- Gorman Cardiovascular Research Group, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - N Yushkevich
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | | | - J H Gorman
- Gorman Cardiovascular Research Group, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - A T Cheung
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Stanford, CA, USA
| | - J H Gorman
- Gorman Cardiovascular Research Group, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - R C Gorman
- Gorman Cardiovascular Research Group, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - P A Yushkevich
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
| | - A M Pouch
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, USA
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DeAnda A, Basu R, Cheung AT, Shaw A. The Economic Consequences of Cardiac Surgery Associated Acute Renal Dysfunction After Heart Surgery. Semin Thorac Cardiovasc Surg 2020; 33:1001-1007. [DOI: 10.1053/j.semtcvs.2020.11.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/05/2020] [Indexed: 11/11/2022]
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8
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Shapeton AD, Cheung AT. Three-Dimensional Transesophageal Echocardiography: Do We Have the Technology to Predict Outcomes in Ischemic Mitral Regurgitation? J Cardiothorac Vasc Anesth 2020; 34:2536-2538. [PMID: 32434721 DOI: 10.1053/j.jvca.2020.04.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 04/18/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Alexander D Shapeton
- Department of Anesthesia, Critical Care and Pain Medicine Boston Veterans Affairs Health Care System West Roxbury, MA; School of Medicine Tufts University Boston, MA.
| | - Albert T Cheung
- Department of Anesthesiology and Perioperative Medicine, Cardiothoracic Anesthesiology and Critical Care Stanford University Stanford, CA
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Tien M, Ku A, Martinez-Acero N, Zvara J, Sun EC, Cheung AT. The Penn Classification Predicts Hospital Mortality in Acute Stanford Type A and Type B Aortic Dissections. J Cardiothorac Vasc Anesth 2020; 34:867-873. [PMID: 31558394 PMCID: PMC7684762 DOI: 10.1053/j.jvca.2019.08.036] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Revised: 08/15/2019] [Accepted: 08/18/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVES Mortality in acute aortic dissection varies depending on anatomic location, extent, and associated complications. The Stanford classification guides surgical versus medical management. The Penn classification stratifies mortality risk in patients with Stanford type A aortic dissections undergoing surgery. The objective of the present study was to determine whether the Penn classification can predict hospital mortality in patients with acute Stanford type A and type B aortic dissections undergoing surgical or medical management. DESIGN Retrospective, observational study. SETTING Tertiary care, university hospital. PARTICIPANTS Patients with acute aortic dissection between January 2008 and December 2017. INTERVENTIONS Examination of hospital mortality after surgical or medical management. MEASUREMENTS AND MAIN RESULTS Three hundred fifty-two patients had confirmed dissections (186 type A, 166 type B). The overall mortality was 18.8% for type A and 13.3% for type B. Penn class A patients with type A or type B dissections undergoing surgical repair had the lowest mortality (both 3.1%). Penn class B, C, or B+C patients with type A dissections and Penn class B+C patients with type B dissections undergoing medical management had the greatest incidence of mortality (50.0%-57.1%). All others had intermediate mortality (6.7%-39.3%). Logistic regression analysis demonstrated that Penn class B, C, and B+C patients had a greater odds of mortality and predicted mortality than did Penn class A patients. CONCLUSIONS The Penn classification predicts hospital mortality in patients with acute Stanford type A or type B aortic dissections undergoing surgical or medical management. Early endovascular repair may confer lower risk of mortality in patients with type B dissections presenting without ischemia.
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Affiliation(s)
- Michael Tien
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Andrew Ku
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Natalia Martinez-Acero
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jessica Zvara
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Eric C Sun
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA
| | - Albert T Cheung
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA.
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Hickerson LC, Madden AM, Keeyapaj W, Cheung AT. Sphenopalatine Ganglion Blockade for the Management of Postdural Puncture Headache After Lumbar Drain Placement in Patients Undergoing Thoracoabdominal Aortic Aneurysm Repair. J Cardiothorac Vasc Anesth 2020; 34:2736-2739. [PMID: 32553645 DOI: 10.1053/j.jvca.2020.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 03/07/2020] [Accepted: 03/09/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Leigh C Hickerson
- Division of Cardiothoracic Anesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, NH.
| | - Anne-Marie Madden
- Division of Cardiothoracic Anesthesiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Worasak Keeyapaj
- Division of Cardiothoracic Anesthesiology, Stanford Health Care, Palo Alto, CA
| | - Albert T Cheung
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Stanford Health Care, Palo Alto, CA
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Gregory AJ, Grant MC, Manning MW, Cheung AT, Ender J, Sander M, Zarbock A, Stoppe C, Meineri M, Grocott HP, Ghadimi K, Gutsche JT, Patel PA, Denault A, Shaw A, Fletcher N, Levy JH. Enhanced Recovery After Cardiac Surgery (ERAS Cardiac) Recommendations: An Important First Step-But There Is Much Work to Be Done. J Cardiothorac Vasc Anesth 2020; 34:39-47. [PMID: 31570245 DOI: 10.1053/j.jvca.2019.09.002] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 09/02/2019] [Indexed: 01/17/2023]
Affiliation(s)
- Alexander J Gregory
- Department of Anesthesiology, Perioperative and Pain Medicine, Cumming School of Medicine, University of Calgary, Alberta, Canada; Department of Anesthesiology, Perioperative and Pain Medicine, Libin Cardiovascular Institute of Alberta, Calgary, Alberta, Canada
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins Medical Institutions, Baltimore, MD; Armstrong Institute for Patient Safety and Quality, The Johns Hopkins Medical Institutions, Baltimore, MD
| | | | - Albert T Cheung
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA
| | - Joerg Ender
- Department of Anesthesiology and Intensive Care Medicine, Herzzentrum Leipzig, Leipzig, Germany
| | - Michael Sander
- Department of Anaesthesiology and Intensive Care Medicine, UKGM University Hospital Gießen, Justus-Liebig-University Giessen, Gießen, Germany
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Christian Stoppe
- Department of Intensive Care Medicine, University Hospital of the RWTH Aachen, Aachen, Germany
| | | | - Hilary P Grocott
- Department of Anesthesiology, Perioperative and Pain Medicine and Department of Surgery, University of Manitoba, Winnipeg, Canada
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Duke University, Durham, NC; Department of Critical Care, Duke University School of Medicine, Durham, NC
| | - Jacob T Gutsche
- Division of Cardiac Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Prakash A Patel
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - Andre Denault
- Département d'Anesthésiologie et de Médecine de la Douleur, Institut de Cardiologie de Montréal, Montréal, Quebec Canada; Division des Soins Intensifs, Département de Chirurgie Cardiaque, Institut de Cardiologie de Montréal, Montréal, Quebec Canada; Département de Pharmacologie et de Physiologie, Institut de Cardiologie de Montréal, Montréal, Quebec Canada
| | - Andrew Shaw
- Department of Anesthesiology and Pain Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Nick Fletcher
- Department of Cardiothoracic Anesthesia and Critical Care, St. Georges University Hospital, London, United Kingdom; Institute of Anesthesia and Critical Care, Cleveland Clinic London, London, United Kingdom
| | - Jerrold H Levy
- Department of Anesthesiology, Duke University, Durham, NC; Department of Critical Care, Duke University School of Medicine, Durham, NC
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Ho L, Li W, Cheung AT, Ho E, Lam K, Chiu SY, Chan G, Chung J. Relationships among hope, psychological well-being and health-related quality of life in childhood cancer survivors. J Health Psychol 2019; 26:1528-1537. [PMID: 31621412 DOI: 10.1177/1359105319882742] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
This cross-sectional study examined the level of hope among Hong Kong childhood cancer survivors and investigated the relationships among hope, depressive symptoms, self-esteem and health-related quality of life. We recruited 176 survivors aged 10-16 years who underwent medical follow-ups at the outpatient clinic. This study revealed that lower levels of hope were associated with an increase in depressive symptoms and reductions in self-esteem and health-related quality of life. Our results contribute to novel findings by demonstrating that hope may be a significant factor associated with health-related quality of life. This understanding could increase healthcare professionals' awareness about the psychological needs of childhood cancer survivors.
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Affiliation(s)
- Llk Ho
- The University of Hong Kong, Hong Kong
| | - Whc Li
- The University of Hong Kong, Hong Kong
| | | | - Eky Ho
- The University of Hong Kong, Hong Kong
| | - Kkw Lam
- The University of Hong Kong, Hong Kong
| | - S Y Chiu
- Hong Kong Children's Hospital, Hong Kong
| | - Gcf Chan
- Queen Mary Hospital, Hospital Authority, Hong Kong
| | - Jok Chung
- The University of Hong Kong, Hong Kong
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Guvakov D, Bezinover D, Lomivorotov VV, Postnov VG, Weiss SJ, Cheung AT, Swain J, Lomivorotov VN. The "Ice Age" in Cardiac Surgery: Evolution of the "Siberian" Method of Brain Protection During Deep Hypothermic Perfusionless Circulatory Arrest. J Cardiothorac Vasc Anesth 2019; 33:3366-3374. [PMID: 31129071 DOI: 10.1053/j.jvca.2019.04.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 03/06/2019] [Accepted: 04/02/2019] [Indexed: 11/11/2022]
Abstract
Deep hypothermic perfusionless circulatory arrest was the first practical neuroprotective technique used for open-heart surgery. It was refined at the Novosibirsk Medical Research Center in Siberia and was actively used from the mid-1950s until 2001.This review describes the development of this technique and its contribution to our understanding of the dynamic changes in human physiology during induced hypothermia for circulatory arrest without extracorporeal perfusion. Deep hypothermic perfusionless circulatory arrest was an important stepping stone in the development of modern approaches in neuroprotection and monitoring during cardiac surgery.
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Affiliation(s)
- Dmitri Guvakov
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA.
| | - Dmitri Bezinover
- Department of Anesthesiology and Perioperative Medicine, Penn State College of Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Vladimir V Lomivorotov
- Department of Anesthesiology, E. Meshalkin National Medical Research Center (MNMRC), Novosibirsk, Russia
| | - Vadim G Postnov
- Department of Anesthesiology, E. Meshalkin National Medical Research Center (MNMRC), Novosibirsk, Russia
| | - Stuart J Weiss
- Department of Anesthesia and Critical Care, University of Pennsylvania Health System, Philadelphia, PA
| | - Albert T Cheung
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Palo Alto, CA
| | - Julie Swain
- Department of Clinical Performance, Mount Sinai Health System, New York, NY
| | - Vladimir N Lomivorotov
- Department of Anesthesiology, E. Meshalkin National Medical Research Center (MNMRC), Novosibirsk, Russia
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Chung J, Lam K, Ho KY, Cheung AT, Ho L, Gibson F, Li W. Relationships among resilience, self-esteem, and depressive symptoms in Chinese adolescents. J Health Psychol 2018; 25:2396-2405. [PMID: 30229681 DOI: 10.1177/1359105318800159] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
This study explored the relationships among resilience, self-esteem, and depressive symptoms in Hong Kong Chinese adolescents. We selected a stratified random sample of 1816 Form 1 students from all 18 districts of Hong Kong. This study revealed that about 21 percent adolescents are experiencing some depressive symptoms. Our results contribute novel findings to the literature showing that resilience is a strong indicator of adolescents at a higher risk of depression and increasing adolescents' resilience to psychological distress is crucial to enhance their mental well-being. It is crucial to develop interventions that can enhance resilience and promote positive mental well-being among adolescents.
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Affiliation(s)
- Jok Chung
- The University of Hong Kong, Hong Kong (SAR)
| | - Kkw Lam
- The University of Hong Kong, Hong Kong (SAR)
| | - K Y Ho
- The University of Hong Kong, Hong Kong (SAR)
| | - A T Cheung
- The University of Hong Kong, Hong Kong (SAR)
| | - Llk Ho
- The University of Hong Kong, Hong Kong (SAR)
| | - F Gibson
- University of Surrey, United Kingdom
| | - Whc Li
- The University of Hong Kong, Hong Kong (SAR)
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Rao V, Ghadimi K, Keeyapaj W, Parsons CA, Cheung AT. Inhaled Nitric Oxide (iNO) and Inhaled Epoprostenol (iPGI 2) Use in Cardiothoracic Surgical Patients: Is there Sufficient Evidence for Evidence-Based Recommendations? J Cardiothorac Vasc Anesth 2017; 32:1452-1457. [PMID: 29336971 DOI: 10.1053/j.jvca.2017.12.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Indexed: 12/19/2022]
Affiliation(s)
- Vidya Rao
- Department of Anesthesiology, Stanford University, Stanford, CA
| | - Kamrouz Ghadimi
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | | | | | - Albert T Cheung
- Department of Anesthesiology, Stanford University, Stanford, CA.
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Bolliger D, Poltera C, Cheung AT, Couture P, Michaux I, Poelaert J, Preisman S, Skarvan K, Buse GL, Seeberger MD. Assessment of Left Ventricular Dimensions by Transoesophageal Echocardiography in Patients During Coronary Artery Bypass Surgery. Turk J Anaesthesiol Reanim 2017; 45:367-373. [PMID: 29359077 PMCID: PMC5772417 DOI: 10.5152/tjar.2017.25483] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2017] [Accepted: 07/10/2017] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Normative values of left ventricular (LV) end-diastolic area and diameter (EDA and EDD) for intraoperative transoesophageal echocardiography (TEE) have not been established. We aimed to define the ranges of LV EDA and EDD for intraoperative TEE examinations in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS A MEDLINE search for studies reporting LV EDA and EDD in CABG patients was performed. Individual-level dataset from 333 anaesthetised and mechanically ventilated patients with preserved LV function (study population) were received from 8 studies. EDA and calculated EDD values in the study population were compared with summary mean EDD values obtained by transthoracic echocardiography (TTE) in 2 studies of 500 awake patients with coronary artery disease (CAD). Further, the influence of prespecified factors on EDD was evaluated through a multivariate regression model. RESULTS LV EDA and EDD values measured by TEE in anaesthetised CABG patients were 16.7±4.7 cm2 and 4.6±0.6 cm, respectively. EDD values measured by TEE in anaesthetised patients were 10% to 13% less those measured by TTE in 2 studies of awake patients (p<0.001). Body surface area, age and fractional area change but not sex were factors that affected LV EDD. CONCLUSION LV EDD values measured by intraoperative TEE in anaesthetised and mechanically ventilated CABG patients were 10% to 13% less than those measured by TTE in awake CAD patients. This finding indicates that independent normative values specific for intraoperative TEE should be established for guiding intraoperative clinical decisions.
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Affiliation(s)
- Daniel Bolliger
- Department of Anesthesiology, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Corsin Poltera
- Department of Anesthesiology, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Albert T. Cheung
- Department of Anesthesia, University of Pennsylvania, Philadelphia, USA
| | - Pierre Couture
- Department of Anesthesiology, Montreal Heart Institution, University of Montréal, Montréal, Quebec, Canada
| | - Isabelle Michaux
- Department of Intensive Care Medicine, Mont-Godinne University Hospital, Université Catholique de Louvain, Yvoir, Belgium
| | - Jan Poelaert
- Department of Anesthesiology and Perioperative Medicine, University Hospital-Free University of Brussels, Brussels, Belgium
| | - Sergey Preisman
- Department of Anesthesiology and Intensive Care, Sheba Medical Center, Tel Aviv University, Sackler School of Medicine, Tel Aviv, Israel
| | - Karl Skarvan
- Department of Anesthesiology, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Giovanna Lurati Buse
- Department of Anesthesiology, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, Basel, Switzerland
| | - Manfred D. Seeberger
- University of Basel, Medical School, Basel, Switzerland; and Institute for Anesthesiology and Intensive Care Medicine, Klinik Hirslanden, Zurich, Switzerland
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Ghadimi K, Gutsche JT, Ramakrishna H, Setegne SL, Jackson KR, Augoustides JG, Ochroch EA, Weiss SJ, Bavaria JE, Cheung AT. Sodium bicarbonate use and the risk of hypernatremia in thoracic aortic surgical patients with metabolic acidosis following deep hypothermic circulatory arrest. Ann Card Anaesth 2017; 19:454-62. [PMID: 27397449 PMCID: PMC4971973 DOI: 10.4103/0971-9784.185527] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Objective: Metabolic acidosis after deep hypothermic circulatory arrest (DHCA) for thoracic aortic operations is commonly managed with sodium bicarbonate (NaHCO3). The purpose of this study was to determine the relationships between total NaHCO3 dose and the severity of metabolic acidosis, duration of mechanical ventilation, duration of vasoactive infusions, and Intensive Care Unit (ICU) or hospital length of stay (LOS). Methods: In a single center, retrospective study, 87 consecutive elective thoracic aortic operations utilizing DHCA, were studied. Linear regression analysis was used to test for the relationships between the total NaHCO3 dose administered through postoperative day 2, clinical variables, arterial blood gas values, and short-term clinical outcomes. Results: Seventy-five patients (86%) received NaHCO3. Total NaHCO3 dose averaged 136 ± 112 mEq (range: 0.0–535 mEq) per patient. Total NaHCO3 dose correlated with minimum pH (r = 0.41, P < 0.0001), minimum serum bicarbonate (r = −0.40, P < 0.001), maximum serum lactate (r = 0.46, P = 0.007), duration of metabolic acidosis (r = 0.33, P = 0.002), and maximum serum sodium concentrations (r = 0.29, P = 0.007). Postoperative hypernatremia was present in 67% of patients and peaked at 12 h following DHCA. Eight percent of patients had a serum sodium ≥ 150 mEq/L. Total NaHCO3 dose did not correlate with anion gap, serum chloride, not the duration of mechanical ventilator support, vasoactive infusions, ICU or hospital LOS. Conclusion: Routine administration of NaHCO3 was common for the management of metabolic acidosis after DHCA. Total dose of NaHCO3 was a function of the severity and duration of metabolic acidosis. NaHCO3 administration contributed to postoperative hypernatremia that was often severe. The total NaHCO3 dose administered was unrelated to short-term clinical outcomes.
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Affiliation(s)
- Kamrouz Ghadimi
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | - Jacob T Gutsche
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Samuel L Setegne
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Kirk R Jackson
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - John G Augoustides
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - E Andrew Ochroch
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Stuart J Weiss
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph E Bavaria
- Department of Surgery, Division of Cardiac Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Albert T Cheung
- Department of Anesthesiology, Stanford University, Stanford, CA, USA
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18
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Woo EY, Bavaria JE, Pochettino A, Gleason TG, Woo YJ, Velazquez OC, Carpenter JP, Cheung AT, Fairman RM. Techniques for Preserving Vertebral Artery Perfusion During Thoracic Aortic Stent Grafting Requiring Aortic Arch Landing. Vasc Endovascular Surg 2016; 40:367-73. [PMID: 17038570 DOI: 10.1177/1538574406293735] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Thoracic endografting offers many advantages over open repair. However, delivery of the device can be difficult and may necessitate adjunctive procedures. We describe our techniques for preserving perfusion to the left subclavian artery despite endograft coverage to obtain a proximal seal zone. We reviewed our experience with the Talent thoracic stent graft (Medtronic, Santa Rosa, CA). From 1999 to 2003, 49 patients received this device (29 men, 20 women). Seventeen patients required adjunctive procedures to facilitate proximal graft placement. We performed left subclavian-to-left common carotid artery transposition (6), left common carotid-to-left subclavian artery bypass with ligation proximal to the vertebral artery (7), and left common carotid-to-left subclavian artery bypass with proximal coil embolization (4). Patients who had anatomy unfavorable to transposition or bypass with proximal ligation (large aneurysms or proximal vertebral artery origin) were treated with coil embolization of the proximal left subclavian artery in order to prevent subsequent type II endoleaks. Technical success rate of the carotid subclavian bypass was 100%. Patient follow-up ranged from 3 to 48 months with a mean of 12 months. Six patients had follow-up <6 months owing to recent graft placement. Primary patency was 100%. No neurologic events occurred during the procedure or upon follow-up. One patient had a transient chyle leak that spontaneously resolved in 24 hours. Another patient had a phrenic nerve paresis that resolved after 3 weeks. We believe that it is important to maintain patency of the vertebral artery specifically when a patent right vertebral system and an intact basilar artery is not demonstrated. Furthermore, we describe a novel technique of coil embolization of the proximal left subclavian artery in conjunction with left common carotid-to-left subclavian artery bypass. This circumvents the need for potentially hazardous mediastinal dissection and ligation of the proximal left subclavian artery in cases of large proximal aneurysms or unfavorable vertebral artery anatomy.
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Affiliation(s)
- Edward Y Woo
- Division of Vascular Surgery, Department of Surgery, University of Pennsylvania Medical Center, Philadelphia, PA, USA.
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19
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Abstract
Objective This manuscript was written to present a systemic protocol for the prevention, early detection, and treatment of spinal cord ischemia following open and endovascular thoracoabdominal aortic operations. Methods This protocol was a collaborative effort between surgeons, anesthesiologists and intensivists. It was implemented at our institution in November 2007. Nurses are trained to prevent, rapidly detect and ultimately aid in the treatment of spinal cord ischemia. Results Implementation of this protocol has aided in prevention, detection and treatment of spinal cord ischemia in patients after open and endovascular thoracoabdominal aortic operations. Conclusion Standardized care and reliance on trained nursing staff to monitor for symptoms following thoracoabdominal aortic operations are safe and aid in the rapid detection, treatment and reversal of spinal cord ischemia.
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Affiliation(s)
- Reilly D Hobbs
- Division of Cardiothoracic and Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Brant W Ullery
- Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Allison R Mentzer
- Division of Cardiothoracic and Vascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Albert T Cheung
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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20
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Wijdh-den Hamer IJ, Bouma W, Lai EK, Levack MM, Shang EK, Pouch AM, Eperjesi TJ, Plappert TJ, Yushkevich PA, Hung J, Mariani MA, Khabbaz KR, Gleason TG, Mahmood F, Acker MA, Woo YJ, Cheung AT, Gillespie MJ, Jackson BM, Gorman JH, Gorman RC. The value of preoperative 3-dimensional over 2-dimensional valve analysis in predicting recurrent ischemic mitral regurgitation after mitral annuloplasty. J Thorac Cardiovasc Surg 2016; 152:847-59. [PMID: 27530639 DOI: 10.1016/j.jtcvs.2016.06.040] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/05/2016] [Accepted: 06/10/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Repair for ischemic mitral regurgitation with undersized annuloplasty is characterized by high recurrence rates. We sought to determine the value of pre-repair 3-dimensional echocardiography over 2-dimensional echocardiography in predicting recurrence at 6 months. METHODS Intraoperative transesophageal 2-dimensional echocardiography and 3-dimensional echocardiography were performed in 50 patients undergoing undersized annuloplasty for ischemic mitral regurgitation. Two-dimensional echocardiography annular diameter and tethering parameters were measured in the apical 2- and 4-chamber views. A customized protocol was used to assess 3-dimensional annular geometry and regional leaflet tethering. Recurrence (grade ≥2) was assessed with 2-dimensional transthoracic echocardiography at 6 months. RESULTS Preoperative 2- and 3-dimensional annular geometry were similar in all patients with ischemic mitral regurgitation. Preoperative 2- and 3-dimensional leaflet tethering were significantly higher in patients with recurrence (n = 13) when compared with patients without recurrence (n = 37). Multivariate logistic regression revealed preoperative 2-dimensional echocardiography posterior tethering angle as an independent predictor of recurrence with an optimal cutoff value of 32.0° (area under the curve, 0.81; 95% confidence interval, 0.68-0.95; P = .002) and preoperative 3-dimensional echocardiography P3 tethering angle as an independent predictor of recurrence with an optimal cutoff value of 29.9° (area under the curve, 0.92; 95% confidence interval, 0.84-1.00; P < .001). The predictive value of the 3-dimensional geometric multivariate model can be augmented by adding basal aneurysm/dyskinesis (area under the curve, 0.94; 95% confidence interval, 0.87-1.00; P < .001). CONCLUSIONS Preoperative 3-dimensional echocardiography P3 tethering angle is a stronger predictor of ischemic mitral regurgitation recurrence after annuloplasty than preoperative 2-dimensional echocardiography posterior tethering angle, which is highly influenced by viewing plane. In patients with a preoperative P3 tethering angle of 29.9° or larger (especially when combined with basal aneurysm/dyskinesis), chordal-sparing valve replacement should be strongly considered.
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Affiliation(s)
- Inez J Wijdh-den Hamer
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wobbe Bouma
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eric K Lai
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Melissa M Levack
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Eric K Shang
- Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Alison M Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Thomas J Eperjesi
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Theodore J Plappert
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Paul A Yushkevich
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Judy Hung
- Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kamal R Khabbaz
- Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | | | - Feroze Mahmood
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Michael A Acker
- Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Albert T Cheung
- Department of Anesthesia, Stanford University, Stanford, Calif
| | - Matthew J Gillespie
- Department of Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Benjamin M Jackson
- Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa.
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21
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Bouma W, Lai EK, Levack MM, Shang EK, Pouch AM, Eperjesi TJ, Plappert TJ, Yushkevich PA, Mariani MA, Khabbaz KR, Gleason TG, Mahmood F, Acker MA, Woo YJ, Cheung AT, Jackson BM, Gorman JH, Gorman RC. Preoperative Three-Dimensional Valve Analysis Predicts Recurrent Ischemic Mitral Regurgitation After Mitral Annuloplasty. Ann Thorac Surg 2015; 101:567-75; discussion 575. [PMID: 26688087 DOI: 10.1016/j.athoracsur.2015.09.076] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 09/08/2015] [Accepted: 09/21/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Valve repair for ischemic mitral regurgitation (IMR) with undersized annuloplasty rings is characterized by high IMR recurrence rates. Patient-specific preoperative imaging-based risk stratification for recurrent IMR would optimize results. We sought to determine if prerepair three-dimensional (3D) echocardiography combined with a novel valve-modeling algorithm would be predictive of IMR recurrence 6 months after repair. METHODS Intraoperative transesophageal real-time 3D echocardiography was performed in 50 patients undergoing undersized ring annuloplasty for IMR and in 21 patients with normal mitral valves. A customized image analysis protocol was used to assess 3D annular geometry and regional leaflet tethering. IMR recurrence (≥ grade 2) was assessed with two-dimensional transthoracic echocardiography 6 months after repair. RESULTS Preoperative annular geometry was similar in all IMR patients, and preoperative leaflet tethering was significantly higher in patients with recurrent IMR (n=13) than in patients in whom IMR did not recur (n=37) (tethering index: 3.91 ± 1.01 vs 2.90 ± 1.17, p = 0.008; tethering angles of A3: 23.5° ± 8.9° vs 14.4° ± 11.4°, p = 0.012; P2: 44.4° ± 8.8° vs 28.2° ± 17.0°, p = 0.002; and P3: 35.2° ± 6.0° vs. 18.6° ± 12.7°, p < 0.001). Multivariate logistic regression analysis revealed the preoperative P3 tethering angle as an independent predictor of IMR recurrence with an optimal cutoff value of 29.9° (area under the curve, 0.92; 95% confidence interval, 0.84 to 1.00; p < 0.001). CONCLUSIONS 3D echocardiography combined with valve modeling is predictive of recurrent IMR. Preoperative regional leaflet tethering of segment P3 is a strong independent predictor of IMR recurrence after undersized ring annuloplasty. In patients with a preoperative P3 tethering angle of 29.9° or larger, chordal-sparing valve replacement rather than valve repair should be strongly considered.
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Affiliation(s)
- Wobbe Bouma
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eric K Lai
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa M Levack
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric K Shang
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alison M Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas J Eperjesi
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Theodore J Plappert
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul A Yushkevich
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kamal R Khabbaz
- Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Thomas G Gleason
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Feroze Mahmood
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Michael A Acker
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Albert T Cheung
- Department of Anesthesia, Stanford University, Stanford, California
| | - Benjamin M Jackson
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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22
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Pouch AM, Tian S, Takebe M, Yuan J, Gorman R, Cheung AT, Wang H, Jackson BM, Gorman JH, Gorman RC, Yushkevich PA. Medially constrained deformable modeling for segmentation of branching medial structures: Application to aortic valve segmentation and morphometry. Med Image Anal 2015; 26:217-31. [PMID: 26462232 PMCID: PMC4679439 DOI: 10.1016/j.media.2015.09.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 09/08/2015] [Accepted: 09/16/2015] [Indexed: 11/28/2022]
Abstract
Deformable modeling with medial axis representation is a useful means of segmenting and parametrically describing the shape of anatomical structures in medical images. Continuous medial representation (cm-rep) is a "skeleton-first" approach to deformable medial modeling that explicitly parameterizes an object's medial axis and derives the object's boundary algorithmically. Although cm-rep has effectively been used to segment and model a number of anatomical structures with non-branching medial topologies, the framework is challenging to apply to objects with branching medial geometries since branch curves in the medial axis are difficult to parameterize. In this work, we demonstrate the first clinical application of a new "boundary-first" deformable medial modeling paradigm, wherein an object's boundary is explicitly described and constraints are imposed on boundary geometry to preserve the branching configuration of the medial axis during model deformation. This "boundary-first" framework is leveraged to segment and morphologically analyze the aortic valve apparatus in 3D echocardiographic images. Relative to manual tracing, segmentation with deformable medial modeling achieves a mean boundary error of 0.41 ± 0.10 mm (approximately one voxel) in 22 3DE images of normal aortic valves at systole. Deformable medial modeling is additionally demonstrated on pathological cases, including aortic stenosis, Marfan syndrome, and bicuspid aortic valve disease. This study demonstrates a promising approach for quantitative 3DE analysis of aortic valve morphology.
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Affiliation(s)
- Alison M Pouch
- Deparment of Surgery, University of Pennsylvania, Philadelphia, PA, United States ; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, United States .
| | - Sijie Tian
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, United States
| | - Manabu Takebe
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, United States
| | - Jiefu Yuan
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, United States
| | - Albert T Cheung
- Deparment of Anesthesiology, Perioperative, and Pain Medicine, Stanford University, Stanford, CA, United States
| | - Hongzhi Wang
- IBM Almaden Research Center, San Jose, CA, United States
| | - Benjamin M Jackson
- Deparment of Surgery, University of Pennsylvania, Philadelphia, PA, United States
| | - Joseph H Gorman
- Deparment of Surgery, University of Pennsylvania, Philadelphia, PA, United States ; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, United States
| | - Robert C Gorman
- Deparment of Surgery, University of Pennsylvania, Philadelphia, PA, United States ; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, United States
| | - Paul A Yushkevich
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States
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Ghadimi K, Gutsche JT, Setegne SL, Jackson KR, Augoustides JG, Ochroch EA, Bavaria JE, Cheung AT. Severity and Duration of Metabolic Acidosis After Deep Hypothermic Circulatory Arrest for Thoracic Aortic Surgery. J Cardiothorac Vasc Anesth 2015; 29:1432-40. [DOI: 10.1053/j.jvca.2015.07.025] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Indexed: 01/05/2023]
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24
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Arora H, Ullery BW, Kumar PA, Cheung AT. Pro: Patients at Risk for Spinal Cord Ischemia After Thoracic Endovascular Aortic Repairs Should Receive Prophylactic Cerebrospinal Fluid Drainage. J Cardiothorac Vasc Anesth 2015; 29:1376-80. [DOI: 10.1053/j.jvca.2015.05.192] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Indexed: 11/11/2022]
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25
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Pouch AM, Tian S, Takabe M, Wang H, Yuan J, Cheung AT, Jackson BM, Gorman JH, Gorman RC, Yushkevich PA. Segmentation of the Aortic Valve Apparatus in 3D Echocardiographic Images: Deformable Modeling of a Branching Medial Structure. Stat Atlases Comput Models Heart 2015; 8896:196-203. [PMID: 26247062 PMCID: PMC4523230 DOI: 10.1007/978-3-319-14678-2_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
3D echocardiographic (3DE) imaging is a useful tool for assessing the complex geometry of the aortic valve apparatus. Segmentation of this structure in 3DE images is a challenging task that benefits from shape-guided deformable modeling methods, which enable inter-subject statistical shape comparison. Prior work demonstrates the efficacy of using continuous medial representation (cm-rep) as a shape descriptor for valve leaflets. However, its application to the entire aortic valve apparatus is limited since the structure has a branching medial geometry that cannot be explicitly parameterized in the original cm-rep framework. In this work, we show that the aortic valve apparatus can be accurately segmented using a new branching medial modeling paradigm. The segmentation method achieves a mean boundary displacement of 0.6 ± 0.1 mm (approximately one voxel) relative to manual segmentation on 11 3DE images of normal open aortic valves. This study demonstrates a promising approach for quantitative 3DE analysis of aortic valve morphology.
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Affiliation(s)
- Alison M. Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA,
| | - Sijie Tian
- Department of Computer and Information Science, University of Pennsylvania, Philadelphia, PA, USA
| | - Manabu Takabe
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Jiefu Yuan
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
| | - Albert T. Cheung
- Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford School of Medicine, Stanford, CA, USA
| | - Benjamin M. Jackson
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA,Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Joseph H. Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA,Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert C. Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA,Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Abstract
Aortic intramural hematoma is a variant of acute aortic dissection characterized by localized hemorrhage into the aortic media causing a separation of the intimal and adventitial layers of the aorta. Malperfusion represents an unusual presenting sign of acute intramural hematoma. Herein, we describe the case of a patient with an acute Type A IMH who developed reversible ischemic spinal cord syndrome after presenting with paraplegia as a consequence of malperfusion. A decision was made to delay operative repair and, instead, emergently apply medical interventions to increase spinal cord perfusion pressure. Medical treatment was effective for the treatment of spinal cord ischemia and operative repair of the intramural hematoma was accomplished after complete recovery of neurologic function. This is the third case ever reported of an intramural hematoma presenting in the form of spinal cord ischemia.
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Affiliation(s)
- Brant W Ullery
- Division of Vascular Surgery, Stanford University Medical Center, Stanford, CA, USA
| | - Reilly D Hobbs
- Division of Vascular Surgery and Endovascular Therapy, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Albert T Cheung
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Cheung AT, Kofke WA. Invited commentary. Ann Thorac Surg 2014; 97:1225-6. [PMID: 24694407 DOI: 10.1016/j.athoracsur.2013.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2013] [Revised: 11/04/2013] [Accepted: 11/11/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Albert T Cheung
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Dulles 680, Philadelphia, PA 19104-4283.
| | - W Andrew Kofke
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce St, Dulles 680, Philadelphia, PA 19104-4283
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Aronson S, Mathew JP, Cheung AT, Shore-Lesserson L, Troianos CA, Reeves S. The Rationale and Development of an Adult Cardiac Anesthesia Module to Supplement the Society of Thoracic Surgeons National Database. Anesth Analg 2014; 118:925-32. [DOI: 10.1213/ane.0000000000000184] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Jassar AS, Levack MM, Solorzano RD, Pouch AM, Ferrari G, Cheung AT, Ferrari VA, Gorman JH, Gorman RC, Jackson BM. Feasibility of in vivo human aortic valve modeling using real-time three-dimensional echocardiography. Ann Thorac Surg 2014; 97:1255-8. [PMID: 24518577 DOI: 10.1016/j.athoracsur.2013.12.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Revised: 12/04/2013] [Accepted: 12/18/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Surgical techniques for aortic valve (AV) repair are directed toward restoring normal structural relationships in the aortic root and rely on detailed assessment of root and valve anatomy. Noninvasive three-dimensional (3D) imaging and modeling may assist in patient selection and operative planning. METHODS Transesophageal real-time 3D echocardiographic images of 5 patients with normal AVs were acquired. The aortic root and the annulus were manually segmented at end diastole using a 36-point rotational template. The AV leaflets and the coaptation zone were manually segmented in parallel 1-mm cross sections. Quantitative 3D models of the AV and root were generated and used to measure standard anatomic parameters and were compared to conventional two-dimensional echocardiographic measurements. All measurements are given as mean±SD. RESULTS Annular, sinus, and sinotubular junction areas were 4.1±0.6 cm2, 7.5±1.2 cm2, and 3.9±1.0 cm2, respectively. Root diameters (measured in three locations) by 3D model inspection and two-dimensional echocardiography measurement correlated (R2=0.75). Noncoapted areas of the left, right, and noncoronary leaflets were 1.9±0.2 cm2, 1.6±0.3 cm2, and 1.6±0.3 cm2, respectively. Mean coaptation areas for the left-right, left-noncoronary, and right-noncoronary coaptation zones were 87.7±36.9 mm2, 69.9±20.7 mm2, and 114.2±23.0 mm2, respectively. The mean ratio of noncoapted leaflet area to annular area was 1.3±0.2. CONCLUSIONS High-resolution 3D models of the in vivo normal human aortic root and valve were generated using 3D echocardiography. Quantitative 3D models and analysis may assist in characterization of pathology and decision making for AV repair.
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Affiliation(s)
- Arminder S Jassar
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa M Levack
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania
| | - Ricardo D Solorzano
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania
| | - Alison M Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania
| | - Giovanni Ferrari
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Albert T Cheung
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victor A Ferrari
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin M Jackson
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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Ridley CH, Adler JV, Cheung AT. Invited commentary. Ann Thorac Surg 2013; 96:1061. [PMID: 23992698 DOI: 10.1016/j.athoracsur.2013.06.057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Revised: 06/14/2013] [Accepted: 06/17/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Clare H Ridley
- Department of Anesthesiology and Critical Care, University of Pennsylvania Perelman School of Medicine, 3400 Spruce St, Ravdin 4 Courtyard, Philadelphia, PA 19104-4283, USA
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Jassar AS, Vergnat M, Jackson BM, McGarvey JR, Cheung AT, Ferrari G, Woo YJ, Acker MA, Gorman RC, Gorman JH. Regional annular geometry in patients with mitral regurgitation: implications for annuloplasty ring selection. Ann Thorac Surg 2013; 97:64-70. [PMID: 24070698 DOI: 10.1016/j.athoracsur.2013.07.048] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Revised: 07/08/2013] [Accepted: 07/11/2013] [Indexed: 11/25/2022]
Abstract
BACKGROUND The saddle shape of the normal mitral annulus has been quantitatively described by several groups. There is strong evidence that this shape is important to valve function. A more complete understanding of regional annular geometry in diseased valves may provide a more educated approach to annuloplasty ring selection and design. We hypothesized that mitral annular shape is markedly distorted in patients with diseased valves. METHODS Real-time 3-dimensional echocardiography was performed in 20 patients with normal mitral valves, 10 with ischemic mitral regurgitation, and 20 with myxomatous mitral regurgitation (MMR). Thirty-six annular points were defined to generate a 3-dimensional model of the annulus. Regional annular parameters were measured from these renderings. Left ventricular inner diameter was obtained from 2-dimensional echocardiographic images. RESULTS Annular geometry was significantly different among the three groups. The annuli were larger in the MMR and in the ischemic mitral regurgitation groups. The annular enlargement was greater and more pervasive in the MMR group. Both diseases were associated with annular flattening, although though the regional distribution of that flattening was different between groups. Left ventricular inner diameter was increased in both groups. However, relative to the Left ventricular inner diameter, the annulus was disproportionately dilated in the MMR group. CONCLUSIONS Patients with MMR and ischemic mitral regurgitation have enlarged and flattened annuli. In the case of MMR, annular distortions may be the driving factor leading to valve incompetence. These data suggest that the goal of annuloplasty should be the restoration of normal annular saddle shape and that the use of flexible, partial, and flat rings may be ill advised.
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Affiliation(s)
- Arminder S Jassar
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mathieu Vergnat
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin M Jackson
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jeremy R McGarvey
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Albert T Cheung
- Department of Anesthesia University of Pennsylvania, Philadelphia, Pennsylvania
| | - Giovanni Ferrari
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Y Joseph Woo
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael A Acker
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert C Gorman
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph H Gorman
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania; Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.
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Ullery BW, Wang GJ, Woo EY, Cheung AT, McGarvey ML, Carpenter JP, Fairman RM, Jackson BM. No Increased Risk of Spinal Cord Ischemia in Delayed AAA Repair Following Thoracic Aortic Surgery. Vasc Endovascular Surg 2013; 47:85-91. [DOI: 10.1177/1538574412474500] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Brant W. Ullery
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Grace J. Wang
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Edward Y. Woo
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Albert T. Cheung
- Department of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael L. McGarvey
- Department of Neurology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey P. Carpenter
- Division of Vascular and Endovascular Surgery, Department of Surgery, Cooper University Hospital, Camden, NJ, USA
| | - Ronald M. Fairman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Benjamin M. Jackson
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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Vergnat M, Levack MM, Jackson BM, Bavaria JE, Herrmann HC, Cheung AT, Weiss SJ, Gorman JH, Gorman RC. The effect of surgical and transcatheter aortic valve replacement on mitral annular anatomy. Ann Thorac Surg 2012; 95:614-9. [PMID: 23245440 DOI: 10.1016/j.athoracsur.2012.10.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 10/04/2012] [Accepted: 10/10/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND The effect of aortic valve replacement on three-dimensional mitral annular geometry has not been well described. Emerging transcatheter approaches for aortic valve replacement employ fundamentally different mechanical techniques for achieving fixation and seal of the prosthetic valve than standard surgical aortic valve replacement. This study compares the immediate impact of transcatheter aortic valve replacement (TAVR) and standard surgical aortic valve replacement (AVR) on mitral annular anatomy. METHODS Real-time three-dimensional echocardiography was performed in patients undergoing TAVR using the Edwards Sapien valve (n = 10 [Edwards Lifesciences, Irvine, CA]) or AVR (n = 10) for severe aortic stenosis. Mitral annular geometric indexes were measured using Tomtec EchoView (Tomtec Imaging Systems, Munich, Germany) to assess regional and global annular geometry. RESULTS Mixed between-within analysis of variance showed no differences between TAVR and AVR groups in any of the mitral annular geometric indices preoperatively. However, postoperative analysis did demonstrate an effect of AVR on geometry. Patients undergoing open AVR had significant decrease in annular height, septolateral diameter, mitral valve transverse diameter, and mitral annular area after valve replacement (p ≤ 0.006). Similar changes were not noted in the TAVR group. CONCLUSIONS Mitral annular geometry is better preserved by TAVR than by AVR. Thus, TAVR may be a more physiologic approach to aortic replacement.
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Affiliation(s)
- Mathieu Vergnat
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Ullery BW, McGarvey M, Cheung AT, Fairman RM, Jackson BM, Woo EY, Desai ND, Wang GJ. Vascular distribution of stroke and its relationship to perioperative mortality and neurologic outcome after thoracic endovascular aortic repair. J Vasc Surg 2012; 56:1510-7. [DOI: 10.1016/j.jvs.2012.05.086] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Revised: 05/18/2012] [Accepted: 05/23/2012] [Indexed: 10/28/2022]
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Gutsche JT, Cheung AT. Invited commentary. Ann Thorac Surg 2012; 94:116. [PMID: 22734979 DOI: 10.1016/j.athoracsur.2012.04.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Revised: 04/19/2012] [Accepted: 04/23/2012] [Indexed: 11/19/2022]
Affiliation(s)
- Jacob T Gutsche
- Department of Anesthesiology and Critical Care, SICU Penn Presbyterian Medical Center, University of Pennsylvania, Philadelphia, PA, USA
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Ullery BW, McGarvey ML, Cheung AT, Fairman RM, Jackson BM, Woo EY, Desai N, Wang GJ. Anatomic Distribution of Stroke and Its Relationship to Perioperative Mortality and Neurologic Outcome Following TEVAR. J Vasc Surg 2012. [DOI: 10.1016/j.jvs.2011.11.081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022]
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Abstract
Thoracic endovascular aortic repair (TEVAR) has decreased the morbidity and mortality associated with open surgical repair of descending thoracic aortic diseases, but important complications unique to the procedure remain. Spinal cord ischemia and infarction is a recognized complication caused by endovascular coverage or injury to spinal cord collateral vessels. Stroke is a consequence of thromboembolism or coverage of aortic arch branch vessels with insufficient collateral circulation. Understanding the risk factors and the pathophysiology of neurological complications of TEVAR are important for the successful anesthetic and surgical management and treatment of patients undergoing endovascular procedures involving the thoracic aorta.
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Affiliation(s)
- Brant W Ullery
- Department of Anesthesiology and Critical Care, University of Pennsylvania, 3400 Spruce Street, Dulles 680, Philadelphia, PA 19104-4283, USA
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Falk SA, Cheung AT. Invited commentary. Ann Thorac Surg 2011; 92:533-4. [PMID: 21801911 DOI: 10.1016/j.athoracsur.2011.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Revised: 03/04/2011] [Accepted: 03/08/2011] [Indexed: 10/17/2022]
Affiliation(s)
- Scott A Falk
- Division of Cardiothoracic and Vascular Anesthesia, University of Pennsylvania, 3400 Spruce St, Dulles 680, Philadelphia, PA 19104-4283, USA
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Ullery BW, Cheung AT, McGarvey ML, Jackson BM, Wang GJ. Reversal of Delayed-Onset Paraparesis After Revision Thoracic Endovascular Aortic Repair For Ruptured Thoracic Aortic Aneurysm. Ann Vasc Surg 2011; 25:840.e19-23. [DOI: 10.1016/j.avsg.2010.12.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Revised: 12/28/2010] [Accepted: 12/30/2010] [Indexed: 11/17/2022]
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Vergnat M, Jackson BM, Cheung AT, Weiss SJ, Ratcliffe SJ, Gillespie MJ, Woo YJ, Bavaria JE, Acker MA, Gorman RC, Gorman JH. Saddle-shape annuloplasty increases mitral leaflet coaptation after repair for flail posterior leaflet. Ann Thorac Surg 2011; 92:797-803. [PMID: 21803330 DOI: 10.1016/j.athoracsur.2011.04.047] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 04/05/2011] [Accepted: 04/07/2011] [Indexed: 10/18/2022]
Abstract
BACKGROUND The primary goal of surgical mitral repair is the reestablishment of normal leaflet coaptation. Surgical techniques that maintain or restore leaflet geometry promote leaflet coaptation. Recent 3-dimensional (3D) echocardiographic studies have shown that saddle-shaped annuloplasty has a salutary influence on leaflet geometry. Therefore we hypothesized that saddle-shaped annuloplasty would improve leaflet coaptation in cases of repair for flail posterior leaflet segments. METHODS Sixteen patients with flail posterior segment and severe mitral regurgitation had valve repair using standard techniques. Eight patients received saddle-shaped annuloplasty and 8 patients received flat annuloplasty. Real-time 3D transesophageal echocardiography was performed before and after repair. Images were analyzed using custom software to calculate mitral annular area (MAA), septolateral dimension (SLD), intercommissural width (CW), total leaflet area (TLA), and leaflet coaptation area (LCA). RESULTS Postrepair MAA (flat, 588.6±26.5 mm2; saddle, 628.0±35.3 mm2; p=0.12) and TLA (flat, 2198.5±151.6 mm2; saddle, 2303.9±183.8 mm2; p=0.67) were similar in both groups. Postrepair LCA was significantly greater in the saddle group than in the flat group (226.8±24.0 mm2 and 154.0±13.0 mm2, respectively; p=0.02). CONCLUSIONS Real-time 3D echocardiography and novel imaging software provide a powerful tool for analyzing mitral leaflet coaptation. When compared with flat annuloplasty, saddle-shaped annuloplasty improves LCA after mitral valve repair for severe mitral regurgitation secondary to flail posterior leaflet segment. Use of saddle-shaped annuloplasty devices may increase repair durability.
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Affiliation(s)
- Mathieu Vergnat
- Gorman Cardiovascular Research Group, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Aronson S, Dyke CM, Levy JH, Cheung AT, Lumb PD, Avery EG, Hu MY, Newman MF. Does Perioperative Systolic Blood Pressure Variability Predict Mortality After Cardiac Surgery? An Exploratory Analysis of the ECLIPSE trials. Anesth Analg 2011; 113:19-30. [DOI: 10.1213/ane.0b013e31820f9231] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Ullery BW, Cheung AT, Fairman RM, Jackson BM, Woo EY, Bavaria J, Pochettino A, Wang GJ. Risk factors, outcomes, and clinical manifestations of spinal cord ischemia following thoracic endovascular aortic repair. J Vasc Surg 2011; 54:677-84. [PMID: 21571494 DOI: 10.1016/j.jvs.2011.03.259] [Citation(s) in RCA: 142] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2011] [Revised: 03/14/2011] [Accepted: 03/15/2011] [Indexed: 11/25/2022]
Abstract
OBJECTIVE The purpose of this study was to assess the incidence, risk factors, and clinical manifestations of spinal cord ischemia (SCI) after thoracic endovascular aortic repair (TEVAR). METHODS A retrospective review of a prospectively collected database was performed for all patients undergoing TEVAR at a single academic institution between July 2002 and June 2010. Preoperative demographics, procedure-related variables, and clinical details related to SCI were examined. Logistic regression analysis was performed to identify risk factors for the development of SCI. RESULTS Of the 424 patients who underwent TEVAR during the study period, 12 patients (2.8%) developed SCI. Mean age of this cohort with SCI was 69.6 years (range, 44-84 years), and 7 were women. One-half of these patients had prior open or endovascular aortic repair. Indication for surgery was either degenerative aneurysm (n = 8) or dissection (n = 4). Six TEVARs were performed electively, with the remaining done either urgently or emergently due to contained rupture (n = 2), dissection with malperfusion (n = 2), or severe back pain (n = 2). All 12 patients underwent extent C endovascular coverage. Multivariate regression analysis demonstrated chronic renal insufficiency to be independently associated with SCI (odds ratio [OR], 4.39; 95% confidence interval [CI], 1.2-16.6; P = .029). Onset of SCI occurred at a median of 10.6 hours (range, 0-229 hours) postprocedure and was delayed in 83% (n = 10) of patients. Clinical manifestations of SCI included lower extremity paraparesis in 9 patients and paraplegia in 3 patients. At SCI onset, average mean arterial pressure (MAP) and lumbar cerebrospinal fluid (CSF) pressure was 77 mm Hg and 10 mm Hg, respectively. Therapeutic interventions increased blood pressure to a significantly higher average MAP of 99 mm Hg (P = .001) and decreased lumbar CSF pressure to a mean of 7 mm Hg (P = .30) at the time of neurologic recovery. Thirty-day mortality was 8% (1 of 12 patients). The single patient who expired, never recovered any lower extremity neurologic function. All patients surviving to discharge experienced either complete (n = 9) or incomplete (n = 2) neurologic recovery. At mean follow-up of 49 months, 7 of 9 patients currently alive continued to exhibit complete, sustained neurologic recovery. CONCLUSION Spinal cord ischemia after TEVAR is an uncommon, but important complication. Preoperative renal insufficiency was identified as a risk factor for the development of SCI. Early detection and treatment of SCI with blood pressure augmentation alone or in combination with CSF drainage was effective in most patients, with the majority achieving complete, long-term neurologic recovery.
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Affiliation(s)
- Brant W Ullery
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Hospital of University of Pennsylvania, Philadelphia, PA 19104, USA
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Lomivorotov VV, Efremov SM, Boboshko VA, Leyderman IN, Lomivorotov VN, Cheung AT, Karaskov AM. Preoperative total lymphocyte count in peripheral blood as a predictor of poor outcome in adult cardiac surgery. J Cardiothorac Vasc Anesth 2011; 25:975-80. [PMID: 21354824 DOI: 10.1053/j.jvca.2010.12.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2010] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the prognostic value of the preoperative total lymphocyte count in peripheral blood as a predictor of postoperative complications and mortality in cardiac surgery. DESIGN A retrospective, observational study. SETTING The Novosibirsk State Research Institute of Circulation Pathology (single institution). PARTICIPANTS All adults undergoing primary cardiopulmonary bypass in 2009. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The cohort size was 1,368 patients operated upon with cardiopulmonary bypass. Patient characteristics, hospital mortality, postoperative complications, ventilation time, intensive care unit, and hospital stay were analyzed. A preoperative total lymphocyte count <1,500 cells/μL was associated with significantly higher mortality by univariate (p < 0.0001) and multivariate (p < 0.044) analyses. A low preoperative total lymphocyte count was associated with more frequent inotropic support (p < 0.001); postoperative heart arrhythmia (p < 0.001); dialysis-dependent acute renal failure (p < 0.001); and a prolonged ventilation time (p = 0.001), intensive care unit stay (p < 0.001), and hospital stay (p = 0.007). CONCLUSIONS A low preoperative total lymphocyte count in peripheral blood is a useful prognostic criterion for the evaluation of a complicated postoperative period in cardiac patients operated under cardiopulmonary bypass.
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Affiliation(s)
- Vladimir V Lomivorotov
- Department of Anaestesiology and Intensive Care, Federal State Institution Academician EN Meshalkin Novosibirsk State Research Institute of Circulation Pathology Rusmedtechnology, Novosibirsk, Russia
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Vergnat M, Jassar AS, Jackson BM, Ryan LP, Eperjesi TJ, Pouch AM, Weiss SJ, Cheung AT, Acker MA, Gorman JH, Gorman RC. Ischemic mitral regurgitation: a quantitative three-dimensional echocardiographic analysis. Ann Thorac Surg 2011; 91:157-64. [PMID: 21172506 DOI: 10.1016/j.athoracsur.2010.09.078] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2010] [Revised: 09/27/2010] [Accepted: 09/30/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND A comprehensive three-dimensional echocardiography based approach is applied to preoperative mitral valve (MV) analysis in patients with ischemic mitral regurgitation (IMR). This method is used to characterize the heterogeneous nature of the pathologic anatomy associated with IMR. METHODS Intraoperative real-time three-dimensional transesophageal echocardiograms of 18 patients with IMR (10 with anterior, 8 with inferior infarcts) and 17 patients with normal MV were analyzed. A customized image analysis protocol was used to assess global and regional determinants of annular size and shape, leaflet tethering and curvature, relative papillary muscle anatomy, and anatomic regurgitant orifice area. RESULTS Both mitral annular area and MV tenting volume were increased in the IMR group as compared with patients with normal MV (mitral annular area=1,065±59 mm2 versus 779±44 mm2, p=0.001; and MV tenting volume=3,413±403 mm3 versus 1,696±200 mm3, p=0.001, respectively). Within the IMR group, patients with anterior infarct had larger annuli (1,168±99 mm2) and greater tenting volumes (4,260±779 mm3 versus 2,735±245 mm3, p=0.06) than the inferior infarct subgroup. Papillary-annular distance was increased in the IMR group relative to normal; these distances were largest in patients with anterior infarcts. Whereas patients with normal MV had very consistent anatomic determinants, annular shape and leaflet tenting distribution in the IMR group were exceedingly variable. Mean anatomic regurgitant orifice area was 25.8±3.0 mm2, and the number of discrete regurgitant orifices varied from 1 to 4. CONCLUSIONS Application of custom analysis techniques to three-dimensional echocardiography images allows a quantitative and systematic analysis of the MV, and demonstrates the extreme variability in pathologic anatomy that occurs in patients with severe IMR.
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Affiliation(s)
- Mathieu Vergnat
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Jassar AS, Brinster CJ, Vergnat M, Robb JD, Eperjesi TJ, Pouch AM, Cheung AT, Weiss SJ, Acker MA, Gorman JH, Gorman RC, Jackson BM. Quantitative mitral valve modeling using real-time three-dimensional echocardiography: technique and repeatability. Ann Thorac Surg 2011; 91:165-71. [PMID: 21172507 DOI: 10.1016/j.athoracsur.2010.10.034] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Revised: 10/13/2010] [Accepted: 10/18/2010] [Indexed: 11/19/2022]
Abstract
BACKGROUND Real-time three-dimensional (3D) echocardiography has the ability to construct quantitative models of the mitral valve (MV). Imaging and modeling algorithms rely on operator interpretation of raw images and may be subject to observer-dependent variability. We describe a comprehensive analysis technique to generate high-resolution 3D MV models and examine interoperator and intraoperator repeatability in humans. METHODS Patients with normal MVs were imaged using intraoperative transesophageal real-time 3D echocardiography. The annulus and leaflets were manually segmented using a TomTec Echo-View workstation. The resultant annular and leaflet point cloud was used to generate fully quantitative 3D MV models using custom Matlab algorithms. Eight images were subjected to analysis by two independent observers. Two sequential images were acquired for 6 patients and analyzed by the same observer. Each pair of annular tracings was compared with respect to conventional variables and by calculating the mean absolute distance between paired renderings. To compare leaflets, MV models were aligned so as to minimize their sum of squares difference, and their mean absolute difference was measured. RESULTS Mean absolute annular and leaflet distance was 2.4±0.8 and 0.6±0.2 mm for the interobserver and 1.5±0.6 and 0.5±0.2 mm for the intraobserver comparisons, respectively. There was less than 10% variation in annular variables between comparisons. CONCLUSIONS These techniques generate high-resolution, quantitative 3D models of the MV and can be used consistently to image the human MV with very small interoperator and intraoperator variability. These data lay the framework for reliable and comprehensive noninvasive modeling of the normal and diseased MV.
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Affiliation(s)
- Arminder Singh Jassar
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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Coady MA, Ikonomidis JS, Cheung AT, Matsumoto AH, Dake MD, Chaikof EL, Cambria RP, Mora-Mangano CT, Sundt TM, Sellke FW. Surgical Management of Descending Thoracic Aortic Disease: Open and Endovascular Approaches. Circulation 2010; 121:2780-804. [PMID: 20530003 DOI: 10.1161/cir.0b013e3181e4d033] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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vergnat M, Chun X, Ryan LP, Jackson BM, Weiss SJ, Cheung AT, Gorman JH, Gorman RC. DOES MITRAL FLAIL IN MYXOMATOUS DISEASE RESULT OF INDIVIDUAL GEOMETRIC PREDISPOSITION? J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)61370-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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vergnat M, Bavaria J, Jackson BM, Cheung AT, Weiss SJ, Gorman JH, Gorman RC. TRANSCATHETER AORTIC VALVE IMPLANTATION PRESERVES MITRAL VALVE 3D GEOMETRY BETTER THAN STANDARD AVR. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)61665-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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vergnat M, Mahmood F, Cheung AT, Khabbaz K, Weiss SJ, Acker MA, Gorman RC, Gorman JH. THE INFLUENCE OF ANNULOPLASTY RING SHAPE ON LEAFLET CURVATURE IN HUMAN ISCHEMIC MITRAL REGURGITATION. J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)61369-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Szeto WY, Moser WG, Desai ND, Milewski RK, Cheung AT, Pochettino A, Bavaria JE. Transapical Deployment of Endovascular Thoracic Aortic Stent Graft for an Ascending Aortic Pseudoaneurysm. Ann Thorac Surg 2010; 89:616-8. [PMID: 20103359 DOI: 10.1016/j.athoracsur.2009.06.090] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2009] [Revised: 06/05/2009] [Accepted: 06/18/2009] [Indexed: 10/19/2022]
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