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Nicoara A, Fielding-Singh V, Bollen BA, Rhee A, Mackay EJ, Abernathy JH, Alfirevic A, John S, Kapoor A, MacDonald AJ, Qu JZ, Roca GQ, Subramanian H, Kertai MD. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: Intraoperative Echocardiography Reporting. J Cardiothorac Vasc Anesth 2024; 38:1103-1111. [PMID: 38365466 DOI: 10.1053/j.jvca.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 12/24/2023] [Accepted: 01/10/2024] [Indexed: 02/18/2024]
Abstract
OBJECTIVES To identify trends in the reporting of intraoperative transesophageal echocardiographic (TEE) data in the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) and the Adult Cardiac Anesthesiology (ACA) module by period, practice type, and geographic distribution, and to elucidate ongoing areas for practice improvement. DESIGN A retrospective study. SETTING STS ACSD. PARTICIPANTS Procedures reported in the STS ACSD between July 2017 and December 2021 in participating programs in the United States. INTERVENTIONS None MEASUREMENTS AND MAIN RESULTS: Intraoperative TEE is reported for 73% of all procedures in ACSD. Although the intraoperative TEE data reporting rate increased from 2017 to 2021 for isolated coronary artery bypass graft surgery, it remained low at 62.2%. The reporting of relevant echocardiographic variables across a wide range of procedures has steadily increased over the study period but also remained low. The reporting in the ACA module is high for most variables and across all anesthesia care models; however, the overall contribution of the ACA module to the ACSD remains low. CONCLUSIONS This progress report suggests a continued need to raise awareness regarding current practices of reporting intraoperative TEE in the ACSD and the ACA, and highlights opportunities for improving reporting and data abstraction.
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Affiliation(s)
- Alina Nicoara
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Vikram Fielding-Singh
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University, Stanford, CA
| | | | - Amanda Rhee
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Emily J Mackay
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA
| | - James H Abernathy
- Division of Cardiac Anesthesiology, Department of Anesthesiology, John Hopkins University, Baltimore, MD
| | - Andrej Alfirevic
- Division of Cardiothoracic Anesthesia, Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Sonia John
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology and Perioperative Medicine, The University of Alabama at Birmingham, Birmingham, AL
| | - Anubhav Kapoor
- Department of Anesthesiology, Mercy General Hospital, Baltimore, MD
| | | | - Jason Z Qu
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Gabriela Querejeta Roca
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Harikesh Subramanian
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Miklos D Kertai
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
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2
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Mendiola Pla M, Chiang Y, Nicoara A, Poehlein E, Green CL, Gross R, Bryner BS, Schroder JN, Daneshmand MA, Russell SD, DeVore AD, Patel CB, Katz JN, Milano CA, Bishawi M. Surgical Treatment of Tricuspid Valve Regurgitation in Patients Undergoing Left Ventricular Assist Device Implantation: Interim analysis of the TVVAD trial. J Thorac Cardiovasc Surg 2024; 167:1810-1820.e2. [PMID: 36639288 PMCID: PMC10185708 DOI: 10.1016/j.jtcvs.2022.10.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 07/29/2022] [Revised: 10/11/2022] [Accepted: 10/29/2022] [Indexed: 11/17/2022]
Abstract
OBJECTIVES Right heart failure remains a serious complication of left ventricular assist device therapy. Many patients presenting for left ventricular assist device implantation have significant tricuspid regurgitation. It remains unknown whether concurrent tricuspid valve surgery reduces postoperative right heart failure. The primary aim was to identify whether concurrent tricuspid valve surgery reduced the incidence of moderate or severe right heart failure within the first 6 months after left ventricular assist device implantation. METHODS Patients with moderate or severe tricuspid regurgitation on preoperative echocardiography were randomized to left ventricular assist device implantation alone (no tricuspid valve surgery) or with concurrent tricuspid valve surgery. Randomization was stratified by preoperative right ventricular dysfunction. The primary end point was the frequency of moderate or severe right heart failure within 6 months after surgery. RESULTS This report describes a planned interim analysis of the first 60 randomized patients. The tricuspid valve surgery group (n = 32) had mild or no tricuspid regurgitation more frequently on follow-up echocardiography studies compared with the no tricuspid valve surgery group (n = 28). However, at 6 months, the incidence of moderate and severe right heart failure was similar in each group (tricuspid valve surgery: 46.9% vs no tricuspid valve surgery: 50%, P = .81). There was no significant difference in postoperative mortality or requirement for right ventricular assist device between the groups. There were also no significant differences in secondary end points of functional status and adverse events. CONCLUSIONS The presence of significant tricuspid regurgitation before left ventricular assist device is associated with a high incidence of right heart failure within the first 6 months after surgery. Tricuspid valve surgery was successful in reducing postimplant tricuspid regurgitation compared with no tricuspid valve surgery but was not associated with a lower incidence of right heart failure.
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Affiliation(s)
| | - Yuting Chiang
- Division of Cardiothoracic Surgery, Columbia University, New York, NY
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center
| | - Emily Poehlein
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Ryan Gross
- Division of Cardiothoracic Surgery, Duke University Medical Center
| | | | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Duke University Medical Center
| | | | | | - Adam D DeVore
- Division of Cardiology, Duke University Medical Center
| | | | - Jason N Katz
- Division of Cardiology, Duke University Medical Center
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center.
| | - Muath Bishawi
- Division of Cardiothoracic Surgery, Duke University Medical Center
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Aslam S, Cowger J, Shah P, Stosor V, Copeland H, Reed A, Morales D, Giblin G, Mathew J, Morrissey O, Morejon P, Nicoara A, Molina E. The International Society of Heart and Lung Transplantation (ISHLT): 2024 infection definitions for durable and acute mechanical circulatory support devices. J Heart Lung Transplant 2024:S1053-2498(24)01526-2. [PMID: 38691077 DOI: 10.1016/j.healun.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 05/03/2024] Open
Abstract
Infections remain a significant concern in patients receiving mechanical circulatory support (MCS), encompassing both durable and acute devices. This consensus manuscript provides updated definitions for infections associated with durable MCS devices and new definitions for infections in acute MCS, integrating a comprehensive review of existing literature and collaborative discussions among multidisciplinary specialists. By establishing consensus definitions, we seek to enhance clinical care, facilitate consistent reporting in research studies, and ultimately improve outcomes for patients receiving MCS.
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Affiliation(s)
- Saima Aslam
- Division of Infectious Diseases and Global Public Health, University of California San Diego, San Diego, California.
| | - Jennifer Cowger
- Division of Cardiology, Henry Ford Health, Detroit, Michigan
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Valentina Stosor
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hannah Copeland
- Department of Surgery, Lutheran Hospital of Indiana/Indiana School of Medicine, Fort Wayne, Indiana
| | - Anna Reed
- Respiratory & Transplant Medicine, Royal Brompton and Harefield Hospitals, Harefield, United Kingdom
| | - David Morales
- Division of Cardiothoracic Surgery, Department of Surgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Gerard Giblin
- Cardiology Unit, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Jacob Mathew
- Cardiology Department, Royal Children's Hospital, Melbourne, Australia
| | - Orla Morrissey
- Department of Infectious Diseases, Monash University and Physician at Alfred Health, Melbourne, Australia
| | | | - Alina Nicoara
- Division of Cardiothoracic Anesthesia, Duke University, Durham, North Carolina
| | - Ezequiel Molina
- Samsky Heart Failure Center, Piedmont Heart Institute, Atlanta, Georgia
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Lerman JB, Patel CB, Casalinova S, Nicoara A, Holley CL, Leacche M, Silvestry S, Zuckermann A, D'Alessandro DA, Milano CA, Schroder JN, DeVore AD. Early Outcomes in Patients With LVAD Undergoing Heart Transplant via Use of the SherpaPak Cardiac Transport System. Circ Heart Fail 2024:e010904. [PMID: 38602105 DOI: 10.1161/circheartfailure.123.010904] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 05/23/2023] [Accepted: 01/08/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Heart transplant (HT) in recipients with left ventricular assist devices (LVADs) is associated with poor early post-HT outcomes, including primary graft dysfunction (PGD). As complicated heart explants in recipients with LVADs may produce longer ischemic times, innovations in donor heart preservation may yield improved post-HT outcomes. The SherpaPak Cardiac Transport System is an organ preservation technology that maintains donor heart temperatures between 4 °C and 8 °C, which may minimize ischemic and cold-induced graft injuries. This analysis sought to identify whether the use of SherpaPak versus traditional cold storage was associated with differential outcomes among patients with durable LVAD undergoing HT. METHODS Global Utilization and Registry Database for Improved Heart Preservation-Heart (NCT04141605) is a multicenter registry assessing post-HT outcomes comparing 2 methods of donor heart preservation: SherpaPak versus traditional cold storage. A retrospective review of all patients with durable LVAD who underwent HT was performed. Outcomes assessed included rates of PGD, post-HT mechanical circulatory support use, and 30-day and 1-year survival. RESULTS SherpaPak (n=149) and traditional cold storage (n=178) patients had similar baseline characteristics. SherpaPak use was associated with reduced PGD (adjusted odds ratio, 0.56 [95% CI, 0.32-0.99]; P=0.045) and severe PGD (adjusted odds ratio, 0.31 [95% CI, 0.13-0.75]; P=0.009), despite an increased total ischemic time in the SherpaPak group. Propensity matched analysis also noted a trend toward reduced intensive care unit (SherpaPak 7.5±6.4 days versus traditional cold storage 11.3±18.8 days; P=0.09) and hospital (SherpaPak 20.5±11.9 days versus traditional cold storage 28.7±37.0 days; P=0.06) lengths of stay. The 30-day and 1-year survival was similar between groups. CONCLUSIONS SherpaPak use was associated with improved early post-HT outcomes among patients with LVAD undergoing HT. This innovation in preservation technology may be an option for HT candidates at increased risk for PGD. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04141605.
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Affiliation(s)
- Joseph B Lerman
- Department of Medicine, Division of Cardiology, Duke University Hospital, Durham, NC. (J.B.L., C.B.P., S.C., C.L.H., A.D.D.)
| | - Chetan B Patel
- Department of Medicine, Division of Cardiology, Duke University Hospital, Durham, NC. (J.B.L., C.B.P., S.C., C.L.H., A.D.D.)
| | - Sarah Casalinova
- Department of Medicine, Division of Cardiology, Duke University Hospital, Durham, NC. (J.B.L., C.B.P., S.C., C.L.H., A.D.D.)
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC. (S.C., A.N., C.A.M., J.N.S.)
| | - Alina Nicoara
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC. (S.C., A.N., C.A.M., J.N.S.)
| | - Christopher L Holley
- Department of Medicine, Division of Cardiology, Duke University Hospital, Durham, NC. (J.B.L., C.B.P., S.C., C.L.H., A.D.D.)
| | - Marzia Leacche
- Division of Cardiothoracic Surgery, Corewell Health, Grand Rapids, MI (M.L.)
| | - Scott Silvestry
- Department of Cardiothoracic Surgery, AdventHealth Transplant Institute, Orlando, FL (S.S.)
| | - Andreas Zuckermann
- Department of Cardiac Surgery, Medical University of Vienna, Austria (A.Z.)
| | - David A D'Alessandro
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston (D.A.D.)
| | - Carmelo A Milano
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC. (S.C., A.N., C.A.M., J.N.S.)
| | - Jacob N Schroder
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Hospital, Durham, NC. (S.C., A.N., C.A.M., J.N.S.)
| | - Adam D DeVore
- Department of Medicine, Division of Cardiology, Duke University Hospital, Durham, NC. (J.B.L., C.B.P., S.C., C.L.H., A.D.D.)
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Culp C, Andrews J, Sun KW, Hunter K, Cherry A, Podgoreanu M, Nicoara A. Right Ventricle-Pulmonary Artery Coupling in Patients Undergoing Cardiac Interventions. Curr Cardiol Rep 2024:10.1007/s11886-024-02052-3. [PMID: 38581563 DOI: 10.1007/s11886-024-02052-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE OF REVIEW This review aims to summarize the fundamentals of RV-PA coupling, its non-invasive means of measurement, and contemporary understanding of RV-PA coupling in cardiac surgery, cardiac interventions, and congenital heart disease. RECENT FINDINGS The need for more accessible clinical means of evaluation of RV-PA coupling has driven researchers to investigate surrogates using cardiac MRI, echocardiography, and right-sided pressure measurements in patients undergoing cardiac surgery/interventions, as well as patients with congenital heart disease. Recent research has aimed to validate these alternative means against the gold standard, as well as establish cut-off values predictive of morbidity and/or mortality. This emerging evidence lays the groundwork for identifying appropriate RV-PA coupling surrogates and integrating them into perioperative clinical practice.
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Affiliation(s)
- Crosby Culp
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA.
| | - Jon Andrews
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Katherine Wang Sun
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Kendall Hunter
- Department of Bioengineering, University of Colorado, Aurora, CO, USA
| | - Anne Cherry
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Mihai Podgoreanu
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
| | - Alina Nicoara
- Department of Anesthesiology, Duke University, 2301 Erwin Road, Box # 3094, Durham, NC, 27710, USA
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Ebadi-Tehrani M, Sheu R, Alfirevic A, Kazanjian P, Zimmerman K, Mathis M, Swaminathan M, Mackensen GB, Nicoara A. Practical Considerations for Obtaining Perioperative Transesophageal Echocardiography Accreditation: Collective Experiences at Early-Adopting Centers. J Cardiothorac Vasc Anesth 2024; 38:616-625. [PMID: 38087669 DOI: 10.1053/j.jvca.2023.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2023] [Revised: 10/30/2023] [Accepted: 11/09/2023] [Indexed: 02/18/2024]
Abstract
The Intersocietal Accreditation Commission (IAC) is a nonprofit accrediting organization committed to ensuring the quality of diagnostic imaging and related procedures. It comprises a collaboration of stakeholders spanning numerous medical professionals and specialties. In a recent initiative, IAC Echocardiography introduced a new accreditation specifically for Perioperative Transesophageal Echocardiography (PTE). This accreditation process is anchored in rigorous clinical peer review to ensure diagnostic quality and report accuracy, thus maintaining high standards of medical care. The authors present the inaugural 4 sites to achieve IAC accreditation for PTE, which have collaborated to share their experiences in achieving this accreditation. This review endeavors to offer actionable insights and proven solutions to navigate the accreditation journey for others. Mirroring the IAC Standards and Guidelines for PTE accreditation, this review is divided into three pivotal sections as follows: (1) organization of a perioperative echocardiography service, including stakeholder engagement to facilitate the application for accreditation; (2) performance of examinations and reporting; and (3) instituting quality improvement strategies and establishing a robust program. The pursuit of accreditation in PTE is to transcend a mere compliance exercise. It signifies a dedication to excellence, continual growth, and, above all, to the well-being of patients.
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Affiliation(s)
- Mehran Ebadi-Tehrani
- Department of Anesthesiology and Pain Medicine, University of Michigan Medical School, Ann Arbor, MI.
| | - Richard Sheu
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Andrej Alfirevic
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH
| | - Paul Kazanjian
- Department of Anesthesiology and Pain Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Karen Zimmerman
- Department of Anesthesiology and Pain Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Michael Mathis
- Department of Anesthesiology and Pain Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Madhav Swaminathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - G Burkhard Mackensen
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Gosling AF, Wright MC, Cherry A, Milano CA, Patel CB, Schroder JN, DeVore A, McCartney S, Kerr D, Bryner B, Podgoreanu M, Nicoara A. The Role of Recipient Thyroid Hormone Supplementation in Primary Graft Dysfunction After Heart Transplantation: A Propensity-Adjusted Analysis. J Cardiothorac Vasc Anesth 2023; 37:2236-2243. [PMID: 37586950 DOI: 10.1053/j.jvca.2023.07.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 08/18/2023]
Abstract
OBJECTIVES To investigate whether recipient administration of thyroid hormone (liothyronine [T3]) is associated with reduced rates of primary graft dysfunction (PGD) after orthotopic heart transplantation. DESIGN Retrospective cohort study. SETTING Single-center, university hospital. PARTICIPANTS Adult patients undergoing orthotopic heart transplantation. INTERVENTIONS A total of 609 adult heart transplant recipients were divided into 2 cohorts: patients who did not receive T3 (no T3 group, from 2009 to 2014), and patients who received T3 (T3 group, from 2015 to 2019). Propensity-adjusted logistic regression was performed to assess the association between T3 supplementation and PGD. MEASUREMENTS AND MAIN RESULTS After applying exclusion criteria and propensity-score analysis, the final cohort included 461 patients. The incidence of PGD was not significantly different between the groups (33.9% no T3 group v 40.8% T3 group; p = 0.32). Mortality at 30 days (3% no T3 group v 2% T3 group; p = 0.53) and 1 year (10% no T3 group v 12% T3 group; p = 0.26) were also not significantly different. When assessing the severity of PGD, there were no differences in the groups' rates of moderate PGD (not requiring mechanical circulatory support other than an intra-aortic balloon pump) or severe PGD (requiring mechanical circulatory support other than an intra-aortic balloon pump). However, segmented time regression analysis revealed that patients in the T3 group were less likely to develop severe PGD. CONCLUSIONS These findings indicated that recipient single-dose thyroid hormone administration may not protect against the development of PGD, but may attenuate the severity of PGD.
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Affiliation(s)
- Andre F Gosling
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC.
| | - Mary C Wright
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Anne Cherry
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Carmelo A Milano
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Chetan B Patel
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Jacob N Schroder
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Adam DeVore
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Sharon McCartney
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Daryl Kerr
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Benjamin Bryner
- Department of Surgery, Duke University School of Medicine, Durham, NC
| | - Mihai Podgoreanu
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Alina Nicoara
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
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McCartney SL, Peskoe S, Wright MC, Mamoun N, Schroder JN, DeVore AD, Nicoara A. Health care resource utilization and clinical outcomes for adult heart transplant recipients with primary graft dysfunction. Clin Transplant 2023; 37:e15048. [PMID: 37363857 DOI: 10.1111/ctr.15048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 05/09/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023]
Abstract
INTRODUCTION The advent of new technologies to reduce primary graft dysfunction (PGD) and improve outcomes after heart transplantation are costly. Adoption of these technologies requires a better understanding of health care utilization, specifically the costs related to PGD. METHODS Records were examined from all adult patients who underwent orthotopic heart transplantation (OHT) between July 1, 2013 and July 30, 2019 at a single institution. Total costs were categorized into variable, fixed, direct, and indirect costs. Patient costs from time of transplantation to hospital discharge were transformed with the z-score transformation and modeled in a linear regression model, adjusted for potential confounders and in-hospital mortality. The quintile of patient costs was modeled using a proportional odds model, adjusted for confounders and in-hospital mortality. RESULTS 359 patients were analyzed, including 142 with PGD and 217 without PGD. PGD was associated with a .42 increase in z-score of total patient costs (95% CI: .22-.62; p < .0001). Additionally, any grade of PGD was associated with a 2.95 increase in odds for a higher cost of transplant (95% CI: 1.94-4.46, p < .0001). These differences were substantially greater when PGD was categorized as severe. Similar results were obtained for fixed, variable, direct, and indirect costs. CONCLUSIONS PGD after OHT impacts morbidity, mortality, and health care utilization. We found that PGD after OHT results in a significant increase in total patient costs. This increase was substantially higher if the PGD was severe. SUMMARY Primary graft dysfunction after heart transplantation impacts morbidity, mortality, and health care utilization. PGD after OHT is costly and investments should be made to reduce the burden of PGD after OHT to improve patient outcomes.
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Affiliation(s)
- Sharon L McCartney
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Sarah Peskoe
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Mary Cooter Wright
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Negmeldeen Mamoun
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jacob N Schroder
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Adam D DeVore
- Department of Medicine and Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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9
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Cai SR, Pollak A, Madsen G, McCartney S, Hashmi N, Haney JC, Nicoara A. Pulmonary Vein Systolic Flow Reversal Seen With Severe Tricuspid Regurgitation. CASE (Phila) 2023; 7:266-272. [PMID: 37546361 PMCID: PMC10403631 DOI: 10.1016/j.case.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 08/08/2023]
Abstract
•Systolic PVF reversal is specific to severe MR. •We report systolic PVF reversal with severe TR and TS. •This may be caused by interatrial dependence due to elevated RAP.
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Affiliation(s)
- Sunny R. Cai
- Correspondence: Sunny R. Cai, MD, ECU Health, Department of Anethesiology, 1905 Belles Ferry Court, Winterville, North Carolina 28590.
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10
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Nagueh SF, Klein AL, Scherrer-Crosbie M, Fine NM, Kirkpatrick JN, Forsha DE, Nicoara A, Mackensen GB, Tilkemeier PL, Doukky R, Cheema B, Adusumalli S, Hill JC, Tanguturi VK, Ouyang D, Bdoyan SB, Strom JB. A Vision for the Future of Quality in Echocardiographic Reporting: The American Society of Echocardiography ImageGuideEcho Registry, Current and Future States. J Am Soc Echocardiogr 2023:S0894-7317(23)00250-X. [PMID: 37256252 DOI: 10.1016/j.echo.2023.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 04/05/2023] [Accepted: 05/01/2023] [Indexed: 06/01/2023]
Affiliation(s)
- Sherif F Nagueh
- Department of Cardiology, Houston Methodist Hospital, Weill Cornell Medical College, Houston, Texas
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marielle Scherrer-Crosbie
- Cardiovascular Medicine Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Nowell M Fine
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - James N Kirkpatrick
- Division of Cardiology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Daniel E Forsha
- Ward Family Heart Center, Children's Mercy Kansas City, Missouri; Department of Pediatrics, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - G Burkhard Mackensen
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
| | - Peter L Tilkemeier
- Department of Medicine, Prisma Health and the University of South Carolina School of Medicine Greenville, Greenville, South Carolina
| | - Rami Doukky
- Division of Cardiology, Cook County Health, Chicago, Illinois
| | - Baljash Cheema
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Srinath Adusumalli
- Cardiovascular Medicine Division, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; CVS Health, Woonsocket, Rhode Island
| | - Jeffrey C Hill
- School of Medical Imaging and Therapeutics, Massachusetts College of Pharmacy and Health Sciences University, Worcester, Massachusetts
| | - Varsha K Tanguturi
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - David Ouyang
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California
| | | | - Jordan B Strom
- Division of Cardiovascular Medicine, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts; Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts.
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11
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Pollak AL, Vega E, Whitacre M, Nicoara A. Ruptured sinus of Valsalva aneurysm with dynamic aortic regurgitation. Echocardiography 2023; 40:74-81. [PMID: 36522841 DOI: 10.1111/echo.15502] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 09/13/2022] [Revised: 11/10/2022] [Accepted: 11/20/2022] [Indexed: 12/23/2022] Open
Abstract
The ruptured sinus of Valsalva aneurysm (SVA) can present with dynamic aortic regurgitation (AR). Hemodynamic changes elicited by induction of general anesthesia can lead to dynamic AR in setting of ruptured SVA. Perioperative echocardiography is critical in understanding the etiology of AR and in guiding surgical decision-making. If the aortic valve is structurally normal, AR may resolve following patch repair of the SVA rupture defect. Conventional measures of assessing AR severity are not accurate with continuous left-to-right flow across a ruptured SVA.
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Affiliation(s)
- Angela L Pollak
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Eleanor Vega
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Meredith Whitacre
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Alina Nicoara
- Department of Anesthesiology, Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
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12
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Stoker A, Gosling A, Williams A, Overbey D, Nicoara A, Pollak A. Transesophageal Echocardiography–Guided Percutaneous Aspiration of a Large Tricuspid Valve Vegetation in a Patient with Infective Endocarditis. CASE 2022; 6:335-339. [PMID: 36172475 PMCID: PMC9510623 DOI: 10.1016/j.case.2022.04.006] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Right-sided IE is associated with IVDU. Percutaneous debulking of TV vegetations can be a therapeutic option. TEE can help guide debulking. TEE can be used to monitor for and prevent complications.
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13
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Nicoara A, Wright MC, Rosenkrans D, Patel CB, Schroder JN, Cherry AD, Hashmi NK, Pollak AL, McCartney SL, Katz J, Milano CA, Podgoreanu MV. Predictive capabilities of the European Registry for Patients with Mechanical Circulatory Support Right-Sided Heart Failure risk score after left ventricular assist device implantation. J Cardiothorac Vasc Anesth 2022; 36:3740-3746. [DOI: 10.1053/j.jvca.2022.06.022] [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] [Received: 04/13/2022] [Revised: 06/09/2022] [Accepted: 06/17/2022] [Indexed: 11/11/2022]
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14
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Raghunathan K, Kerr D, Xian Y, McCarthy G, Habib R, Nicoara A, Zhang S, Rankin JS, Shaw AD. Cerebral Oximetry during Adult Cardiac Surgery is associated with Improved Postoperative Outcomes. J Cardiothorac Vasc Anesth 2022; 36:3529-3542. [DOI: 10.1053/j.jvca.2022.04.022] [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] [Received: 01/24/2022] [Revised: 03/31/2022] [Accepted: 04/17/2022] [Indexed: 11/11/2022]
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15
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Cole SP, Martinez-Acero N, Peterson A, Von Homeyer P, Gebhardt B, Nicoara A. Imaging for Temporary Mechanical Circulatory Support Devices. J Cardiothorac Vasc Anesth 2021; 36:2114-2131. [PMID: 34740543 DOI: 10.1053/j.jvca.2021.09.031] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 04/02/2021] [Revised: 09/04/2021] [Accepted: 09/20/2021] [Indexed: 11/11/2022]
Abstract
Heart failure is an important cause of mortality and morbidity in the world. Changes in organ allocation for solid thoracic (lung and heart) transplantation has increased the number of patients on mechanical circulatory support. Temporary mechanical support devices include devices tht support the circulation directly or indirectly such as extracorporeal membrane oxygenation (ECMO) and temporary support for right-sided failure, left-sided failure or biventricular failure. Most often, these devices are placed percutaneously and require either guidance with echocardiography, continuous radiography (fluoroscopy) or both. Furthermore, these devices need imaging in the intensive care unit to confirm continued accurate placement. This review contains the imaging views and nuances of the temporary assist devices (including ECMO) at the time of placement and the complications that can be associated with each individual device.
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Affiliation(s)
- Sheela Pai Cole
- Clinical Professor, Department of Anesthesiology, Perioperative and Pain medicine, Stanford University, Palo Alto, CA 94305.
| | - Natalia Martinez-Acero
- Associate Physician, Cardiac Anesthesiology and Critical Care, Kaiser Permanente, Santa Clara, CA.
| | - Ashley Peterson
- Clinical Assistant Professor, Department of Anesthesiology, Perioperative and Pain medicine, Stanford University, Palo Alto, CA 94305.
| | - Peter Von Homeyer
- Associate Professor, Department of Anesthesiology, University of Washington, Seattle, WA 98195.
| | | | - Alina Nicoara
- Associate Professor, Department of Anesthesiology, Duke University, Raleigh, NC 27708.
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16
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Gosling AF, Andrew BY, Stafford-Smith M, Nicoara A, Cherry AD. Renal-Resistive Index for Prediction of Acute Kidney Injury in the Setting of Aortic Insufficiency. J Cardiothorac Vasc Anesth 2021; 35:3819-3825. [PMID: 34548205 DOI: 10.1053/j.jvca.2021.08.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 07/31/2021] [Accepted: 08/22/2021] [Indexed: 01/21/2023]
Abstract
Acute kidney injury (AKI) is a common postoperative complication after cardiac surgery with cardiopulmonary bypass (CPB), and leads to significant morbidity, mortality, and cost. Although early recognition and management of AKI may reduce the burden of renal disease, reliance on serum creatinine accumulation to confidently diagnose it leads to a significant and important delay (up to 48 hours). Hence, a search for earlier AKI biomarkers is warranted. The renal-resistive index (RRI) is a promising early AKI biomarker that reflects intrarenal arterial pulsatility as reflected by the peak systolic and end-diastolic blood velocities divided by the peak systolic velocity. During cardiac surgery, post-CPB elevation of RRI is correlated with renal injury. The RRI is influenced by intrarenal and extrarenal factors, as well as different hemodynamic states. Understanding its limitations may increase its usefulness as an early AKI biomarker. For example, tachycardia or aortic stenosis typically results in a lower RRI, whereas bradycardia or increased systemic pulse pressure (as seen with aortic insufficiency) are associated with a higher RRI, unrelated to any intrarenal effects. In this E-Challenge, the authors present two cases in which the RRI was used to evaluate a patient's risk of developing AKI.
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Affiliation(s)
- Andre F Gosling
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC.
| | - Benjamin Y Andrew
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Mark Stafford-Smith
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Alina Nicoara
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Anne D Cherry
- Department of Anesthesiology, Duke University School of Medicine, Durham, NC
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17
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Nicoara A, Song P, Bollen BA, Paone G, Abernathy JJ, Taylor MA, Habib RH, Del Rio JM, Lauer RE, Nussmeier NA, Glance LG, Petty JV, Mackensen GB, Vener DF, Kertai MD. The Society of Thoracic Surgeons Adult Cardiac Surgery Database: 2021 Update on Echocardiography. Ann Thorac Surg 2021; 113:13-24. [PMID: 34536378 DOI: 10.1016/j.athoracsur.2021.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 06/17/2021] [Revised: 08/05/2021] [Accepted: 09/07/2021] [Indexed: 11/01/2022]
Abstract
The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) is the world's premier clinical outcomes registry for adult cardiac surgery and a driving force for quality improvement in cardiac surgery. Echocardiographic data provide a wealth of hemodynamic, structural, and functional data and have been part of STS ACSD data collection since its inception. An increasing body of evidence suggests that the use of echocardiography in patients undergoing cardiac surgery has a positive impact on postoperative outcomes. In this report, we describe and summarize the type and rate of reporting of echocardiography-related variables in the STS ACSD, including the Adult Cardiac Anesthesiology Module, from July 2017 to December 2019 for the most frequently performed cardiac surgical procedures. With this review, we aim to increase awareness of the importance of collecting accurate and consistent echocardiography data in the STS ACSD and to highlight opportunities for growth and improvement.
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Affiliation(s)
- Alina Nicoara
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | - Pinping Song
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - Bruce A Bollen
- International Heart Institute of Montana, Missoula Anesthesiology, PC, Missoula, Montana
| | - Gaetano Paone
- Department of Surgery, Emory University, Atlanta, Georgia
| | - James Jake Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland
| | - Mark A Taylor
- Anesthesiology Institute/Cleveland Clinic Foundation, Cleveland, Ohio
| | - Robert H Habib
- STS Research Center, The Society of Thoracic Surgeons, Chicago, Illinois
| | | | - Ryan E Lauer
- Department of Anesthesiology, Loma Linda University, Loma Linda, California
| | - Nancy A Nussmeier
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurent G Glance
- Department of Anesthesiology and Perioperative Medicine, University of Rochester, Rochester, New York
| | - Joseph V Petty
- CHI Health Clinic Physician Enterprise Anesthesia, CHI Health Nebraska Heart, Lincoln, Nebraska
| | - G Burkhard Mackensen
- Department of Anesthesiology & Pain Medicine, University of Washington, Seattle, Washington
| | - David F Vener
- Department of Anesthesiology, Perioperative and Pain Medicine, Texas Children Hospital, Baylor College of Medicine, Houston, Texas
| | - Miklos D Kertai
- Department of Anesthesiology Vanderbilt University, Nashville, Tennessee.
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18
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Privratsky JR, Diaz S, Nicoara A, Daneshmand MA. In reply to: "Intra-aortic balloon pump protects against hydrostatic pulmonary oedema during peripheral venoarterial-extracorporeal membrane oxygenation". Eur Heart J Acute Cardiovasc Care 2021; 10:81-82. [PMID: 29792510 DOI: 10.1177/2048872618779772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 05/02/2018] [Indexed: 11/17/2022]
Abstract
Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is an increasingly utilized life-saving measure. However, left-ventricular distention from inadequate left-ventricular off-loading can lead to unwanted pulmonary and cardiac complications. We are writing to indicate our agreement with a recent article by Brechot et al. published in the June 2017 issue where the authors demonstrated that intra-aortic balloon pump provides mechanical support to off-load the left ventricle during VA-ECMO, which prevents pulmonary edema.
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Affiliation(s)
- Jamie R Privratsky
- Department of Anesthesiology, Duke University Medical Center, Durham, USA
| | - Sebastian Diaz
- Department of Surgery, Division of Perfusion Services, Duke University Medical Center, Durham, USA
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, USA
| | - Mani A Daneshmand
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, USA
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19
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20
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Brockbank B, Nicoara A, Klinger RY, Swaminathan M, Haney JC, Maisonave Y. Transesophageal Echocardiographic Evaluation of Novel Extracellular Matrix Valve for Tricuspid Valve Endocarditis. ACTA ACUST UNITED AC 2020; 4:429-432. [PMID: 33117943 PMCID: PMC7581605 DOI: 10.1016/j.case.2020.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Intravenous drug abuse is a common cause of infective TV endocarditis. The use of a novel ECM valve is a surgical alternative to TV replacement. TEE evaluation is a useful tool to evaluate the unique valve appearance and function.
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Affiliation(s)
- Benjamin Brockbank
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Rebecca Y Klinger
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Madhav Swaminathan
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - John C Haney
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Yasmin Maisonave
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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21
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Bottiger BA, Aghajani K, Swaminathan M, Nicoara A. Intraoperative Assessment and Significance of Diastolic Mitral Regurgitation by Transesophageal Echocardiography. A A Pract 2020; 14:e01290. [DOI: 10.1213/xaa.0000000000001290] [Citation(s) in RCA: 1] [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] [Indexed: 11/05/2022]
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22
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Jones MM, Thompson A, Nicoara A, Swaminathan M. Diversity, Inclusion and Leadership: Perspectives From an Academic Department. J Cardiothorac Vasc Anesth 2020; 35:18-21. [PMID: 32888806 DOI: 10.1053/j.jvca.2020.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2020] [Accepted: 08/06/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Mandisa-Maia Jones
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Annemarie Thompson
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Alina Nicoara
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, NC
| | - Madhav Swaminathan
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine, Durham, NC.
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23
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Black-Maier E, Piccini JP, Bishawi M, Pokorney SD, Bryner B, Schroder JN, Fowler VG, Katz JN, Haney JC, Milano CA, Nicoara A, Hegland DD, Daubert JP, Lewis RK. Lead Extraction for Cardiovascular Implantable Electronic Device Infection in Patients With Left Ventricular Assist Devices. JACC Clin Electrophysiol 2020; 6:672-680. [PMID: 32553217 DOI: 10.1016/j.jacep.2020.02.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [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: 01/13/2020] [Revised: 02/04/2020] [Accepted: 02/05/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The goal of this study was to assess the utility of transvenous lead extraction for cardiovascular implantable electronic device (CIED) infection in patients with a left ventricular assist device (LVAD). BACKGROUND The use of transvenous lead extraction for the management CIED infection in patients with a durable LVAD has not been well described. METHODS Clinical and outcomes data were collected retrospectively among patients who underwent lead extraction for CIED infection after LVAD implantation at Duke University Hospital. RESULTS Overall, 27 patients (n = 6 HVAD; n = 15 HeartMate II; n = 6 Heartmate III) underwent lead extraction for infection. Median (interquartile range) time from LVAD implantation to infection was 6.1 (2.5 to 14.9) months. Indications included endocarditis (n = 16), bacteremia (n = 9), and pocket infection (n = 2). Common pathogens were Staphylococcus aureus (n = 10), coagulase-negative staphylococci (n = 7), and Enterococcus faecalis (n = 3). Sixty-eight leads were removed, with a median lead implant time of 5.7 (3.6 to 9.2) years. Laser sheaths were used in all procedures, with a median laser time of 35.0 s (17.5 to 85.5s). Mechanical cutting tools were required in 11 (40.7%) and femoral snaring in 4 (14.8%). Complete procedural success was achieved in 25 (93.6%) patients and clinical success in 27 (100%). No procedural failures or major adverse events occurred. Twenty-one patients (77.8%) were alive without persistent endovascular infection 1 year after lead extraction. Most were treated with oral suppressive antibiotics after extraction (n = 23 [82.5%]). Persistent infection after extraction occurred in 4 patients and was associated with 50% 1-year mortality. CONCLUSIONS Transvenous lead extraction for LVAD-associated CIED infection can be performed safely with low rates of persistent infection and 1-year mortality.
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Affiliation(s)
- Eric Black-Maier
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Jonathan P Piccini
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Muath Bishawi
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Sean D Pokorney
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Benjamin Bryner
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Vance G Fowler
- Division of Infectious Disease, Duke University Medical Center, Durham, North Carolina, USA
| | - Jason N Katz
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - John C Haney
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Alina Nicoara
- Division of Anesthesiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Donald D Hegland
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - James P Daubert
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Robert K Lewis
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina, USA.
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24
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Nicoara A, Skubas N, Ad N, Finley A, Hahn RT, Mahmood F, Mankad S, Nyman CB, Pagani F, Porter TR, Rehfeldt K, Stone M, Taylor B, Vegas A, Zimmerman KG, Zoghbi WA, Swaminathan M. Guidelines for the Use of Transesophageal Echocardiography to Assist with Surgical Decision-Making in the Operating Room: A Surgery-Based Approach: From the American Society of Echocardiography in Collaboration with the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. J Am Soc Echocardiogr 2020; 33:692-734. [PMID: 32503709 DOI: 10.1016/j.echo.2020.03.002] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Intraoperative transesophageal echocardiography is a standard diagnostic and monitoring tool employed in the management of patients undergoing an entire spectrum of cardiac surgical procedures, ranging from "routine" surgical coronary revascularization to complex valve repair, combined procedures, and organ transplantation. Utilizing a protocol as a starting point for imaging in all procedures and all patients enables standardization of image acquisition, reduction in variability in quality of imaging and reporting, and ultimately better patient care. Clear communication of the echocardiographic findings to the surgical team, as well as understanding the impact of new findings on the surgical plan, are paramount. Equally important is the need for complete understanding of the technical steps of the surgical procedures being performed and the complications that may occur, in order to direct the postprocedure evaluation toward aspects directly related to the surgical procedure and to provide pertinent echocardiographic information. The rationale for this document is to outline a systematic approach describing how to apply the existing guidelines to questions on cardiac structure and function specific to the intraoperative environment in open, minimally invasive, or hybrid cardiac surgery procedures.
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Affiliation(s)
| | | | - Niv Ad
- White Oak Medical Center and University of Maryland, Silver Spring, Maryland
| | - Alan Finley
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Feroze Mahmood
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | | | | | - Bradley Taylor
- University of Maryland Medical Center, Baltimore, Maryland
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25
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Nicoara A, Mackensen GB. Echoes from the 2019 Fall Meeting of the Council on Perioperative Echocardiography Steering Committee. J Am Soc Echocardiogr 2020; 33:A13. [DOI: 10.1016/j.echo.2020.04.016] [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: 11/28/2022]
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26
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Nicoara A, Kretzer A, Cooter M, Bartz R, Lyvers J, Patel CB, Schroder JN, McCartney SL, Podgoreanu MV, Milano CA, Swaminathan M, Stafford‐Smith M. Association between primary graft dysfunction and acute kidney injury after orthotopic heart transplantation – a retrospective, observational cohort study. Transpl Int 2020; 33:887-894. [DOI: 10.1111/tri.13615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Revised: 12/09/2019] [Accepted: 04/09/2020] [Indexed: 01/05/2023]
Affiliation(s)
- Alina Nicoara
- Department of Anesthesiology Duke University Medical Center Durham NC USA
| | - Adam Kretzer
- Department of Anesthesiology Duke University Medical Center Durham NC USA
| | - Mary Cooter
- Department of Anesthesiology Duke University Medical Center Durham NC USA
| | - Raquel Bartz
- Department of Anesthesiology Duke University Medical Center Durham NC USA
- Department of Medicine Duke University Medical Center Durham NC USA
| | - Jeffrey Lyvers
- Department of Anesthesiology Duke University Medical Center Durham NC USA
| | - Chetan B. Patel
- Department of Medicine Duke University Medical Center Durham NC USA
| | | | | | | | | | - Madhav Swaminathan
- Department of Anesthesiology Duke University Medical Center Durham NC USA
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27
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Barac Y, Bishawi M, Milano C, Schroder J, Daneshmand M, Hashmi N, Velazquez E, Rogers J, Patel C, Nicoara A. Impact of Tricuspid Valve Repair for Moderate Tricuspid Regurgitation at the Time of Left Ventricular Assist Device Implantation on the Occurrence of Right Heart Failure. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.259] [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: 11/25/2022] Open
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28
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Rosenkrans D, Qi W, Cooter M, Cherry A, McCartney S, Hashmi N, Schroder J, Milano C, Podgoreanu M, Nicoara A. EUROMACS-RHF Risk Score and 3D Echocardiography as Predictors of Right Heart Failure after Left Ventricular Assist Device Implantation. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.149] [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: 10/24/2022] Open
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29
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Barac YD, Nicoara A, Bishawi M, Schroder JN, Daneshmand MA, Hashmi NK, Velazquez E, Rogers JG, Patel CB, Milano CA. Durability and Efficacy of Tricuspid Valve Repair in Patients Undergoing Left Ventricular Assist Device Implantation. JACC Heart Fail 2019; 8:141-150. [PMID: 31838034 DOI: 10.1016/j.jchf.2019.08.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 07/03/2019] [Accepted: 08/16/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES This study sought to determine the durability of tricuspid valve repair (TVr) performed concurrently with left ventricular assist device (LVAD) implantation and its association with the development of late right heart failure (RHF). BACKGROUND Surgical management of tricuspid regurgitation (TR) at the time of LVAD implantation is performed in an attempt to reduce the occurrence of postoperative RHF. Limited data exist regarding the durability of TVr in patients with LVAD as well as its impact on development of late RHF. METHODS A retrospective review was conducted of consecutive adult patients who underwent durable LVAD implantation and concurrent TVr at the authors' institution between 2009 and 2017. Late RHF was defined as readmission for HF requiring inotropic or diuretic therapy. TVr failure was defined as moderate or severe TR at any follow-up echocardiographic examination after LVAD implantation. RESULTS A total of 156 patients underwent LVAD and concurrent TVr during the study. Of the total, 59 patients (37.8%) had a failed TVr. The mean duration of echocardiographic follow-up was 23 ± 22 months. Of the 146 patients who were discharged after the index hospitalization, 53 patients (36.3%) developed late RHF. Multivariate Cox proportional hazard analysis demonstrated that TVr failure was an independent predictor of late RHF development (hazard ratio: 2.62; 95% confidence interval: 1.38 to 4.96; p = 0.003). CONCLUSIONS Failure of TVr in this cohort occurred at a significant rate. Failure of TVr is an independent risk factor for development of late RHF. Future studies should investigate strategies to reduce recurrence of significant TR.
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Affiliation(s)
- Yaron D Barac
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina.
| | - Alina Nicoara
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Muath Bishawi
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mani A Daneshmand
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Nazish K Hashmi
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Eric Velazquez
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Joseph G Rogers
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Chetan B Patel
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
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Cherry AD, Hauck JN, Andrew BY, Li YJ, Privratsky JR, Kartha LD, Nicoara A, Thompson A, Mathew JP, Stafford-Smith M. Intraoperative renal resistive index threshold as an acute kidney injury biomarker. J Clin Anesth 2019; 61:109626. [PMID: 31699495 DOI: 10.1016/j.jclinane.2019.109626] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/13/2019] [Accepted: 09/20/2019] [Indexed: 01/07/2023]
Abstract
STUDY OBJECTIVE The lag in creatinine-mediated diagnosis of cardiac surgery-associated acute kidney injury (AKI) may be impeding the development of renoprotection therapies. Postoperative renal resistive index (RRI) measured by transabdominal Doppler ultrasound is a promising early AKI biomarker. RRI measured intraoperatively by transesophageal echocardiography (TEE) is available even earlier but is less evaluated. Therefore, we conducted an assessment of intraoperative RRI as an AKI biomarker using previously reported post-renal insult thresholds. DESIGN Retrospective convenience sample. SETTING Intraoperative. PATIENTS 180 adult cardiac surgical patients between July 2013 and July 2014. INTERVENTION None. MEASUREMENTS Pre- and post-cardiopulmonary bypass (CPB) RRI thresholds, measured using intraoperative TEE, exceeding 0.74 or 0.79 were used to evaluate for an association with KDIGO AKI risk using the Chi-square test. Other consensus AKI criteria (AKIN, RIFLE) were similarly evaluated. Additional t-test analyses examined the relationship of pre- and pre-to-post (delta) CPB RRI with AKI. MAIN RESULTS Post-CPB RRI for 99 patients included 36 and 23 with values exceeding 0.74 and 0.79, respectively. Analyses confirmed associations of both RRI thresholds with all consensus AKI definitions (0.74; KDIGO: p = 0.05, AKIN: p = 0.03, RIFLE: p = 0.03, 0.79; KDIGO: p = 0.002, AKIN: p = 0.001, RIFLE: p = 0.004). In contrast, pre-CPB and pre-to post-CPB RRI were not associated with AKI. CONCLUSIONS RRI obtained intraoperatively in cardiac surgery patients, assessed using previously reported thresholds, is highly associated with AKI and warrants further evaluation as a promising "earliest" AKI biomarker. These significant findings suggest that RRI assessment should be included in the standard intraoperative TEE exam.
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Affiliation(s)
- Anne D Cherry
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Jennifer N Hauck
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Benjamin Y Andrew
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Yi-Ju Li
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Jamie R Privratsky
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Lakshmi D Kartha
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA; MetroHealth Hospital, Dept. of Internal Medicine, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
| | - Alina Nicoara
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Annemarie Thompson
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Joseph P Mathew
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
| | - Mark Stafford-Smith
- Duke University Medical Center, Department of Anesthesiology, 2301 Erwin Road, Durham, NC 27710, USA.
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Nicoara A. The Added Power of the Third Dimension. J Cardiothorac Vasc Anesth 2019; 33:3509-3510. [PMID: 31255402 DOI: 10.1053/j.jvca.2019.05.045] [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: 05/28/2019] [Accepted: 05/29/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Tawil JN, Adams BA, Nicoara A, Boisen ML. Noteworthy Literature Published in 2018 for Thoracic Organ Transplantation. Semin Cardiothorac Vasc Anesth 2019; 23:171-187. [PMID: 31064319 DOI: 10.1177/1089253219845408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/17/2022]
Abstract
Publications of note from 2018 are reviewed for the cardiothoracic transplant anesthesiologist. Strategies to expand the availability of donor organs were highlighted, including improved donor management, accumulating experience with increased-risk donors, ex vivo perfusion techniques, and donation after cardiac death. A number of reports examined posttransplant outcomes, including outcomes other than mortality, with new data-driven risk models. Use of extracorporeal support in cardiothoracic transplantation was a prominent theme. Major changes in adult heart allocation criteria were implemented, aiming to improve objectivity and transparency in the listing process. Frailty and prehabilitation emerged as targets of comprehensive perioperative risk mitigation programs.
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Affiliation(s)
| | | | | | - Michael L Boisen
- 4 University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Sigurdsson MI, Brockbank B, Haney JC, Andrews J, MacLeod DB, Vaslef SN, Brooks KR, Manning EL, Nicoara A. Abdominal Gunshot Causing Ventricular Septal Injury Without Perforation into the Pericardium. J Cardiothorac Vasc Anesth 2019; 33:772-775. [DOI: 10.1053/j.jvca.2018.02.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Indexed: 11/11/2022]
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Alenezi F, Fudim M, Rymer J, Dunning A, Chiswell K, Swaminathan M, Bottiger B, Velagapudi P, Nicoara A, Kisslo J, Velazquez E, Vemulapalli S, Bloomfield GS, Samad Z. Predictors and Changes in Cardiac Hemodynamics and Geometry With Transcatheter Aortic Valve Implantation. Am J Cardiol 2019; 123:813-819. [PMID: 30598241 DOI: 10.1016/j.amjcard.2018.11.038] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Revised: 11/16/2018] [Accepted: 11/21/2018] [Indexed: 11/26/2022]
Abstract
The introduction of transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of patients with severe aortic stenosis (AS). However, despite the great clinical success of TAVI, less is known about the cardiac hemodynamics and structural changes to post-TAVI. We analyzed patients with AS who had a transthoracic echocardiography at most 6 months before index TAVI and follow-up transthoracic echocardiography 9 to 18 months later, performed at Duke University Medical Center from 2012 to 2014. A total of 152 TAVI patients with a median age of 81 years (median interquartile range 74 to 86) were included. TAVI resulted in the reduction of left ventricle (LV) mass index (g/m2), median (interquartile range) 130 (115 to 157) pre versus 106 (85 to 135) post, p <0.001; LV end-diastolic volume (ml) 127 (105 to 143) pre versus 120 (100 to 143) post, p = 0.013; and LV end-systolic volume (ml) 55 (38 to 77) pre versus 45 (40 to 65) post, p = 0.027. TAVI also significantly improved LV global longitudinal strain (%) -14.4 (-11.3, -15.5) pre versus -14.8 (-12.2, -16.6) post (p <0.001, respectively). Post-TAVI LV mass regression was predicted by baseline LV mass and LV global longitudinal strain whereas post-TAVI LV ejection fraction was predicted by baseline LV ejection fraction, LV mass, and post-TAVI paravalvular leak. In conclusion, TAVI results in significant cardiac hemodynamic, geometrical, and functional changes at approximately 1-year postprocedure for patients with AS. Better baseline myocardial structure and function leads to more reverse remodeling.
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Abstract
Functional tricuspid regurgitation is a common finding in patients with left-sided heart disease. If left untreated, it may reduce survival, limit functional capacity and cause end-organ dysfunction. Annulus dilation and leaflet tethering due to right ventricle remodeling are 2 major pathophysiologic mechanisms in functional tricuspid regurgitation. Even if surgical treatment remains the gold standard, indication and timing of surgical interventions remain the object of debate in the medical community. More recently, numerous transcatheter therapies have been developed in order to offer less invasive options to patients who otherwise would have a high risk of mortality and morbidity with surgical interventions.
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Affiliation(s)
| | - Bradley S Taylor
- 2 Department of Surgery, University of Maryland Medical Center, Baltimore, USA
| | - Alina Nicoara
- 1 Department of Anesthesiology, Duke University, Durham, NC, USA
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Abstract
Right ventricular (RV) function is an independent prognostic factor for short- and long-term outcomes in cardiac surgical patients. Patients with mitral valve (MV) disease are at increased risk of RV dysfunction before and after MV operations. Yet RV function is not part of criteria for decision making or risk stratification in this setting. The role of MV disease in the development of pulmonary hypertension (PHTN) and the ultimate impact of PHTN on RV function have been well described. Nonetheless, there are other mechanisms by which MV disease and MV surgery affect RV performance. Research suggests that PHTN may not be the most important determinant of RV dysfunction. Both RV dysfunction and PHTN have independent prognostic significance. This review explores the unique anatomic and functional features of the RV and the pathophysiologic and prognostic implications of RV dysfunction in patients with MV disease in the perioperative period.
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Affiliation(s)
- J. Mauricio Del Rio
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine / Duke University Medical Center, Durham, NC, USA
| | - Loreta Grecu
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine / Duke University Medical Center, Durham, NC, USA
| | - Alina Nicoara
- Divisions of Cardiothoracic Anesthesiology & Critical Care Medicine, Department of Anesthesiology, Duke University School of Medicine / Duke University Medical Center, Durham, NC, USA
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Bottiger BA, Nicoara A, Snyder LD, Wischmeyer PE, Schroder JN, Patel CB, Daneshmand MA, Sladen RN, Ghadimi K. Frailty in the End-Stage Lung Disease or Heart Failure Patient: Implications for the Perioperative Transplant Clinician. J Cardiothorac Vasc Anesth 2018; 33:1382-1392. [PMID: 30193783 DOI: 10.1053/j.jvca.2018.08.002] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [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: 04/18/2018] [Indexed: 12/13/2022]
Abstract
The syndrome of frailty for patients undergoing heart or lung transplantation has been a recent focus for perioperative clinicians because of its association with postoperative complications and poor outcomes. Patients with end-stage cardiac or pulmonary failure may be under consideration for heart or lung transplantation along with bridging therapies such as ventricular assist device implantation or venovenous extracorporeal membrane oxygenation, respectively. Early identification of frail patients in an attempt to modify the risk of postoperative morbidity and mortality has become an important area of study over the last decade. Many quantification tools and risk prediction models for frailty have been developed but have not been evaluated extensively or standardized in the cardiothoracic transplant candidate population. Heightened awareness of frailty, coupled with a better understanding of distinct cellular mechanisms and biomarkers apart from end-stage organ disease, may play an important role in potentially reversing frailty related to organ failure. Furthermore, the clinical management of these critically ill patients may be enhanced by waitlist and postoperative physical rehabilitation and nutritional optimization.
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Affiliation(s)
- Brandi A Bottiger
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Critical Care, Duke University, Durham, NC
| | - Alina Nicoara
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Critical Care, Duke University, Durham, NC
| | - Laurie D Snyder
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Duke University, Durham, NC
| | - Paul E Wischmeyer
- Division of Critical Care Medicine, Department of Anesthesiology & Critical Care, Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, NC
| | - Chetan B Patel
- Division of Cardiology, Department of Medicine, Duke University, Durham, NC
| | - Mani A Daneshmand
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, NC
| | - Robert N Sladen
- Department of Anesthesiology, Columbia University, New York, NY
| | - Kamrouz Ghadimi
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology & Critical Care, Duke University, Durham, NC; Division of Critical Care Medicine, Department of Anesthesiology & Critical Care, Duke University, Durham, NC.
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Abstract
A Gerbode VSD is a communication between the left ventricle and right atrium. Etiologies include trauma, infective endocarditis, and iatrogenic causes. Echocardiographic evaluation for this defect requires a careful interrogation.
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Affiliation(s)
- Adam Kretzer
- Department of Anesthesiology, Northwestern University Medical Center, Chicago, Illinois
| | - Hassan Amhaz
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Mark Kendall
- Department of Anesthesiology, Rhode Island Hospital, Providence, Rhode Island
| | - Donald Glower
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mandisa-Maia Jones
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Nicoara A, Ruffin D, Cooter M, Patel CB, Thompson A, Schroder JN, Daneshmand MA, Hernandez AF, Rogers JG, Podgoreanu MV, Swaminathan M, Kretzer A, Stafford-Smith M, Milano CA, Bartz RR. Primary graft dysfunction after heart transplantation: Incidence, trends, and associated risk factors. Am J Transplant 2018; 18:1461-1470. [PMID: 29136325 DOI: 10.1111/ajt.14588] [Citation(s) in RCA: 92] [Impact Index Per Article: 15.3] [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: 12/27/2016] [Revised: 10/28/2017] [Accepted: 11/08/2017] [Indexed: 01/25/2023]
Abstract
Changes in heart transplantation (HT) donor and recipient demographics may influence the incidence of primary graft dysfunction (PGD). We conducted a retrospective study to evaluate PGD incidence, trends, and associated risk factors by analyzing consecutive adult patients who underwent HT between January 2009 and December 2014 at our institution. Patients were categorized as having PGD using the International Society for Heart & Lung Transplantation (ISHLT)-defined criteria. Variables, including clinical and demographic characteristics of donors and recipients, were selected to assess their independent association with PGD. A time-trend analysis was performed over the study period. Three-hundred seventeen patients met inclusion criteria. Left ventricular PGD, right ventricular PGD, or both, were observed in 99 patients (31%). Risk factors independently associated with PGD included ischemic time, recipient African American race, and recipient amiodarone treatment. Over the study period, there was no change in the PGD incidence; however, there was an increase in the recipient pretransplantation use of amiodarone. The rate of 30-day mortality was significantly elevated in those with PGD versus those without PGD (6.06% vs 0.92%, P = .01). Despite recent advancements, incidence of PGD remains high. Understanding associated risk factors may allow for implementation of targeted therapeutic interventions.
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Affiliation(s)
- Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - David Ruffin
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Mary Cooter
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Chetan B Patel
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Annemarie Thompson
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jacob N Schroder
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Mani A Daneshmand
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | | | - Joseph G Rogers
- Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Mihai V Podgoreanu
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Madhav Swaminathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Adam Kretzer
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Mark Stafford-Smith
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Carmelo A Milano
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Raquel R Bartz
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.,Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Nicoara A, Mackensen GB. The Sound and Science of Perioperative Echocardiography. J Am Soc Echocardiogr 2018; 31:A21. [PMID: 29625652 DOI: 10.1016/j.echo.2018.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 11/12/2022]
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Sigurdsson MI, Eoh EJ, Chow VW, Waldron NH, Cleve J, Nicoara A, Swaminathan M. Utility of Angle Correction for Hemodynamic Measurements with Doppler Echocardiography. J Cardiothorac Vasc Anesth 2018; 32:1768-1774. [PMID: 29752056 DOI: 10.1053/j.jvca.2018.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 02/12/2018] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The routine application angle correction (AnC) in hemodynamic measurements with transesophageal echocardiography currently is not recommended but potentially could be beneficial. The authors hypothesized that AnC can be applied reliably and may change grading of aortic stenosis (AS). DESIGN Retrospective analysis. SETTING Single institution, university hospital. PARTICIPANTS During phase I, use of AnC was assessed in 60 consecutive patients with intraoperative transesophageal echocardiography. During phase II, 129 images from a retrospective cohort of 117 cases were used to quantify AS by mean pressure gradient. INTERVENTIONS A panel of observers used custom-written software in Java to measure intra-individual and inter-individual correlation in AnC application, correlation with preoperative transthoracic echocardiography gradients, and regrading of AS after AnC. MEASUREMENTS AND MAIN RESULTS For phase I, the median AnC was 21 (16-35) degrees, and 17% of patients required no AnC. For phase II, the median AnC was 7 (0-15) degrees, and 37% of assessed images required no AnC. The mean inter-individual and intra-individual correlation for AnC was 0.50 (95% confidence interval [CI] 0.49-0.52) and 0.87 (95% CI 0.82-0.92), respectively. AnC did not improve agreement with the transthoracic echocardiography mean pressure gradient. The mean inter-rater and intra-rater agreement for grading AS severity was 0.82 (95% CI 0.81-0.83) and 0.95 (95% CI 0.91-0.95), respectively. A total of 241 (7%) AS gradings were reclassified after AnC was applied, mostly when the uncorrected mean gradient was within 5 mmHg of the severity classification cutoff. CONCLUSIONS AnC can be performed with a modest inter-rater and intra-rater correlation and high degree of inter-rater and intra-rater agreement for AS severity grading.
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Affiliation(s)
- Martin I Sigurdsson
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - Eun J Eoh
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Vinca W Chow
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Nathan H Waldron
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Jayne Cleve
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC
| | - Alina Nicoara
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Madhav Swaminathan
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Andrew BY, Andrew EY, Cherry AD, Hauck JN, Nicoara A, Pieper CF, Stafford-Smith M. Intraoperative Renal Resistive Index as an Acute Kidney Injury Biomarker: Development and Validation of an Automated Analysis Algorithm. J Cardiothorac Vasc Anesth 2018; 32:2203-2209. [PMID: 29753670 DOI: 10.1053/j.jvca.2018.04.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Indexed: 12/22/2022]
Abstract
OBJECTIVE Intraoperative Doppler-determined renal resistive index (RRI) is a promising early acute kidney injury (AKI) biomarker. As RRI continues to be studied, its clinical usefulness and robustness in research settings will be linked to the ease, efficiency, and precision with which it can be interpreted. Therefore, the authors assessed the usefulness of computer vision technology as an approach to developing an automated RRI-estimating algorithm with equivalent reliability and reproducibility to human experts. DESIGN Retrospective. SETTING Single-center, university hospital. PARTICIPANTS Adult cardiac surgery patients from 7/1/2013 to 7/10/2014 with intraoperative transesophageal echocardiography-determined renal blood flow measurements. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Renal Doppler waveforms were obtained retrospectively and assessed by blinded human expert raters. Images (430) were divided evenly into development and validation cohorts. An algorithm for automated RRI analysis was built using computer vision techniques and tuned for alignment with experts using bootstrap resampling in the development cohort. This algorithm then was applied to the validation cohort for an unbiased assessment of agreement with human experts. Waveform analysis time per image averaged 0.144 seconds. Agreement was excellent by intraclass correlation coefficient (0.939; 95% confidence interval [CI] 0.921 to 0.953) and in Bland-Altman analysis (mean difference [human-algorithm] -0.0015; 95% CI -0.0054 to 0.0024), without evidence of systematic bias. CONCLUSION The authors confirmed the value of computer vision technology to develop an algorithm for RRI estimation from automatically processed intraoperative renal Doppler waveforms. This simple-to-use and efficient tool further adds to the clinical and research value of RRI, already the "earliest" among several early AKI biomarkers being assessed.
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Affiliation(s)
- Benjamin Y Andrew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC; Clinical Research Training Program, Duke University School of Medicine, Durham, NC
| | - Elias Y Andrew
- Department of Electrical and Computer Engineering, School of Engineering and Applied Sciences, The George Washington University, Washington, DC
| | - Anne D Cherry
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Jennifer N Hauck
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Carl F Pieper
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC
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Hahn RT, Nicoara A, Kapadia S, Svensson L, Martin R. Echocardiographic Imaging for Transcatheter Aortic Valve Replacement. J Am Soc Echocardiogr 2018; 31:405-433. [DOI: 10.1016/j.echo.2017.10.022] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2017] [Indexed: 02/06/2023]
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Nicoara A, Allen Luis S. The Perfect Storm: Carcinoid Heart Disease and Acute Right Ventricular Failure. J Cardiothorac Vasc Anesth 2018; 32:846-847. [DOI: 10.1053/j.jvca.2017.12.053] [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] [Received: 12/27/2017] [Accepted: 12/31/2017] [Indexed: 11/11/2022]
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Andrew BY, Cherry AD, Hauck JN, Nicoara A, Maxwell CD, Konoske RM, Thompson A, Kartha LD, Swaminathan M, Stafford-Smith M. The Association of Aortic Valve Pathology With Renal Resistive Index as a Kidney Injury Biomarker. Ann Thorac Surg 2018; 106:107-114. [PMID: 29427619 DOI: 10.1016/j.athoracsur.2018.01.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 11/14/2017] [Accepted: 01/03/2018] [Indexed: 12/29/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common serious complication after cardiac surgery. Doppler-determined renal resistive index (RRI) is a promising early AKI biomarker in this population. However, the relationship between aortic valve pathology (insufficiency and/or stenosis) and RRI is unknown. This study aimed to investigate RRI variability related to aortic valve pathology. METHODS In a retrospective review of cardiac surgery patients, RRI and aortic valve pathology were assessed prior to cardiopulmonary bypass using transesophageal echocardiography. Aortic valve status was categorized into four subgroups: normal (insufficiency and stenosis, none/trace/mild), insufficiency (insufficiency, moderate/severe; stenosis, none/trace/mild), combined insufficiency/stenosis (insufficiency and stenosis, moderate/severe), or stenosis (insufficiency, none/trace/mild; stenosis, moderate/severe). RRI and time-matched hemodynamic and Doppler measurements were compared among subgroups. RESULTS Of 175 patients, 60 had aortic valve pathology (16 insufficiency, 18 insufficiency/stenosis, 26 stenosis). Compared with the normal subgroup, patients with aortic insufficiency had lower diastolic blood pressure and trough renal Doppler velocities, and higher RRI (0.77 versus 0.69; p < 0.001); patients with combined insufficiency/stenosis also had higher RRI (0.72 versus 0.69, p = 0.042). CONCLUSIONS Patients with aortic insufficiency and combined insufficiency/stenosis had higher median RRI values compared with normal patients. For these individuals, diastolic flow differences related to aortic insufficiency may explain why their presurgery RRI values often exceeded postoperative thresholds typically associated with AKI. Strategies to account for the potentially confounding effects of aortic insufficiency on renal flow patterns, independent of renal injury, may add to the value of RRI as an early AKI biomarker.
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Affiliation(s)
- Benjamin Y Andrew
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; Clinical Research Training Program, Duke University School of Medicine, Durham, North Carolina
| | - Anne D Cherry
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Jennifer N Hauck
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Alina Nicoara
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Cory D Maxwell
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Ryan M Konoske
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Annemarie Thompson
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Lakshmi D Kartha
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Madhav Swaminathan
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Mark Stafford-Smith
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina.
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Affiliation(s)
- Anne D Cherry
- From the Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
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Amhaz H, Kretzer A, Podgoreanu M, Glower D, Nicoara A. Tricuspid Regurgitation Due to Absent Tricuspid Valve Leaflet: Utility of Three-Dimensional Echocardiography. A A Pract 2018; 10:45-48. [PMID: 29611828 DOI: 10.1213/xaa.0000000000000700] [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] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Hassan Amhaz
- From the Department of Anesthesiology, Duke University, Durham, North Carolina; Department of Anesthesiology, Northwestern University, Chicago, Illinois; and Department of Surgery, Duke University, Durham, North Carolina
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Amhaz H, Kretzer A, Podgoreanu M, Glower D, Nicoara A. Tricuspid Regurgitation Due to Absent Tricuspid Valve Leaflet: Utility of Three-Dimensional Echocardiography. Anesth Analg 2017:1. [PMID: 29099430 DOI: 10.1213/ane.0000000000002307] [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] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Hassan Amhaz
- From the *Department of Anesthesiology, Duke University, Durham, North Carolina; †Department of Anesthesiology, Northwestern University, Chicago, Illinois; and ‡Department of Surgery, Duke University, Durham, North Carolina
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Abstract
Perioperative management of patients undergoing lung transplantation is challenging and requires constant communication among the surgical, anesthesia, perfusion, and nursing teams. Although all aspects of anesthetic management are important, certain intraoperative strategies (mechanical ventilation, fluid management, extracorporeal mechanical support deployment) have tremendous impact on the subsequent evolution of the lung transplant recipient, especially with respect to allograft function, and should be carefully considered. This review highlights some of the intraoperative anesthetic challenges and opportunities during lung transplantation.
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Affiliation(s)
- Alina Nicoara
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Duke University Medical Center, 2301 Erwin Road, HAFS Building, Box 3094, Durham, NC 27710, USA.
| | - John Anderson-Dam
- Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine, University of California, 757 Westwood Boulevard, Suite 3325, Los Angeles, CA 90095, USA
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Dunkman WJ, Nicoara A, Schroder J, Wahidi MM, El Manafi A, Bonadonna D, Giovacchini CX, Lombard FW. Elective Venovenous Extracorporeal Membrane Oxygenation for Resection of Endotracheal Tumor. ACTA ACUST UNITED AC 2017; 9:97-100. [DOI: 10.1213/xaa.0000000000000537] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
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