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Kelava M, Milam AJ, Mi J, Alfirevic A, Grady P, Unai S, Elgharably H, McCurry K, Koprivanac M, Duncan A. Arterial Hyperoxemia During Cardiopulmonary Bypass Was Not Associated With Worse Postoperative Pulmonary Function: A Retrospective Cohort Study. Anesth Analg 2024; 138:1003-1010. [PMID: 37733624 PMCID: PMC10994185 DOI: 10.1213/ane.0000000000006627] [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] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Arterial hyperoxemia may cause end-organ damage secondary to the increased formation of free oxygen radicals. The clinical evidence on postoperative lung toxicity from arterial hyperoxemia during cardiopulmonary bypass (CPB) is scarce, and the effect of arterial partial pressure of oxygen (Pa o2 ) during cardiac surgery on lung injury has been underinvestigated. Thus, we aimed to examine the relationship between Pa o2 during CPB and postoperative lung injury. Secondarily, we examined the relationship between Pa o2 and global (lactate), and regional tissue malperfusion (acute kidney injury). We further explored the association with regional tissue malperfusion by examining markers of cardiac (troponin) and liver injury (bilirubin). METHODS This was a retrospective cohort study including patients who underwent elective cardiac surgeries (coronary artery bypass, valve, aortic, or combined) requiring CPB between April 2015 and December 2021 at a large quaternary medical center. The primary outcome was postoperative lung function defined as the ratio of Pa o2 to fractional inspired oxygen concentration (F io2 ); P/F ratio 6 hours following surgery or before extubation. The association between CPB in-line sample monitor Pa o2 and primary, secondary, and exploratory outcomes was evaluated using linear or logistic regression models adjusting for available baseline confounders. RESULTS A total of 9141 patients met inclusion and exclusion criteria, and 8429 (92.2%) patients had complete baseline variables available and were included in the analysis. The mean age of the sample was 64 (SD = 13), and 68% were men (n = 6208). The time-weighted average (TWA) of in-line sample monitor Pa o2 during CPB was weakly positively associated with the postoperative P/F ratio. With a 100-unit increase in Pa o2 , the estimated increase in postoperative P/F ratio was 4.61 (95% CI, 0.71-8.50; P = .02). Our secondary analysis showed no significant association between Pa o2 with peak lactate 6 hours post CPB (geometric mean ratio [GMR], 1.01; 98.3% CI, 0.98-1.03; P = .55), average lactate 6 hours post CPB (GMR, 1.00; 98.3% CI, 0.97-1.03; P = .93), or acute kidney injury by Kidney Disease Improving Global Outcomes (KDIGO) criteria (odds ratio, 0.91; 98.3% CI, 0.75-1.10; P = .23). CONCLUSIONS Our investigation found no clinically significant association between Pa o2 during CPB and postoperative lung function. Similarly, there was no association between Pa o2 during CPB and lactate levels, postoperative renal function, or other exploratory outcomes.
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Affiliation(s)
- Marta Kelava
- From the Departments of Cardiothoracic Anesthesiology
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio
| | - Adam J. Milam
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Phoenix, Arizona
| | - Junhui Mi
- Departments of Quantitative Health Sciences
| | | | | | - Shinya Unai
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Kenneth McCurry
- Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | - Andra Duncan
- From the Departments of Cardiothoracic Anesthesiology
- Outcomes Research, Cleveland Clinic, Cleveland, Ohio
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Kakavand M, Stembal F, Chen L, Mahboubi R, Layoun H, Harb SC, Xiang F, Elgharably H, Soltesz EG, Bakaeen FG, Hodges K, Vargo PR, Rajeswaran J, Firth A, Blackstone EH, Gillinov M, Roselli EE, Svensson LG, Pettersson GB, Unai S, Koprivanac M, Johnston DR. Contemporary experience with the Commando procedure for anterior mitral anular calcification. JTCVS Open 2024; 18:12-30. [PMID: 38690415 PMCID: PMC11056448 DOI: 10.1016/j.xjon.2023.10.038] [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] [Received: 05/06/2023] [Revised: 09/22/2023] [Accepted: 10/10/2023] [Indexed: 05/02/2024]
Abstract
Objective Anterior mitral anular calcification, particularly in radiation heart disease, and previous valve replacement with destroyed intervalvular fibrosa are challenging for prosthesis sizing and placement. The Commando procedure with intervalvular fibrosa reconstruction permits double-valve replacement in these challenging conditions. We referenced outcomes after Commando procedures to standard double-valve replacements. Methods From January 2011 to January 2022, 129 Commando procedures and 1191 aortic and mitral double-valve replacements were performed at the Cleveland Clinic, excluding endocarditis. Reasons for the Commando were severe calcification after radiation (n = 67), without radiation (n = 43), and others (n = 19). Commando procedures were referenced to a subset of double-valve replacements using balancing-score methods (109 pairs). Results Between balanced groups, Commando versus double-valve replacement had higher total calcium scores (median 6140 vs 2680 HU, P = .03). Hospital outcomes were similar, including operative mortality (12/11% vs 8/7.3%, P = .35) and reoperation for bleeding (9/8.3% vs 5/4.6%, P = .28). Survival and freedom from reoperation at 5 years were 54% versus 67% (P = .33) and 87% versus 100% (P = .04), respectively. Higher calcium score was associated with lower survival after double-valve replacement but not after the Commando. The Commando procedure had lower aortic valve mean gradients at 4 years (9.4 vs 11 mm Hg, P = .04). After Commando procedures for calcification, 5-year survival was 60% and 59% with and without radiation, respectively (P = .47). Conclusions The Commando procedure with reconstruction of the intervalvular fibrosa destroyed by mitral anular calcification, radiation, or previous surgery demonstrates acceptable outcomes similar to standard double-valve replacement. More experience and long-term outcomes are required to refine patient selection for and application of the Commando approach.
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Affiliation(s)
- Mona Kakavand
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Filip Stembal
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lin Chen
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Rashed Mahboubi
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Habib Layoun
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Serge C. Harb
- Department of Cardiovascular Medicine, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Fei Xiang
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G. Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G. Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick R. Vargo
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Austin Firth
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H. Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E. Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G. Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B. Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R. Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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Barron JO, Jain N, Mubashir M, Elgharably H, Raymond DP, Schraufnagel DP. Novel Repair of Clamshell Thoracotomy Sternal Dehiscence after Lung Transplant: A Case Report. J Chest Surg 2024; 57:213-216. [PMID: 38221730 DOI: 10.5090/jcs.23.099] [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: 08/02/2023] [Revised: 10/31/2023] [Accepted: 11/10/2023] [Indexed: 01/16/2024] Open
Abstract
Bilateral transverse thoracosternotomy, or "clamshell" thoracotomy, can be complicated by dehiscence. A 65-year-old male underwent lung transplantation via clamshell thoracotomy, with subsequent sternal dehiscence on postoperative day 11. Upon repair, the previous sternal wires had pulled through, so a Sternal Talon connected to a Recon Talon was utilized to re-approximate the inferior sternum. On follow-up at 3 months, the patient recovered well. Use of the Sternal Talon provides an effective technique for repairing transverse sternal dehiscence.
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Affiliation(s)
- John O Barron
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Nethra Jain
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Mujtaba Mubashir
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Daniel P Raymond
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Dean P Schraufnagel
- Department of Thoracic and Cardiovascular Surgery, Division of Thoracic Surgery, Cleveland Clinic, Cleveland, OH, USA
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Javorski MJ, Rosinski BF, Shah S, Thompson MA, Streem D, Gordon SM, Insler S, Houghtaling PL, Griffin B, Blackstone EH, Unai S, Svensson LG, Pettersson GB, Elgharably H. Infective Endocarditis in Patients Addicted to Injected Opioid Drugs. J Am Coll Cardiol 2024; 83:811-823. [PMID: 38383096 DOI: 10.1016/j.jacc.2023.12.016] [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: 08/31/2023] [Revised: 11/17/2023] [Accepted: 12/19/2023] [Indexed: 02/23/2024]
Abstract
BACKGROUND Persons who inject drugs and require surgery for infective endocarditis have 2 potentially lethal diseases. Current postoperative rehabilitation efforts seem ineffective in preventing loss to follow-up, injection drug use relapse (relapse), and death. OBJECTIVES The purpose of this study was to characterize drug use, psychosocial issues, surgical outcome, and postoperative addiction management, as well as loss to follow-up, relapse, and mortality and their risk factors. METHODS From January 2010 to June 2020, 227 persons who inject drugs, age 36 ± 9.9 years, underwent surgery for infective endocarditis at a quaternary hospital having special interest in developing addiction management programs. Postsurgery loss to follow-up, relapse, and death were assessed as competing risks and risk factors identified parametrically and by machine learning. CIs are 68% (±1 SE). RESULTS Heroin was the most self-reported drug injected (n = 183 [81%]). Psychosocial issues included homelessness (n = 56 [25%]), justice system involvement (n = 150 [66%]), depression (n = 118 [52%]), anxiety (n = 104 [46%]), and post-traumatic stress disorder (n = 33 [15%]). Four (1.8%) died in-hospital. Medication for opioid use disorder prescribed at discharge increased from 0% in 2010 to 100% in 2020. At 1 and 5 years, conditional probabilities of loss to follow-up were 16% (68% CI: 13%-22%) and 59% (68% CI: 44%-65%), relapse 32% (68% CI: 28%-34%) and 79% (68% CI: 74%-83%), and mortality 21% (68% CI: 18%-23%) and 68% (68% CI: 62%-72%). Younger age, heroin use, and lower education level were predictors of relapse. CONCLUSIONS Infective endocarditis surgery can be performed with low mortality in persons who inject drugs, but addiction is far more lethal. Risk of loss to follow-up and relapse require more effective addiction strategies without which this major loss to society will continue.
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Affiliation(s)
- Michael J Javorski
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brad F Rosinski
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shawn Shah
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Matthew A Thompson
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, Ohio, USA
| | - David Streem
- Department of Psychiatry, Cleveland Clinic, Cleveland, Ohio, USA
| | - Steven M Gordon
- Department of Infectious Disease, Cleveland Clinic, Cleveland, Ohio, USA
| | - Steven Insler
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio, USA
| | - Penny L Houghtaling
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Brian Griffin
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio, USA.
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5
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Kassab J, Harb SC, Desai MY, Gillinov AM, Layoun H, El Dahdah J, Chedid El Helou M, Nakhla S, Elgharably H, Kapadia SR, Cremer PC, Mentias A. Incidence, Risk Factors, and Outcomes Associated With Permanent Pacemaker Implantation Following Tricuspid Valve Surgery. J Am Heart Assoc 2024; 13:e032760. [PMID: 38293932 PMCID: PMC11056159 DOI: 10.1161/jaha.123.032760] [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: 10/16/2023] [Accepted: 12/19/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Data regarding permanent pacemaker (PPM) implantation following tricuspid valve surgery (TVS) are limited. We sought to evaluate its incidence, risk factors, and outcomes. METHODS AND RESULTS Medicare beneficiaries who underwent TVS from 2013 to 2020 were identified. Patients who underwent TVS for endocarditis were excluded. The primary exposure of interest was new PPM after TVS. Outcomes included all-cause mortality and readmission with endocarditis or heart failure on follow-up. Among the 13 294 patients who underwent TVS, 2518 (18.9%) required PPM placement. Risk factors included female sex (relative risk [RR], 1.26 [95% CI, 1.17-1.36], P<0.0001), prior sternotomy (RR, 1.12 [95% CI, 1.02-1.23], P=0.02), preoperative second-degree heart block (RR, 2.20 [95% CI, 1.81-2.69], P<0.0001), right bundle-branch block (RR, 1.21 [95% CI, 1.03-1.41], P=0.019), bifascicular block (RR, 1.43 [95% CI, 1.06-1.93], P=0.02), and prior malignancy (RR, 1.23 [95% CI, 1.01-1.49], P=0.04). Tricuspid valve (TV) replacement was associated with a significantly higher risk of PPM implantation when compared with TV repair (RR, 3.20 [95% CI, 2.16-4.75], P<0.0001). After a median follow-up of 3.1 years, mortality was not different in patients who received PPM compared with patients who did not (hazard ratio [HR], 1.02 [95% CI, 0.93-1.12], P=0.7). PPM placement was not associated with a higher risk of endocarditis but was associated with a higher risk of heart failure readmission (HR, 1.28 [95% CI, 1.14-1.43], P<0.001). CONCLUSIONS PPM implantation frequently occurs after TVS, notably in female patients and patients undergoing TV replacement. Although mortality is not increased, it is associated with higher rates of heart failure rehospitalization.
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Affiliation(s)
- Joseph Kassab
- Department of Cardiovascular MedicineHeart, Vascular and Thoracic Institute, Cleveland Clinic FoundationClevelandOHUSA
| | - Serge C. Harb
- Department of Cardiovascular MedicineHeart, Vascular and Thoracic Institute, Cleveland Clinic FoundationClevelandOHUSA
| | - Milind Y. Desai
- Department of Cardiovascular MedicineHeart, Vascular and Thoracic Institute, Cleveland Clinic FoundationClevelandOHUSA
| | - A. Marc Gillinov
- Department of Cardiovascular SurgeryHeart, Vascular and Thoracic Institute, Cleveland Clinic FoundationClevelandOHUSA
| | - Habib Layoun
- Department of Cardiovascular MedicineHeart, Vascular and Thoracic Institute, Cleveland Clinic FoundationClevelandOHUSA
| | - Joseph El Dahdah
- Department of Cardiovascular MedicineHeart, Vascular and Thoracic Institute, Cleveland Clinic FoundationClevelandOHUSA
| | - Michel Chedid El Helou
- Department of Cardiovascular MedicineHeart, Vascular and Thoracic Institute, Cleveland Clinic FoundationClevelandOHUSA
| | - Shady Nakhla
- Department of Cardiovascular MedicineHeart, Vascular and Thoracic Institute, Cleveland Clinic FoundationClevelandOHUSA
| | - Haytham Elgharably
- Department of Cardiovascular SurgeryHeart, Vascular and Thoracic Institute, Cleveland Clinic FoundationClevelandOHUSA
| | - Samir R. Kapadia
- Department of Cardiovascular MedicineHeart, Vascular and Thoracic Institute, Cleveland Clinic FoundationClevelandOHUSA
| | - Paul C. Cremer
- Department of Cardiovascular MedicineHeart, Vascular and Thoracic Institute, Cleveland Clinic FoundationClevelandOHUSA
| | - Amgad Mentias
- Department of Cardiovascular MedicineHeart, Vascular and Thoracic Institute, Cleveland Clinic FoundationClevelandOHUSA
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6
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Elgharably H, Unai S, Pettersson GB. Sutureless Prosthesis for Prosthetic Aortic Valve Endocarditis: Time to put Brakes on a Speedy Bus? Ann Thorac Surg 2024:S0003-4975(24)00070-5. [PMID: 38286205 DOI: 10.1016/j.athoracsur.2024.01.014] [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: 12/22/2023] [Accepted: 01/06/2024] [Indexed: 01/31/2024]
Affiliation(s)
- Haytham Elgharably
- Endocarditis Center, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195.
| | - Shinya Unai
- Endocarditis Center, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195
| | - Gösta B Pettersson
- Endocarditis Center, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195
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Jenkins H, Elkilany I, Guler E, Cummins K, Ayyat K, Pennacchio C, Kapadia SR, Bakaeen F, Gillinov AM, Svensson LG, Elgharably H. Predictors and outcomes of discharge to long-term acute care facilities after cardiac surgery. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00087-4. [PMID: 38278439 DOI: 10.1016/j.jtcvs.2024.01.029] [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: 08/27/2023] [Revised: 12/18/2023] [Accepted: 01/10/2024] [Indexed: 01/28/2024]
Abstract
OBJECTIVE An increasing number of patients with significant comorbidities present for complex cardiac surgery, with a subgroup requiring discharge to long-term acute care facilities. We aim to examine predictors and mortality after discharge to a long-term acute care facility. METHODS From January 1, 2015, to April 30, 2021, all adult cardiac surgeries were queried and patients discharged to long-term acute care facilities were identified. Baseline characteristics, procedures, and in-hospital complications were compared between long-term acute care facility and non-long-term acute care facility discharges. Random forest analysis was conducted to establish predictors of discharge to long-term acute care facilities. Kaplan-Meier survival analysis was used to determine probability of survival over 7 years. Multivariate regression modeling was used to establish predictors of death after long-term acute care facility discharge. RESULTS Of 29,884 patients undergoing cardiac surgery, 324 (1.1%) were discharged to a long-term acute care facility. The long-term acute care facility group had higher rates of urgent/emergency operation (54% vs 23%; 10% vs 3%, P < .001) and longer mean cardiopulmonary bypass (167 vs 110 minutes, P < .001). By random forest analysis, emergency/urgent status, longer cardiopulmonary bypass duration, redo surgery, endocarditis, and history of dialysis were the most predictive of discharge to a long-term acute care facility. Although the non-long-term acute care facility group demonstrated greater than 95% survival at 6 months, Kaplan-Meier survival analysis showed 28% 6-month mortality in the long-term acute care facility cohort. Random forest analysis demonstrated that chronic lung disease and postoperative respiratory complications were significant predictors of death at 6 months after discharge to a long-term acute care facility. CONCLUSIONS Patients with chronic lung and kidney disease undergoing prolonged procedures are at higher risk to be discharged to long-term acute care facilities after surgery with worse survival. Efforts to minimize postoperative respiratory complications may reduce mortality after discharge to long-term acute care facilities.
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Affiliation(s)
- Haley Jenkins
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ibrahim Elkilany
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Erhan Guler
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kaleigh Cummins
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kamal Ayyat
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Caroline Pennacchio
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samir R Kapadia
- Department of Cardiovascular Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Fasial Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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8
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Insler JE, Tipton AE, Bakaeen FG, Bakhos JJ, Houghtaling PL, Blackstone EH, Roselli EE, Soltesz EG, Tong MZ, Unai S, McCurry K, Vargo P, Hodges K, Smedira NG, Pettersson GB, Weiss A, Koprivanac M, Elgharably H, Gillinov AM, Svensson LG. What determines outcomes in multivalve reoperations? Effect of patient and surgical complexity. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01192-3. [PMID: 38081538 DOI: 10.1016/j.jtcvs.2023.12.005] [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: 05/09/2023] [Revised: 12/01/2023] [Accepted: 12/04/2023] [Indexed: 01/15/2024]
Abstract
OBJECTIVE Patient characteristics, risks, and outcomes associated with reoperative multivalve cardiac surgery are poorly characterized. Effect of patient variables and surgical components of each reoperation were evaluated with regard to operative mortality. METHODS From January 2008 to January 2022, 2324 patients with previous cardiac surgery underwent 2352 reoperations involving repair or replacement of multiple cardiac valves at Cleveland Clinic. Mean age was 66 ± 14 years. Number of surgical components representing surgical complexity (valve procedures, aortic surgery, coronary artery bypass grafting, and atrial fibrillation procedures) ranged from 2 to 6. Random forest for imbalanced data was used to identify risk factors for operative mortality. RESULTS Surgery was elective in 1327 (56%), urgent in 1006 (43%), and emergency in 19 (0.8%). First-time reoperations were performed in 1796 (76%) and 556 (24%) had 2 or more previous operations. Isolated multivalve operations comprised 54% (1265) of cases; 1087 incorporated additional surgical components. Two valves were operated on in 80% (1889) of cases, 3 in 20% (461), and 4 in 0.09% (2). Operative mortality was 4.2% (98 out of 2352), with 1.7% (12 out of 704) for elective, isolated multivalve reoperations. For each added surgical component, operative mortality incrementally increased, from 2.4% for 2 components (24 out of 1009) to 17% for ≥5 (5 out of 30). Predictors of operative mortality included coronary artery bypass grafting, surgical urgency, cardiac, renal dysfunction, peripheral artery disease, New York Heart Association functional class, and anemia. CONCLUSIONS Elective, isolated reoperative multivalve surgery can be performed with low mortality. Surgical complexity coupled with key physiologic factors can be used to inform surgical risk and decision making.
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Affiliation(s)
- Joshua E Insler
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Aaron E Tipton
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Jules J Bakhos
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Penny L Houghtaling
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shinya Unai
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kenneth McCurry
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick Vargo
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas G Smedira
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Aaron Weiss
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular & Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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9
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Cikach F, Sale S, Roselli EE, Pettersson G, Elgharably H. Re-operation for a detached left coronary button from an aortic root conduit causing a large retro-sternal pseudoaneurysm. Multimed Man Cardiothorac Surg 2023; 2023. [PMID: 38058148 DOI: 10.1510/mmcts.2023.026] [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: 12/08/2023]
Abstract
Our goal was to replace the previous composite graft with a bioprosthesis. The approach involved axillary artery and femoral vein cannulation and cardiopulmonary bypass with moderate hypothermia for re-entry of the chest and deep hypothermia with circulatory arrest to get control of and to clamp the aorta when entering the pseudoaneurysm. The myocardial protection strategy was general cooling and retrograde cardioplegia through direct coronary sinus cannulation and antegrade cardioplegia in the coronary ostia when possible. After the pseudoaneurysm was entered, the graft was divided in the middle, and the distal end was dissected out under circulatory arrest sufficiently to allow clamping and to resume systemic circulation. The graft was not dissected out beyond the previous anastomosis. Under another period of circulatory arrest, the distal graft was removed to the mid-arch, and a new graft was attached with a hemiarch anastomosis. Then the root was dissected out, and both coronary ostia were mobilized. The mechanical aortic valve and previous graft material were explanted. A new bioprosthetic valved conduit was used to replace the aortic root, and the coronary buttons were re-implanted directly in the new graft.
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Affiliation(s)
- Frank Cikach
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Shiva Sale
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic, Cleveland, OH, USA
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Gosta Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
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10
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Awad AK, Sayed A, Elbadawy MA, Ahmed A, Ming Wang TK, Elgharably H. Concomitant tricuspid valve repair for mild-moderate tricuspid regurgitation patients undergoing mitral valve surgery? A meta-analysis and meta-regression. J Cardiovasc Surg (Torino) 2023; 64:657-667. [PMID: 37486236 DOI: 10.23736/s0021-9509.23.12760-1] [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] [Subscribe] [Scholar Register] [Indexed: 07/25/2023]
Abstract
The development of tricuspid regurgitation (TR) is a common complication of mitral valve disease. Although severe TR is usually operated on at the same time of mitral valve surgery (MVS), controversies remain regarding whether mild to moderate TR patients should be operated. Concomitant tricuspid valve repair with MVS for mild-moderate TR patients. Electronic databases were searched from inception to November 20, 2022 to include any observational or randomized controlled trials (RCT) that compare concomitant tricuspid repair with MVS versus MVS alone. Mantel-Haenszel method was used to pool study estimates and calculate odds ratios (OR) with 95% confidence intervals (CI). A total of 9813 patients from 25 studies were included. Regarding primary outcomes, concomitant repair group had significantly lower 30 days mortality (OR: 0.66; 95% CI 0.45 to 0.96), all-cause mortality-based on RCTs- (OR: 0.40; 95% CI 0.22 to 0.71), cardiovascular mortality (OR: 0.53; 95% CI: 0.33 to 0.86) and heart failure hospitalizations (OR: 0.41; 95% CI: 0.26 to 0.63). However, was associated with higher permanent pacemaker implantation rates (OR: 2.09; 95% CI: 1.45 to 3.00). There were no significant differences in terms of secondary outcomes: tricuspid valve reinterventions, stroke and acute kidney injury. Furthermore, repair group showed lower risk for TR progression degrees (OR 0.08; 95% CI 0.05 to 0.16) and decreased mean of TR progression (MD -1.85; 95% CI -1.92 to -1.77). Concomitant tricuspid valve repair in mild or moderate TR at time of MVS appears to reduce not only 30 days but also long-term all-cause and cardiovascular mortality weighed against the increased risk of pacemaker implantation.
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Affiliation(s)
- Ahmed K Awad
- Faculty of Medicine, Ain-shams University, Cairo, Egypt -
| | - Ahmed Sayed
- Faculty of Medicine, Ain-shams University, Cairo, Egypt
| | | | | | - Tom K Ming Wang
- Department of Cardiovascular Medicine, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
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11
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Javorski MJ, Xu B, Fraser T, Elgharably H. A 73-Year-Old Woman with a Fall. NEJM Evid 2023; 2:EVIDmr2300254. [PMID: 38320502 DOI: 10.1056/evidmr2300254] [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] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
A 73-Year-Old Woman with a FallA 73-year-old woman who had a cholecystectomy 2 months ago presented for evaluation after a fall. How do you approach the evaluation, and what is your differential diagnosis?
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Affiliation(s)
- Michael J Javorski
- from the Cleveland Clinic Thoracic Surgery Residency Program, the Cleveland Clinic Cardiology Fellowship Program, and the Cleveland Clinic Infectious Disease Institute
| | - Bo Xu
- from the Cleveland Clinic Thoracic Surgery Residency Program, the Cleveland Clinic Cardiology Fellowship Program, and the Cleveland Clinic Infectious Disease Institute
| | - Thomas Fraser
- from the Cleveland Clinic Thoracic Surgery Residency Program, the Cleveland Clinic Cardiology Fellowship Program, and the Cleveland Clinic Infectious Disease Institute
| | - Haytham Elgharably
- from the Cleveland Clinic Thoracic Surgery Residency Program, the Cleveland Clinic Cardiology Fellowship Program, and the Cleveland Clinic Infectious Disease Institute
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12
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Zaki A, Witten JC, Pettersson GB, Elgharably H. Patch reconstruction of the aorto-mitral curtain without posterior extension: Alternative to the Commando procedure for double valve replacement. JTCVS Tech 2023; 22:181-184. [PMID: 38152184 PMCID: PMC10750764 DOI: 10.1016/j.xjtc.2023.08.021] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Revised: 07/29/2023] [Accepted: 08/07/2023] [Indexed: 12/29/2023] Open
Affiliation(s)
- Anthony Zaki
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - James C. Witten
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gosta B. Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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13
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Krishnan S, Soltesz E, Hanks J, Adi A, Elgharably H, McCurry K, Bribriesco A. Radiation Exposure in Extracorporeal Life Support. ASAIO J 2023; 69:1049-1054. [PMID: 37875016 DOI: 10.1097/mat.0000000000002037] [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] [Subscribe] [Scholar Register] [Indexed: 10/26/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) exposes patients to multiple radiologic studies. We hypothesized ECMO patients endure radiation exposure in excess of the International Commission of Radiological Protection (ICRP) recommendations of cumulative effective dose (CED, >20 mSv and 5-year cumulative limit of CED >100 mSv). We conducted a retrospective observational study in an academic medical center between January 2016 and December 2018 involving adult admissions (N = 306) on ECMO. Ionizing radiation was calculated from reference values to determine CED. Approximately 9.4% (N = 29) patients accrued CED >50 mSv and 4.5% (N = 14) accrued CED >100 mSv during ECMO. Over the entire hospitalization, 28% (N = 85) accrued >50 mSv and 14.7% (N = 45) accrued CED >100 mSv. Median CED during ECMO was 2.3 mSv (IQR, -0.82 to 8.1 mSv), and the entire hospitalization was 17.4 mSv (IQR, -4.5 to 56.6 mSv). Thirteen percent of the median CED accrued during hospitalization could be attributed to ECMO. Longer hospitalization was associated with a higher CED (50 days [IQR, -25 to 76 days] in CED >50 vs. 19 days [IQR, -10 to 32 days] in CED <50). Computer tomography (CT) scans and interventional radiology (IR) procedures contributed to 43.8% and 44.86%, respectively, of CED accrued on ECMO and 52.2% and 37.1% of CED accumulated during the whole hospitalization. Guidelines aimed at mitigating radiation exposure are urgently needed.
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Affiliation(s)
- Sudhir Krishnan
- From the Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward Soltesz
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Justin Hanks
- From the Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ahmad Adi
- Anesthesia Institute, Cleveland Clinic, Cleveland, Ohio
| | - Haytham Elgharably
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kenneth McCurry
- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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14
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Shah A, Elgharably H, Mehta A, Lum J. First Case of Cupravidus paculus Infection in a Lung Transplant Recipient: A Case Report. Transplant Proc 2023; 55:1984-1987. [PMID: 37517882 DOI: 10.1016/j.transproceed.2023.05.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 05/03/2023] [Accepted: 05/30/2023] [Indexed: 08/01/2023]
Abstract
Cupravidus paculus is a rare Gram-negative bacterium that can cause a wide range of severe infections, largely in immunocompromised patients. It is a ubiquitous organism found in natural and man-made environments and in the hospital. Herein, we present the first case of C. paculus infection in a lung transplant recipient, which required prolonged antibiotic therapy to achieve complete clearance. Additionally, we review the existing literature on the clinical and microbiological profile of C. paculus, along with previously documented cases of clinical infections. Our case highlights the potential sources of C. paculus infections, the importance of appropriate disinfection protocols for medical devices, and the need for antibiotic sensitivities to guide treatment.
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Affiliation(s)
- Aniruddh Shah
- Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio.
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Atul Mehta
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jessica Lum
- Department of Infectious Disease, Cleveland Clinic, Cleveland, Ohio
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15
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Umana Pizano JB, Arain FD, Harb SC, Bakaeen FG, Elgharably H. Is right ventricular free wall revascularization underrated? Sequential bypass of mid-right coronary artery to resolve acute right ventricular dysfunction. JTCVS Tech 2023; 21:118-121. [PMID: 37854834 PMCID: PMC10580089 DOI: 10.1016/j.xjtc.2023.07.012] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 06/30/2023] [Accepted: 07/10/2023] [Indexed: 10/20/2023] Open
Affiliation(s)
- Juan B. Umana Pizano
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Faisal D. Arain
- Department of Cardiothoracic Anesthesiology, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Serge C. Harb
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Faisal G. Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, Ohio
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16
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Hanks J, Unai S, Bribriesco A, Insler S, Yu E, Banzon J, Mireles-Cabodevila E, Adi A, Elgharably H, Yun J, Krishnan S. Successful treatment of pulmonary mucormycosis ( Lichtheimia spp.) in a post-partum patient with COVID-19 ARDS requiring extra-corporeal membrane oxygenation using salvage therapy. Perfusion 2023; 38:1315-1318. [PMID: 35979585 PMCID: PMC9389274 DOI: 10.1177/02676591221111031] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Case Summary: A 31-year-old female presented to a regional hospital at 27 weeks pregnant and was found to have COVID-19 ARDS. She underwent intubation and caesarian section for worsening hypoxia and non-reassuring fetal heart tones. Hypoxemia was refractory to proning requiring ECMO and transfer to a tertiary care center. Admission chest radiography showed a new right lower lobe cavitating lesion with computed tomography scan revealing a large multi-loculated cavity in the right lung and extensive bilateral ground-glass opacities. The patient was started on amphotericin and posaconazole, with final respiratory cultures growing Lichtheimia spp. Source control was discussed via possible open thoracostomy, but medical management alone was continued. Total ECMO support was 3 weeks. At the time of discharge to acute rehab, 1 month of amphotericin and posaconazole had been completed, with continuation of posaconazole. At last update, she had been discharged from rehab and was back home with her infant. Conclusion: Pulmonary mucormycosis, even in the non-ECLS population, carries a high mortality. Treatment in pulmonary disease with surgery improves mortality but is not always feasible. Salvage therapy with extended course antifungal medications may be an option for those not amendable.
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Affiliation(s)
- Justin Hanks
- Department of Internal Medicine, Cleveland Clinic
Foundation, Cleveland OH, USA
| | - Shinya Unai
- Department of Thoracic and
Cardiovascular Surgery, Cleveland Clinic
Foundation, Cleveland OH, USA
| | - Alejandro Bribriesco
- Department of Thoracic and
Cardiovascular Surgery, Cleveland Clinic
Foundation, Cleveland OH, USA
| | - Steven Insler
- Department of Intensive Care and
Resuscitation, Cleveland Clinic
Foundation, Cleveland OH, USA
| | - Eileen Yu
- Case Western Reserve
University, Cleveland OH, USA
| | - Jona Banzon
- Department of Infectious Disease, Cleveland Clinic
Foundation, Cleveland OH, USA
| | | | - Ahmad Adi
- Department of Intensive Care and
Resuscitation, Cleveland Clinic
Foundation, Cleveland OH, USA
| | - Haytham Elgharably
- Department of Thoracic and
Cardiovascular Surgery, Cleveland Clinic
Foundation, Cleveland OH, USA
| | - James Yun
- Case Western Reserve
University, Cleveland OH, USA
| | - Sudhir Krishnan
- Department of Critical Care
Medicine, Cleveland Clinic
Foundation, Cleveland OH, USA
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17
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Elgharably H, Ibrahim A, Rosinski B, Thuita L, Blackstone EH, Collier PH, Pettersson GB. Right heart failure and patient selection for isolated tricuspid valve surgery. J Thorac Cardiovasc Surg 2023; 166:740-751.e8. [PMID: 35123790 DOI: 10.1016/j.jtcvs.2021.10.059] [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: 10/26/2020] [Revised: 10/04/2021] [Accepted: 10/12/2021] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To characterize patients with right heart failure undergoing isolated tricuspid valve surgery, focusing on right heart morphology and function. PATIENTS AND METHODS From January 2007 to January 2014, 62 patients underwent isolated tricuspid valve surgery. Forty-five patients (73%) had undergone previous heart operations. Right heart morphology and function variables were measured de novo from stored echocardiographic images, and clinical and hemodynamic data were extracted from patient registries and records. Cluster analysis was performed and outcomes assessed. RESULTS On average, the right ventricle was dilated (diastolic area 32 cm2), but its function was preserved (free-wall strain -17% ± 5.8%) and right heart failure manifestations were moderate, with 40 (65%) having congested neck veins, 35 (56%) dependent edema, and 15 (24%) ascites. Average model for end-stage liver disease with sodium score was 11 ± 4.4, but individual values varied widely. Tricuspid valve variables split patients into 2 equal clusters: those with functional tricuspid regurgitation (TR) and those with structural TR. These groups had similar right ventricular function, but the functional TR group had worse right ventricular morphology and more severe manifestations of right heart failure, including greater model for end-stage liver disease with sodium scores (12 ± 44 vs 9.1 ± 3.9; P = .008). Both groups survived operation with low morbidity, but patients with functional TR had worse long-term survival, 48% versus 73% at 10 years after surgery. CONCLUSIONS The cluster analysis of patients with right heart failure undergoing isolated tricuspid valve surgery separated functional and structural tricuspid valve disease. Good early outcomes suggest expanding criteria for tricuspid valve surgery and earlier intervention for functional TR with right heart failure.
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Affiliation(s)
- Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ahmed Ibrahim
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bradley Rosinski
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lucy Thuita
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Patrick H Collier
- Department of Cardiovascular Medicine, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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18
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Zaki A, Yang B, Oh N, Umana-Pizano J, Heresi G, Haddadin I, Goyanes A, Smedira N, Elgharably H, Tong M. Impact of a Multidisciplinary Team on Surgical Management of Chronic Thromboembolic Pulmonary Hypertension. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1085] [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: 04/05/2023] Open
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19
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Tantawi A, Itoda Y, Ayyat K, Okamoto T, Thuita L, Sakanoue I, Elgharably H, Yun J, McCurry K. Impact of Donor Age on Survival of Lung Transplant Recipients According to Their Primary Diagnosis. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.112] [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: 04/05/2023] Open
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20
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Okamoto T, Ayyat K, Sakanoue I, Tantawi A, Unai S, Ahmad U, Elgharably H, Yun J, Budev M, McCurry K. Impact of Ex Vivo Lung Perfusion on a Lung Transplant Program: A Single Center Experience. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1015] [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: 04/05/2023] Open
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21
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Ayyat K, Okamoto T, Tantawi A, Sakanoue I, Elgharably H, Ahmad U, Unai S, Yun J, Budev M, McCurry K. Back-Table Evaluation Prior to Ex-Vivo Lung Perfusion: An Approach for Improving Utilization Rates. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.1013] [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: 04/05/2023] Open
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22
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Ayyat K, Okamoto T, Tantawi A, Sakanoue I, Elgharably H, Ahmad U, Unai S, Yun J, Budev M, McCurry K. Screening for Donor Lung Pulmonary Emboli During Ex-Vivo Lung Perfusion. J Heart Lung Transplant 2023. [DOI: 10.1016/j.healun.2023.02.083] [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: 04/05/2023] Open
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23
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Johnston DR, Mahboubi R, Soltesz EG, Artis AS, Roselli EE, Blackstone EH, Svensson LG, Gillinov AM, Kapadia S, Desai MY, Burns D, Vargo PR, Unai S, Pettersson GB, Weiss A, Elgharably H, Puri R, Reed GW, Popovic ZB, Jaber W, Thomas SA, Bakaeen FG, Karamlou T, Najm H, Griffin B, Krishnaswamy A, McCurry KR, Rodriguez LL, Smedira NG, Zhen-Yu Tong M, Wierup P, Yun J. Redefining "low risk": Outcomes of surgical aortic valve replacement in low-risk patients in the transcatheter aortic valve replacement era. J Thorac Cardiovasc Surg 2023; 165:591-604.e3. [PMID: 36635021 DOI: 10.1016/j.jtcvs.2021.01.145] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 07/14/2020] [Revised: 01/13/2021] [Accepted: 01/26/2021] [Indexed: 01/18/2023]
Abstract
OBJECTIVES Guidelines suggest aortic valve replacement (AVR) for low-risk asymptomatic patients. Indications for transcatheter AVR now include low-risk patients, making it imperative to understand state-of-the-art surgical AVR (SAVR) in this population. Therefore, we compared SAVR outcomes in low-risk patients with those expected from Society of Thoracic Surgeons (STS) models and assessed their intermediate-term survival. METHODS From January 2005 to January 2017, 3493 isolated SAVRs were performed in 3474 patients with STS predicted risk of mortality <4%. Observed operative mortality and composite major morbidity or mortality were compared with STS-expected outcomes according to calendar year of surgery. Logistic regression analysis was used to identify risk factors for these outcomes. Patients were followed for time-related mortality. RESULTS With 15 observed operative deaths (0.43%) compared with 55 expected (1.6%), the observed:expected ratio was 0.27 for mortality (95% confidence interval [CI], 0.14-0.42), stroke 0.65 (95% CI, 0.41-0.89), and reoperation 0.50 (95% CI, 0.42-0.60). Major morbidity or mortality steadily declined, with probabilities of 8.6%, 6.7%, and 5.2% in 2006, 2011, and 2016, respectively, while STS-expected risk remained at approximately 12%. Mitral valve regurgitation, ventricular hypertrophy, pulmonary, renal, and hepatic failure, coronary artery disease, and earlier surgery date were residual risk factors. Survival was 98%, 91%, and 82% at 1, 5, and 9 years, respectively, superior to that predicted for the US age-race-sex-matched population. CONCLUSIONS STS risk models overestimate contemporary SAVR risk at a high-volume center, supporting efforts to create a more agile quality assessment program. SAVR in low-risk patients provides durable survival benefit, supporting early surgery and providing a benchmark for transcatheter AVR.
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Affiliation(s)
- Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Rashed Mahboubi
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Amanda S Artis
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; The Aortic Valve Center, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
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24
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Hariri E, Layoun H, Hansen J, Abou Hassan O, Kassab J, Kassis N, Cremer PC, Hanna M, Mentias A, Flamm SD, Daou R, Griffin B, Elgharably H, Unai S, Pettersson G, Kapadia S, Harb SC. Imaging and haemodynamic parameters associated with clinical outcomes following isolated tricuspid valve surgery. Open Heart 2022; 9:openhrt-2022-002124. [PMID: 36522126 PMCID: PMC9756202 DOI: 10.1136/openhrt-2022-002124] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 10/24/2022] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Isolated tricuspid valve surgery (TVS) may be associated with high morbidity and mortality. The aim of this study was to investigate the association of preoperative imaging and haemodynamic data derived from echocardiography (ECHO), cardiac magnetic resonance (CMR) and right heart catheterisation (RHC) with postoperative outcomes following TVS. METHODS In a retrospective cohort study, patients who underwent isolated TVS at our institution between 2012 and 2020 were screened and followed up to 1 year. We only included those who had all three tests before surgery: ECHO, CMR and RHC. Patients with congenital heart disease, infective endocarditis and those who underwent concomitant valve or pericardial surgery were excluded. The primary outcome was a composite of mortality and congestive heart failure at 1 year. Time-to-event analyses at 1 year and Cox proportional hazards regression analyses were performed. RESULTS A total of 60 patients were included (mean age of 60±14 years, 63% women), of whom 67% underwent TV repair. The primary outcome occurred in 16 patients (27%) with a 1-year mortality of 7%. It was associated with ECHO-derived right ventricular (RV) free wall strain and RHC-derived RV systolic and diastolic as well as mean pulmonary pressures. On multivariable Cox regression analysis, only RV systolic and diastolic pressures were significantly associated with the primary outcome at 1 year (HRs=5.9 and 3.4, respectively, p<0.05). CONCLUSION Baseline invasive haemodynamic assessment could have a strong association with clinical outcomes and help risk-stratify patients undergoing isolated TVS.
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Affiliation(s)
- Essa Hariri
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Habib Layoun
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jonathan Hansen
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ossama Abou Hassan
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Joseph Kassab
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Nicholas Kassis
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Paul C Cremer
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Mazen Hanna
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amgad Mentias
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Scott D Flamm
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Remy Daou
- Family Medicine Department, Hotel-Dieu De France, Achrafieh, Lebanon
| | - Brian Griffin
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Haytham Elgharably
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Shinya Unai
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gosta Pettersson
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Samir Kapadia
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Serge C Harb
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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Othman AA, Elgharably H, Vargo PR, Ayyat KS, Bakaeen FG, Johnston DR, Tong MZ, Unai S, Kalahasti V, Sevensson LG, Roselli EE. Valve-Preserving Root Reimplantation Combined with Arch Procedure: Optimizing Patient Selection. Innovations (Phila) 2022; 17:201-208. [PMID: 35604783 DOI: 10.1177/15569845221094007] [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: 11/16/2022]
Abstract
OBJECTIVE Patients with thoracic aortic disease commonly present with concomitant multisegment pathology. We describe the patient population, analyze outcomes, and define the patient selection strategy for valve-preserving aortic root reimplantation (VPARR) combined with the arch procedure. Methods: From 2008 to 2018, 98 patients underwent VPARR combined with the aortic arch procedure (hemi-arch, 50% [n = 49, limited repair]; total arch, 50% [n = 49, complete repair] including 39 with elephant trunk). Indications for surgery were aneurysmal disease (61%) and aortic dissection (39%). The median follow-up was 17 months (IQR, 8 to 60 months). Results: There were no operative deaths or paraplegia, and 5 patients underwent re-exploration for bleeding. During follow-up, 2 patients required aortic valve replacement for severe aortic insufficiency at 1 and 5 years, and 4 patients died. In the limited repair group, 1 patient underwent reintervention for aortic arch replacement, whereas 4 patients underwent planned intervention (1 endovascular and 3 open thoracoabdominal aortic repair). In the complete repair group, 23 patients underwent planned intervention (15 endovascular and 8 open thoracoabdominal repair). Conclusions: Single-stage, complete, proximal aortic repair including VPARR combined with total aortic arch replacement is as safe and feasible to perform as limited arch repair and facilitates further intervention in carefully selected patients with diffuse aortic pathology at centers of expertise.
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Affiliation(s)
- Ahmed A Othman
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,8959Liverpool Heart and Chest Hospital, Liverpool, UK
| | - Haytham Elgharably
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Patrick R Vargo
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Kamal S Ayyat
- Lerner Research Institute, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Faisal G Bakaeen
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Douglas R Johnston
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Michael Z Tong
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Shinya Unai
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Vidyasagar Kalahasti
- Cardiovascular Medicine, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Lars G Sevensson
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
| | - Eric E Roselli
- Aorta Center, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA.,Department of Thoracic and Cardiovascular Surgery, Heart Vascular and Thoracic Institute, 2569Cleveland Clinic, Cleveland, OH, USA
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Tsiouris A, Elgharably H, Ahmad U, Budev M, Lane C, Gadre S, Turowski J, Akindipe O, Koval C, Krishnan S, Unai S, Anandamurthy B, McCurry K, Yun J. Lung Transplant for Patients with COVID-19 Bridged with VV ECMO: Initial Experience. J Heart Lung Transplant 2022. [PMCID: PMC8988694 DOI: 10.1016/j.healun.2022.01.1213] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Purpose During the COVID-19 pandemic, veno-venous Extracorporeal Membrane Oxygenation (VV ECMO) has been used extensively for respiratory failure refractory to conventional mechanical ventilation (MV) and rescue maneuvers. However, the worldwide experience with COVID-19 patients undergoing lung transplant (LTx) with pre-LTx VV ECMO support is limited. Therefore, we sought to report our institution's early experience with COVID-19 patients who underwent LTx after VV ECMO. Methods We retrospectively identified 5 COVID-19 patients who underwent LTx after VV ECMO support. Patients were required to have a negative nasopharyngeal swab and a negative bronchoalveolar lavage for COVID-19 prior to LTx listing. We analyzed preoperative and operative characteristics, details of VV ECMO support and early post-transplant outcomes. Results The mean age of our cohort was 50 years (range 39-57 years) and all patients were male. Mean recipient BMI was 30 (range 22-37). Mean duration of VV ECMO pre-Ltx was 60 days (range 44-72 days). At the time of the LTx operation, 60% (3/5) of patients were on VV ECMO, 20% (1/5) were on mechanical ventilation (MV), and 20% (1/5) were on supplemental oxygen only. Preoperatively, 80% (4/5) had acute kidney injury and 20% (2/5) were on dialysis. LTx was performed via clamshell approach with intraoperative venoaterial ECMO support in all cases. For 60% (3/5) patients, VV ECMO support was continued after LTx and discontinued on postoperative days 0, 1 and 6, respectively. All-cause mortality was 40% (2/5), related to sepsis and multi-organ failure, and both deaths occurred an average of 115 days post-LTx. Mean length of stay for surviving patients was 59 days (range 22-117). In the first 3 months postop-LTx, grade A2 acute cellular rejection was noted in 2 patients, A1 in 2 patients, and antibody-mediated rejection in 1 patient. Conclusion Our early experience with LTx for COVID-19 patients supported with VV ECMO support is notable for 1) prolonged VV-ECMO duration and significant morbidity pre-LTx, and 2) early mortalities related to sepsis and multiple organ failure. These data highlight a uniquely complex patient population that carries high risk of multi-organ failure and other comorbidities dictating careful selection for transplant.
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Ayyat K, Weingarten N, Okamoto T, Sakanoue I, Ahmad U, Unai S, Yun J, Budev M, Elgharably H, McCurry K. Mechanical Circulatory Support During Lung Transplantation: Choices, Outcomes and Impact of Duration. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.645] [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: 10/18/2022] Open
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28
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Ayyat K, Okamoto T, Sakanoue I, Elgharably H, Ahmad U, Unai S, Yun J, Budev M, McCurry K. Ex-Vivo Pulmonary Artery Angioscopy: A Novel Technique for Management of Donor Lung Pulmonary Embolism. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.625] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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29
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Sakanoue I, Okamoto T, Ayyat K, Yun J, Elgharably H, Unai S, Ahmad U, Budev M, McCurry K. Pulmonary Dead Space Fraction: A Predictive Factor for Transplant Suitability in Clinical Ex Vivo Lung Perfusion. J Heart Lung Transplant 2022. [DOI: 10.1016/j.healun.2022.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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30
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Lad S, Parker W, Elgharably H, Ridgway EA, Singh T. SURGICAL RESECTION FOR A MOBILE MITRAL ANNULAR CALCIFICATION MIMICKING A CARDIAC MYXOMA. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)03941-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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31
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Okamoto T, Ayyat KS, Sakanoue I, Niikawa H, Said SA, Ahmad U, Unai S, Bribriesco A, Elgharably H, Budev MM, Yun JJ, McCurry KR. Clinical Significance of Donor Lung Weight at Procurement and during Ex Vivo Lung Perfusion. J Heart Lung Transplant 2022; 41:818-828. [DOI: 10.1016/j.healun.2022.02.011] [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] [Received: 03/10/2021] [Revised: 02/10/2022] [Accepted: 02/12/2022] [Indexed: 11/29/2022] Open
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Abstract
The surgical technique for lung transplantation has evolved dramatically over the last three decades. Significant improvements in short term outcomes in the early years of lung transplantation were due, in large part, to techniques developed to reduce airway anastomotic complications in single lung transplantation. Following development of the technique of en bloc double lung transplantation, evolution to the bilateral sequential technique further reduced airway complications for double lung transplantation. More recently, some programs have utilized the en bloc double lung transplant technique with bronchial artery revascularization to aid airway healing and potentially improve short- and long-term outcomes. The experience with bronchial artery revascularization remains limited to a few series, with the technique having not been widely adopted by most lung transplant programs. With the implementation of priority allocations schemes in many countries, patients with higher risk profiles are being prioritized for transplantation which results in more complex procedures in fragile recipients with multiple comorbidities. This includes the increased need for concomitant cardiac procedures as well as performing lung transplantation after prior cardiothoracic surgery. Different surgical approaches have been described for bilateral sequential lung transplantation with or without intra-operative mechanical circulatory support (MCS), such as sternotomy, clamshell (bilateral anterior thoracotomies with transverse sternotomy), and bilateral thoracotomy incisions. Herein, we aim, not only to describe the various surgical approaches for double lung transplantation, but to provide a comprehensive review of other aspects related to the recipient pathology and different anatomical variants as well as handling technical challenges that might be encountered during the procedure.
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Affiliation(s)
- Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Michael J Javorski
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Kenneth R McCurry
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
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33
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Elgharably H, Ayyat K, Okamoto T, Thuita L, Yun J, Ahmad U, McCurry K. High Grade Primary Graft Dysfunction after Lung Transplantation is Associated with Acute Rejection but Not Chronic Allograft Dysfunction. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1067] [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: 10/21/2022] Open
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34
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Elgharably H, Kish D, Keslar K, Okamoto T, Ayyat K, McCurry K, Fairchild F. Cold Storage of Lung Allograft Modulates microRNA-223 Expression & NF-kB-Mediated Reperfusion Response. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1908] [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: 11/16/2022] Open
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35
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Ayyat K, Okamoto T, Sakanoue I, Elgharably H, Niikawa H, Said S, Yun J, Nowacki A, McCurry K. The Complete Score for Assessment of Donor Lungs: A Comprehensive Evaluation System in Clinical Ex-Vivo Lung Perfusion. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1901] [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: 10/21/2022] Open
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36
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Elgharably H, Pettersson GB, Navia JL. Aortic allograft for endocarditis of the intervalvular fibrosa. Ann Thorac Surg 2021; 112:1383-1384. [PMID: 33621557 DOI: 10.1016/j.athoracsur.2020.11.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 11/08/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195
| | - Jose L Navia
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, 9500 Euclid Ave, Desk J4-1, Cleveland, OH 44195
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Javorski MJ, Zaki A, Abas M, Elgharably H, Attia TS. Current era left ventricular assist devices. Future Cardiol 2021; 17:971-984. [PMID: 33563033 DOI: 10.2217/fca-2020-0177] [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: 11/21/2022] Open
Abstract
Left ventricular assist devices (LVADs) have changed the landscape of treatment options for patients with end stage heart failure. Due to the limited availability of donor hearts for transplantation, LVADs have become an important option for many of these patients. Much progress has been made in the device industry since then, and newer devices continue to improve patient outcomes. In this review, we will discuss some of the key transitions in LVADs over the years, the current LVADs used in practice today, implantation techniques, the impact of the new heart allocation system on LVAD use and future prospective LVADs.
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Affiliation(s)
- Michael J Javorski
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular & Thoracic Institute, Cleveland Clinic Foundation, OH 44195, USA
| | - Anthony Zaki
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular & Thoracic Institute, Cleveland Clinic Foundation, OH 44195, USA
| | - Motaz Abas
- Ross University School of Medicine, Bridgetown, BB11093, Barbados
| | - Haytham Elgharably
- Department of Thoracic & Cardiovascular Surgery, Heart Vascular & Thoracic Institute, Cleveland Clinic Foundation, OH 44195, USA.,Kaufman Center for Heart Failure Treatment & Recovery, Cleveland Clinic Foundation, Cleveland, OH 44195, USA
| | - Tamer S Attia
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30322, USA
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Reyaldeen R, Lo Presti Vega S, Elgharably H, Xu B. More Than a Simple Vegetation: The Trifecta of Mitral Valve Leaflet Perforation, Windsock Aneurysm, and Mitral Valve Abscess. ACTA ACUST UNITED AC 2020; 5:20-25. [PMID: 33644509 PMCID: PMC7887516 DOI: 10.1016/j.case.2020.10.008] [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: 11/29/2022]
Abstract
MV abscesses and aneurysms are uncommon complications of IE. Serial echocardiography is important to identify perivalvular complications. Three-dimensional transesophageal echocardiography has incremental value in diagnosis.
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Affiliation(s)
- Reza Reyaldeen
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Saberio Lo Presti Vega
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bo Xu
- Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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Elgharably H, Gamaleldin M, Ayyat KS, Zaki A, Hodges K, Kindzelski B, Sharma S, Hassab T, Yongue C, Serna SDL, Perez J, Spencer C, Bakaeen FG, Steele SR, Gillinov AM, Svensson LG, Pettersson GB. Serious Gastrointestinal Complications After Cardiac Surgery and Associated Mortality. Ann Thorac Surg 2020; 112:1266-1274. [PMID: 33217398 DOI: 10.1016/j.athoracsur.2020.09.034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2020] [Revised: 08/26/2020] [Accepted: 09/11/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Severe gastrointestinal (GI) complications (GICs) after cardiac surgery are associated with poor outcomes. Herein, we characterize the severe forms of GICs and associated risk factors of mortality. METHODS We retrospectively analyzed the clinically significant postoperative GICs after cardiac surgical procedures performed at our institution from January 2010 to April 2017. Multivariable analysis was used to identify predictors for in-hospital mortality. RESULTS Of 29,909 cardiac surgical procedures, GICs occurred in 1037 patients (3.5% incidence), with overall in-hospital mortality of 14% compared with 1.6% in those without GICs. GICs were encountered in older patients with multiple comorbidities who underwent complex prolonged procedures. The most lethal GICs were mesenteric ischemia (n = 104), hepatopancreatobiliary (HPB) dysfunction (n = 139), and GI bleeding (n = 259), with mortality rates of 45%, 27%, and 17%, respectively. In the mesenteric ischemia subset, coronary artery disease (odds ratio [OR], 4.57; P = .002], coronary bypass grafting (OR, 6.50; P = .005), reoperation for bleeding/tamponade (OR, 12.07; P = .01), and vasopressin use (OR, 11.27; P < .001) were predictors of in-hospital mortality. In the HPB complications subset, hepatic complications occurred in 101 patients (73%), pancreatitis in 38 (27%), and biliary disease in 31 (22%). GI bleeding occurred in 20 patients (31%) with HPB dysfunction. In the GI bleeding subset, HPB disease (OR, 10.99; P < .001) and bivalirudin therapy (OR, 12.84; P = .01) were predictors for in-hospital mortality. CONCLUSIONS Although relatively uncommon, severe forms of GICs are associated with high mortality. Early recognition and aggressive treatment are mandatory to improve outcomes.
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Affiliation(s)
- Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
| | | | - Kamal S Ayyat
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Anthony Zaki
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Bogdan Kindzelski
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Shashank Sharma
- Colorectal Surgery, and Quantitative Health Sciences, Cleveland, Ohio
| | - Tarek Hassab
- Colorectal Surgery, and Quantitative Health Sciences, Cleveland, Ohio
| | - Camille Yongue
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Solanus de la Serna
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Juan Perez
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Capri Spencer
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Scott R Steele
- Colorectal Surgery, and Quantitative Health Sciences, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Gosta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
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40
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Elgharably H, Javadikasgari H, Koprivanac M, Lowry AM, Sato K, Blackstone EH, Klein AL, Gillinov AM, Svensson LG, Navia JL. Right versus left heart reverse remodelling after treating ischaemic mitral and tricuspid regurgitation. Eur J Cardiothorac Surg 2020; 59:ezaa326. [PMID: 33188424 DOI: 10.1093/ejcts/ezaa326] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 07/28/2020] [Accepted: 07/31/2020] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Repair outcomes of tricuspid regurgitation (TR) associated with ischaemic mitral regurgitation (IMR) are inferior to functional TR in terms of TR recurrence and right ventricular (RV) reverse remodelling. Our objective is to analyse right versus left heart reverse remodelling after surgery for IMR-associated TR. METHODS From 2001 to 2011, 568 patients with severe IMR underwent mitral valve surgery (repair 87%, replacement 13%), and 131 had concomitant tricuspid valve repair. Median follow-up was 3.0 years; 25% of living patients were followed up for 6.3 years. Longitudinal analysis of 1527 follow-up echocardiograms was performed to assess ventricular reverse remodelling and function. RESULTS Unlike the left heart, the right heart failed to reverse remodel (failed to recover ventricular function or halt dilatation). During follow-up after surgery, the right ventricle continued to dilate while the left ventricle regressed in size. RV ejection fraction decreased (46% at 1 month and 44% at 5 years), while left ventricular ejection fraction increased (33% and 37%, respectively). RV strain showed early (-11% at 1 month) and late (-12% at 5 years) dysfunction. Patients who underwent tricuspid valve repair had worse RV function. Mitral regurgitation remained stable after surgical intervention, and TR gradually recurred (37% moderate, 20% severe at 7 years). CONCLUSIONS Surgical treatment of IMR and TR along with revascularization failed to induce reverse remodelling of the right heart. These findings warrant further investigations to identify optimal timing and approach of intervention for IMR-associated TR with respect to RV remodelling.
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Affiliation(s)
- Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Hoda Javadikasgari
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Marijan Koprivanac
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ashley M Lowry
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kimi Sato
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Allan L Klein
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - José L Navia
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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Weingarten N, Schraufnagel D, Plitt G, Zaki A, Ayyat KS, Elgharably H. Comparison of mechanical cardiopulmonary support strategies during lung transplantation. Expert Rev Med Devices 2020; 17:1075-1093. [PMID: 33090042 DOI: 10.1080/17434440.2020.1841630] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [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: 10/23/2022]
Abstract
INTRODUCTION Lung transplantation outcomes are influenced by the intraoperative mechanical cardiopulmonary support strategy used. This surgery was historically done either on cardiopulmonary bypass (CPB) or off pump. Recently, there has been increased interest in intraoperative support with veno-arterial (VA) or veno-venous (VV) extracorporeal membrane oxygenation (ECMO). However, there is a lack of consensus on the relative risks, benefits and indications for each intraoperative support strategy. AREAS COVERED This review includes information from cohort studies, case-control studies, and case series that compare morbidity and/or mortality of two or more intraoperative cardiopulmonary support strategies during lung transplantation. EXPERT OPINION The optimal strategy for intraoperative cardiopulmonary support during lung transplantation remains an area of debate. Current data suggest that off pump is associated with better outcomes and could be considered whenever feasible. ECMO is generally associated with preferable outcomes to CPB, but the data supporting this association is not robust. Interestingly, whether CPB is unplanned or prolonged might influence outcomes more than the use of CPB itself. These observations can help guide surgical teams in their approach for intraoperative mechanical support strategy during lung transplantation and should serve as the basis for further investigations.
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Affiliation(s)
- Noah Weingarten
- Department of General Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Dean Schraufnagel
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Gilman Plitt
- Department of General Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Anthony Zaki
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Kamal S Ayyat
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation , Cleveland, OH, USA
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Hansen J, Hariri E, Elgharably H, Pettersson G, Kapadia S, Hassan OA. TCT CONNECT-489 Pre-Operative Clinical and Imaging Predictors of Outcomes in Isolated Tricuspid Valve Surgery. J Am Coll Cardiol 2020. [DOI: 10.1016/j.jacc.2020.09.518] [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: 11/26/2022]
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Wang TKM, Elgharably H, Cremer P. "Holes-in-one": A case of concurrent windsock mitral valve, root abscess, and Gerbode defect. Echocardiography 2020; 37:935-938. [PMID: 32426868 DOI: 10.1111/echo.14703] [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: 01/06/2020] [Revised: 04/27/2020] [Accepted: 04/29/2020] [Indexed: 11/29/2022] Open
Abstract
Infective endocarditis is a heterogeneous disease with a wide array of pathological lesions. We present a 55-year-old man with severe mitral and aortic regurgitation on transthoracic echocardiography. Transesophageal echocardiogram characterized the mechanisms detecting a windsock mitral valve perforation, aortic root abscess, and Gerbode ventricular septal defect, with the deep transgastric view showing all three pathologies concurrently. The etiologies of mitral valve perforation and Gerbode defects are discussed. Transesophageal echocardiography remains a critical imaging modality to diagnose and evaluate the extent of infective endocarditis with superior sensitivity to transthoracic echocardiography.
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Affiliation(s)
- Tom Kai Ming Wang
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Paul Cremer
- Section of Cardiovascular Imaging, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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Siddiqi S, Ravichandren K, Soltesz EG, Johnston DR, Roselli EE, Tong MZ, Navia JL, Elgharably H, Ayyat K, Houghtaling PL, Pettersson GB, Blackstone EH, Svensson LG, Bakaeen FG. Coronary Artery Bypass Graft Patency and Survival in Patients on Dialysis. J Surg Res 2020; 254:1-6. [PMID: 32388058 DOI: 10.1016/j.jss.2020.03.069] [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: 12/11/2019] [Revised: 03/26/2020] [Accepted: 03/29/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Little is known about graft patency after coronary artery bypass grafting (CABG) performed in patients on dialysis. Our aim was to assess patency of internal thoracic artery (ITA) grafts and saphenous vein grafts (SVGs) in these patients. METHODS From 1/1997 to 1/2018, 500 patients on dialysis underwent primary CABG with or without concomitant procedures at Cleveland Clinic, 40 of whom had 48 postoperative angiograms for recurrent ischemic symptoms. Complete follow-up was obtained on all but 1 patient lost to follow-up 1 y after CABG. Thirty-six ITA grafts and 65 SVGs were evaluable for stenosis and occlusion. RESULTS Two of 40 patients (5%) had emergency CABG; 3 (7.5%) with calcified aortas had a change in operative strategy to avoid ascending aortic manipulation, 2 (5%) had poor conduit quality, and 12 (30%) had severe diffuse atherosclerotic disease with calcification of the coronary targets causing technical difficulties. Thirty-three patients (82%) were bypassed with an in situ ITA and 3 (7.5%) had a free ITA graft. Three of 36 ITA grafts were occluded at 0.78, 1.8, and 9.4 y (too few to model). SVG patency was 52% and 37% at 1 and 2 y, respectively. CONCLUSIONS Among patients on dialysis who underwent CABG, coronary angiography for ischemic symptoms in a select subset revealed that SVG patency was lower than expected from published reports in the general CABG population and may contribute to the poor prognosis of this cohort. Further work is needed to guide graft selection and improve graft patency in dialysis patients.
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Affiliation(s)
- Shirin Siddiqi
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kirthi Ravichandren
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jose L Navia
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kamal Ayyat
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Penny L Houghtaling
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Faisal G Bakaeen
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
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Ayyat K, Elgharably H, Okamoto T, Sakanoue I, Said S, Yun J, Budev M, Pettersson G, McCurry K. Lung Transplantation on Cardiopulmonary Bypass: Time Matters. J Heart Lung Transplant 2020. [DOI: 10.1016/j.healun.2020.01.341] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [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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Navia JL, Elgharably H, Hakim AH, Witten JC, Haupt MJ, Germano E, Houghtaling PL, Bakaeen FG, Pettersson GB, Lytle BW, Roselli EE, Gillinov AM, Svensson LG. Long-term Outcomes of Surgery for Invasive Valvular Endocarditis Involving the Aortomitral Fibrosa. Ann Thorac Surg 2019; 108:1314-1323. [DOI: 10.1016/j.athoracsur.2019.04.119] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
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Elgharably H, Tong MZ, Soltesz EG. HeartMate 3 Implantation in a Myosplint Device-Supported Left Ventricle. Ann Thorac Surg 2019; 109:e177-e178. [PMID: 31445907 DOI: 10.1016/j.athoracsur.2019.06.088] [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: 06/19/2019] [Accepted: 06/24/2019] [Indexed: 10/26/2022]
Abstract
Implantation of a left ventricular assist device in a patient who has a passive cardiac support device can present a surgical challenge. This case demonstrates a safe and feasible surgical approach for HeartMate 3 (Abbott, Abbott Park, IL) implantation after remote Mysoplint device (Myocor, Maple Grove, MN) placement.
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Affiliation(s)
- Haytham Elgharably
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio; Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic Foundation, Cleveland, Ohio.
| | - Michael Z Tong
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio; Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio; Kaufman Center for Heart Failure Treatment and Recovery, Cleveland Clinic Foundation, Cleveland, Ohio
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Navia JL, Kapadia S, Elgharably H, Harb SC, Krishnaswamy A, Unai S, Mick S, Rodriguez L, Hammer D, Gillinov AM, Svensson LG. First-in-Human Implantations of the NaviGate Bioprosthesis in a Severely Dilated Tricuspid Annulus and in a Failed Tricuspid Annuloplasty Ring. Circ Cardiovasc Interv 2019; 10:CIRCINTERVENTIONS.117.005840. [PMID: 29246915 DOI: 10.1161/circinterventions.117.005840] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jose L Navia
- From the Departments of Thoracic and Cardiovascular Surgery (J.L.N., H.E., S.U., S.M., A.M.G., L.G.S.) and Cardiovascular Medicine (S.K., S.C.H., A.K., L.R., D.H.), Cleveland Clinic, OH.
| | - Samir Kapadia
- From the Departments of Thoracic and Cardiovascular Surgery (J.L.N., H.E., S.U., S.M., A.M.G., L.G.S.) and Cardiovascular Medicine (S.K., S.C.H., A.K., L.R., D.H.), Cleveland Clinic, OH
| | - Haytham Elgharably
- From the Departments of Thoracic and Cardiovascular Surgery (J.L.N., H.E., S.U., S.M., A.M.G., L.G.S.) and Cardiovascular Medicine (S.K., S.C.H., A.K., L.R., D.H.), Cleveland Clinic, OH
| | - Serge C Harb
- From the Departments of Thoracic and Cardiovascular Surgery (J.L.N., H.E., S.U., S.M., A.M.G., L.G.S.) and Cardiovascular Medicine (S.K., S.C.H., A.K., L.R., D.H.), Cleveland Clinic, OH
| | - Amar Krishnaswamy
- From the Departments of Thoracic and Cardiovascular Surgery (J.L.N., H.E., S.U., S.M., A.M.G., L.G.S.) and Cardiovascular Medicine (S.K., S.C.H., A.K., L.R., D.H.), Cleveland Clinic, OH
| | - Shinya Unai
- From the Departments of Thoracic and Cardiovascular Surgery (J.L.N., H.E., S.U., S.M., A.M.G., L.G.S.) and Cardiovascular Medicine (S.K., S.C.H., A.K., L.R., D.H.), Cleveland Clinic, OH
| | - Stephanie Mick
- From the Departments of Thoracic and Cardiovascular Surgery (J.L.N., H.E., S.U., S.M., A.M.G., L.G.S.) and Cardiovascular Medicine (S.K., S.C.H., A.K., L.R., D.H.), Cleveland Clinic, OH
| | - Leonardo Rodriguez
- From the Departments of Thoracic and Cardiovascular Surgery (J.L.N., H.E., S.U., S.M., A.M.G., L.G.S.) and Cardiovascular Medicine (S.K., S.C.H., A.K., L.R., D.H.), Cleveland Clinic, OH
| | - Donald Hammer
- From the Departments of Thoracic and Cardiovascular Surgery (J.L.N., H.E., S.U., S.M., A.M.G., L.G.S.) and Cardiovascular Medicine (S.K., S.C.H., A.K., L.R., D.H.), Cleveland Clinic, OH
| | - A Marc Gillinov
- From the Departments of Thoracic and Cardiovascular Surgery (J.L.N., H.E., S.U., S.M., A.M.G., L.G.S.) and Cardiovascular Medicine (S.K., S.C.H., A.K., L.R., D.H.), Cleveland Clinic, OH
| | - Lars G Svensson
- From the Departments of Thoracic and Cardiovascular Surgery (J.L.N., H.E., S.U., S.M., A.M.G., L.G.S.) and Cardiovascular Medicine (S.K., S.C.H., A.K., L.R., D.H.), Cleveland Clinic, OH
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Schraufnagel DP, Elgharably H, Siddiqi S, Hakim AH, Sale S, Mehta A, Skubas NJ, Gordon SM, Bakaeen F, Gillinov AM, Svensson LG, Navia JL. Value of perioperative inhaled epoprostenol with low tidal volume ventilation for complex endocarditis surgery. J Card Surg 2019; 34:676-683. [DOI: 10.1111/jocs.14095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2019] [Accepted: 05/17/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Dean P. Schraufnagel
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Haytham Elgharably
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Shirin Siddiqi
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Ali H. Hakim
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Shiva Sale
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Anand Mehta
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Nikolaos J. Skubas
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Steven M. Gordon
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Faisal Bakaeen
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - A. Marc Gillinov
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Lars G. Svensson
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
| | - Jose L. Navia
- Department of Thoracic and Cardiovascular SurgeryCleveland Clinic Foundation Cleveland Ohio
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Siddiqi S, Schraufnagel DP, Siddiqui HU, Javorski MJ, Mace A, Elnaggar AS, Elgharably H, Vargo PR, Steffen R, Hasan SM, Raja S. Recent advancements in the minimally invasive management of esophageal perforation, leaks, and fistulae. Expert Rev Med Devices 2019; 16:197-209. [PMID: 30767693 DOI: 10.1080/17434440.2019.1582329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [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: 02/06/2023]
Abstract
INTRODUCTION Historically, the gold standard management of esophageal perforations, leaks, and fistulae has been traditional open surgery, but it is associated with significant morbidity and mortality. Minimally invasive approaches offer alternatives to surgery in treating hemodynamically stable patients with such defects. In this review article, we will discuss the recent advancements in the minimally invasive management of esophageal perforations, leaks, and fistulas. AREAS COVERED This review includes information from case reports, case series, and clinical trials on minimally invasive management of esophageal perforations, leaks, and fistulas. The focus is on the devices, outcomes, and application of the technology. EXPERT COMMENTARY Minimally invasive treatment represents significant progress in the management of esophageal perforations, leaks, and fistulas. Based on current evidence, it seems safe and effective but it is evolving and more studies are needed to help draw definitive conclusions.
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Affiliation(s)
- Shirin Siddiqi
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Dean P Schraufnagel
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Hafiz Umair Siddiqui
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Michael J Javorski
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Adam Mace
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Abdulrhman S Elnaggar
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Haytham Elgharably
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Patrick R Vargo
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Robert Steffen
- b Department of Cardiovascular Surgery , Minneapolis Heart Institute Foundation , Minneapolis , MN , USA
| | - Saad M Hasan
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Siva Raja
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
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