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Zwischenberger BA, Gaca JG, Haney JC, Carr K, Glower DD. Late Outcomes of Porcine and Pericardial Bioprostheses after Mitral Valve Replacement in 1162 Patients. Ann Thorac Surg 2024:S0003-4975(24)00286-8. [PMID: 38631662 DOI: 10.1016/j.athoracsur.2024.04.002] [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: 11/05/2023] [Revised: 03/05/2024] [Accepted: 04/02/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Debate continues regarding the superiority of porcine versus pericardial bioprostheses, and data relevant to this comparison are scant. We therefore compare late survival and structural valve deterioration of porcine and pericardial mitral valve prostheses. METHODS Adults undergoing mitral valve replacement with one first-generation porcine valve model and one pericardial valve line were reviewed from our prospectively-maintained institutional database between 1976 and 2020. Multivariable regression and Cox proportional hazards analysis were used to compare late outcomes. RESULTS Of 1162 consecutive patients, 612 (53%) received porcine valves and 550 (47%) received pericardial valves. At 10 years, patient survival (porcine 36±2%, pericardial 38±3%, P=0.5) and cumulative incidence (CI) of mitral valve structural deterioration (porcine 18±2%, pericardial 19±3%, P=0.3) were similar. The structural failure mode was more likely severe mitral stenosis in pericardial valves (35/50(70%) versus 38/106(36%), P<0.001), and more likely severe mitral regurgitation in porcine valves (80/106(75%) versus 19/50(38%), P<0.0001). After adjustment, structural deterioration was associated with younger patient age (P<0.001), but not valve type. At 10 years, porcine valves demonstrated a higher CI of mitral reoperation (19±2% vs 9±2%, P<0.001) and reoperation for structural deterioration (15±1% vs 6±2%, P=0.007). CONCLUSIONS We demonstrate similar rates of 10-year survival and structural deterioration with porcine and pericardial bioprosthetics in mitral valve replacement. This study suggests a lack of major improvement in durability of mitral bioprosthetic valves over time. Failure mode may have greater influence on surgeon decision-making of valve choice.
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Affiliation(s)
| | - Jeffrey G Gaca
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, NC
| | - John C Haney
- Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, FL
| | - Keith Carr
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, NC
| | - Donald D Glower
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, NC
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2
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Vekstein AM, Jensen CW, Weissler EH, Downey PS, Kang L, Gaca JG, Long CA, Hughes GC. Long-term outcomes for hybrid aortic arch repair. J Vasc Surg 2024; 79:711-720.e2. [PMID: 38008268 DOI: 10.1016/j.jvs.2023.11.032] [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] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/17/2023] [Accepted: 11/19/2023] [Indexed: 11/28/2023]
Abstract
OBJECTIVE Since its inception in the early 2000s, hybrid arch repair (HAR) has evolved from novel approach to well-established treatment modality for aortic arch pathology in appropriately selected patients. Despite this nearly 20-year history of use, long-term results of HAR remain to be determined. As such, objectives of this study are to detail the long-term outcomes for HAR within an expanded classification scheme. METHODS From August 2005 to August 2022, 163 consecutive patients underwent HAR at a single referral institution. Operative approach was selected according to an institutional algorithm and included zone 0/1 HAR in 25% (n = 40), type I HAR in 34% (n = 56), and type II/III HAR in 41% (n = 67). Specific zone 0/1 technique was zone 1 HAR in 31 (78%), zone 0 with innominate snorkel (zone 0S HAR) in 7 (18%), and zone 0 with single side-branch endograft (zone 0B HAR) in 2 (5%). The 30-day and long-term outcomes, including overall and aortic-specific survival, as well as freedom from reintervention, were assessed. RESULTS The mean age was 63 ± 13 years and almost one-half of patients (47% [n = 77]) had prior sternotomy. Presenting pathology included degenerative aneurysm in 44% (n = 71), residual dissection after prior type A repair in 38% (n = 62), chronic type B dissection in 12% (n = 20), and other indications in 6% (n = 10). Operative outcomes included 9% mortality (n = 14) at 30 days, 5% mortality (n = 8) in hospital, 4% stroke (n = 7), 2% new dialysis (n = 3), and 2% permanent paraparesis/plegia (n = 3). The median follow-up was 44 month (interquartile range, 12-84 months). Overall survival was 59% and 47% at 5 and 10 years, respectively, whereas aorta-specific survival was 86% and 84% at the same time points. At 5 and 10 years, freedom from major reintervention was 92% and 91%, respectively. Institutional experience had a significant impact on both early and late outcomes: comparing the first (2005-2012) and second (2013-2022) halves of the series, 30-day mortality decreased from 14% to 1% (P = .01) and stroke from 6% to 3% (P = .62). Improved operative outcomes were accompanied by improved late survival, with 78% of patients in the later era vs 45% in the earlier era surviving to 5 years. CONCLUSIONS HAR is associated with excellent operative outcomes, as well as sustained protection from adverse aortic events as evidenced by high long-term aorta-specific survival and freedom from reintervention. However, surgeon and institutional experience appear to play a major role in achieving these superior outcomes, with a five-fold decrease in operative mortality and a two-fold decrease in stroke rate in the latter half of the series. These long-term results expand on prior midterm data and continue to support use of HAR for properly selected patients with arch disease.
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Affiliation(s)
- Andrew M Vekstein
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Christopher W Jensen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - E Hope Weissler
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Peter S Downey
- Division of Cardiac Surgery, Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Lillian Kang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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3
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Hughes GC, Chen EP, Browndyke JN, Szeto WY, DiMaio JM, Brinkman WT, Gaca JG, Blumenthal JA, Karhausen JA, Bisanar T, James ML, Yanez D, Li YJ, Mathew JP. Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest Trial (GOT ICE): A Randomized Clinical Trial Comparing Outcomes After Aortic Arch Surgery. Circulation 2024; 149:658-668. [PMID: 38084590 PMCID: PMC10922813 DOI: 10.1161/circulationaha.123.067022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Accepted: 11/10/2023] [Indexed: 02/28/2024]
Abstract
BACKGROUND Deep hypothermia has been the standard for hypothermic circulatory arrest (HCA) during aortic arch surgery. However, centers worldwide have shifted toward lesser hypothermia with antegrade cerebral perfusion. This has been supported by retrospective data, but there has yet to be a multicenter, prospective randomized study comparing deep versus moderate hypothermia during HCA. METHODS This was a randomized single-blind trial (GOT ICE [Cognitive Effects of Body Temperature During Hypothermic Circulatory Arrest]) of patients undergoing arch surgery with HCA plus antegrade cerebral perfusion at 4 US referral aortic centers (August 2016-December 2021). Patients were randomized to 1 of 3 hypothermia groups: DP, deep (≤20.0 °C); LM, low-moderate (20.1-24.0 °C); and HM, high-moderate (24.1-28.0 °C). The primary outcome was composite global cognitive change score between baseline and 4 weeks postoperatively. Analysis followed the intention-to-treat principle to evaluate if: (1) LM noninferior to DP on global cognitive change score; (2) DP superior to HM. The secondary outcomes were domain-specific cognitive change scores, neuroimaging findings, quality of life, and adverse events. RESULTS A total of 308 patients consented; 282 met inclusion and were randomized. A total of 273 completed surgery, and 251 completed the 4-week follow-up (DP, 85 [34%]; LM, 80 [34%]; HM, 86 [34%]). Mean global cognitive change score from baseline to 4 weeks in the LM group was noninferior to the DP group; likewise, no significant difference was observed between DP and HM. Noninferiority of LM versus DP, and lack of difference between DP and HM, remained for domain-specific cognitive change scores, except structured verbal memory, with noninferiority of LM versus DP not established and structured verbal memory better preserved in DP versus HM (P = 0.036). There were no significant differences in structural or functional magnetic resonance imaging brain imaging between groups postoperatively. Regardless of temperature, patients who underwent HCA demonstrated significant reductions in cerebral gray matter volume, cortical thickness, and regional brain functional connectivity. Thirty-day in-hospital mortality, major morbidity, and quality of life were not different between groups. CONCLUSIONS This randomized multicenter study evaluating arch surgery HCA temperature strategies found low-moderate hypothermia noninferior to traditional deep hypothermia on global cognitive change 4 weeks after surgery, although in secondary analysis, structured verbal memory was better preserved in the deep group. The verbal memory differences in the low- and high-moderate groups and structural and functional connectivity reductions from baseline merit further investigation and suggest opportunities to further optimize brain perfusion during HCA. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02834065.
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Affiliation(s)
- G Chad Hughes
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Edward P Chen
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - Jeffrey N Browndyke
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Wilson Y Szeto
- Department of Surgery, Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia (W.Y.S.)
| | - J Michael DiMaio
- The Heart Hospital, Baylor Scott and White, Plano, TX (J.M.D., W.T.B.)
| | | | - Jeffrey G Gaca
- Department of Surgery, Division of Thoracic and Cardiovascular Surgery (G.C.H., E.P.C., J.G.G.), Duke University Medical Center, Durham, NC
| | - James A Blumenthal
- Department of Psychiatry & Behavioral Sciences, Division of Behavioral Medicine & Neurosciences (J.N.B., J.A.B.), Duke University Medical Center, Durham, NC
| | - Jorn A Karhausen
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Tiffany Bisanar
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
| | - Michael L James
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
- Department of Neurology (M.L.J.), Duke University School of Medicine, Durham, NC
| | - David Yanez
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics (D.Y., Y.-J.L.), Duke University School of Medicine, Durham, NC
| | - Joseph P Mathew
- Department of Anesthesiology (J.A.K., T.B., M.L.J., J.P.M.), Duke University School of Medicine, Durham, NC
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Zwischenberger BA, Gaca JG, Milano C, Carr K, Glower DD. Late Survival After Redo Mitral Operation With Minithoracotomy Compared With Sternotomy. Ann Thorac Surg 2024; 117:353-359. [PMID: 37930297 DOI: 10.1016/j.athoracsur.2023.08.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 07/14/2023] [Accepted: 08/15/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The long-term effectiveness of minithoracotomy over redo median sternotomy for reoperative mitral operation is not well described. Here we present long-term survival after reoperative mitral operation based on operative approach. METHODS Adults undergoing mitral valve operation with previous sternotomy by redo sternotomy and minithoracotomy were reviewed from our prospectively maintained institutional database from 1997 to 2022. Propensity score matching was performed to compare short- and long-term outcomes. RESULTS Of 750 consecutive patients, thoracotomy was performed in 503 (67%). Median follow-up was 5.0 years (interquartile range, 0-23 years). Intraoperatively, sternotomy patients were more likely to have central aortic cannulation (205 of 223 [93%] vs 265 of 481 [56%]), cardioplegic arrest (220 of 223 [99%] vs 124 of 481 [26%]), and mitral valve replacement (190 of 223 [85%] vs 358 of 481 [74%]). Thoracotomy patients were older (63 ± 13 vs 58 ± 14 years) with elective presentation (387 of 503 [77%] vs 128 of 247 [52%]). Sternotomy patients were more likely to have endocarditis (52 of 247 [21%] vs 45 of 503 [9%], P < .001). At 10 years, thoracotomy patients experienced improved survival (52% ± 3% vs 46% ± 4%, P = .004). After propensity matching, 10-year survival was significantly higher for thoracotomy patients compared with sternotomy patients (60% ± 5% vs 42% ± 5%, P = .0006). The greatest difference in survival was at the first 6 months after operation (96% ± 1% vs 81% ± 3%, P < .001). CONCLUSIONS For patients undergoing reoperative mitral valve operation, minimally invasive right anterior thoracotomy can significantly decrease risk of death in the first 6 months, with durable survival benefit out to 10 years. We present a large single-center series to suggest an important opportunity to durably improve outcomes after reoperative mitral operation through wider use of right minithoracotomy.
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Affiliation(s)
| | - Jeffrey G Gaca
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Carmelo Milano
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Keith Carr
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina
| | - Donald D Glower
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, North Carolina
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5
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Williams AR, Moya-Mendez ME, Mehta S, Vekstein A, Harrison JK, Milano CA, Plichta RP, Haney J, Schroder JN, Zwischenberger B, Glower D, Gaca JG. Infarct exclusion repair of postmyocardial infarction ventricular septal rupture with a hybrid patch and septal occluder device compared with patch only. JTCVS Tech 2023; 22:228-236. [PMID: 38152175 PMCID: PMC10750469 DOI: 10.1016/j.xjtc.2023.07.022] [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] [Received: 05/28/2023] [Revised: 07/09/2023] [Accepted: 07/22/2023] [Indexed: 12/29/2023] Open
Abstract
Objective We developed a hybrid technique for repairing post-myocardial infarction (MI) ventricular septal defect (VSD) that combines infarct exclusion with patch and a nitinol-mesh septal occluder device (SOD) to provide a scaffold to support the damaged septal wall. Here, we compare outcomes of patients with post-MI VSD repaired using patch only or hybrid patch/SOD. Methods Patients undergoing post-MI VSD repair at our institution from 2013 to 2022 who received patch alone or patch/SOD repair were analyzed. Primary outcome was survival to hospital discharge. Clinical outcomes and echocardiograms were also analyzed. Results Over a 9-year period, 24 patients had post-MI VSD repair at our institution with either hybrid patch/SOD (n = 10) or patch only repair (n = 14). VSD size was 18 ± 5.8 mm for patch/SOD and 17 ± 4.6 mm for patch only. In the patch/SOD repair cohort, average size of SOD implant was 23.6 ± 5.6 mm. Mild left ventricular dysfunction was present prerepair and was unchanged postrepair in both groups; however, moderate-to-severe right ventricular (RV) dysfunction was common in both groups before repair. RV function worsened or persisted as severe in 10% of hybrid versus 54% of patch-only patients postrepair. Tricuspid annular systolic excursion and RV:left ventricle diameter ratio, quantitative metrics of RV function, improved after patch/SOD repair. No intraoperative mortality occurred in either group. Postoperative renal, hepatic, and respiratory failure requiring tracheostomy was common in both groups. Survival to hospital discharge in both cohorts was 70%. Conclusions Post-MI VSD repair with patch/SOD has comparable short-term outcomes with patch alone. Addition of a SOD to patch repair provides a scaffold that may enhance the repair of post-MI VSD with patch exclusion.
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Affiliation(s)
- Adam R. Williams
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Hospital, Durham, NC
| | - Mary E. Moya-Mendez
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Hospital, Durham, NC
| | - Sachin Mehta
- Division of Cardiothoracic Anesthesia, Department of Anesthesia, Duke University Hospital, Durham, NC
| | - Andrew Vekstein
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Hospital, Durham, NC
| | - J. Kevin Harrison
- Division of Cardiology, Department of Medicine, Duke University Hospital, Durham, NC
| | - Carmelo A. Milano
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Hospital, Durham, NC
| | - Ryan P. Plichta
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Hospital, Durham, NC
| | - John Haney
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Hospital, Durham, NC
| | - Jacob N. Schroder
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Hospital, Durham, NC
| | - Brittany Zwischenberger
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Hospital, Durham, NC
| | - Donald Glower
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Hospital, Durham, NC
| | - Jeffrey G. Gaca
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Hospital, Durham, NC
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6
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Vekstein AM, Doberne JW, Weissler EH, Wojnarski CM, Long CA, Williams AR, Plichta RP, Gaca JG, Hughes GC. Tailored approach and outcomes of aortic arch reconstruction after acute type A dissection repair. J Thorac Cardiovasc Surg 2023; 166:996-1008.e1. [PMID: 35282930 DOI: 10.1016/j.jtcvs.2022.02.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 01/11/2022] [Accepted: 02/02/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE After limited root/ascending with or without hemiarch repair for acute type A aortic dissection (ATAAD), 20% to 30% of patients require distal reintervention, frequently for arch pathology. In this report, we describe an institutional algorithm for arch management after previous limited ATAAD repair and detail operative and long-term outcomes. METHODS From August 2005 to April 2021, 71 patients status post previous limited ATAAD repair underwent reoperative arch repair involving zones 1 to 3 for aneurysmal degeneration of residual arch dissection including complete cervical debranching with zone 0/1 thoracic endovascular aortic repair in 6 (8%), open total arch in 13 (18%), type I hybrid arch repair in 23 (32%), and type II/III hybrid arch repair in 29 (41%). RESULTS Mean age was 59 ± 12 years; time from index ATAAD repair to reoperation was 4 (interquartile range, 2-9) years. There were 2 (2.8%) in-hospital deaths and 2 (2.8%) postdischarge deaths within 30 days of surgery. Three patients suffered stroke (4.2%) and 2 (2.8%) had acute renal failure requiring dialysis. Overall Kaplan-Meier survival was 78%, 70%, and 58% at 1, 3, and 5 years, respectively. Institutional experience appeared to play a significant role in early and late outcomes, because there have been no operative mortalities in the past 9 years and improved survival of 87% versus 66%, 79% versus 58%, and 79% versus 40% at 1, 3, and 5 years in comparisons of the past 9 years with the previous era (P = .01). CONCLUSIONS Aneurysmal degeneration of residual arch dissection after limited ATAAD repair presents a complex reoperative challenge. An algorithmic operative approach tailored to patient anatomy and comorbidities yields excellent early and late outcomes, which continue to improve with increasing institutional experience.
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Affiliation(s)
- Andrew M Vekstein
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Julie W Doberne
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - E Hope Weissler
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Charles M Wojnarski
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Chandler A Long
- Division of Vascular and Endovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Adam R Williams
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ryan P Plichta
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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7
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Rao VN, Giczewska A, Chiswell K, Felker GM, Wang A, Glower DD, Gaca JG, Parikh KS, Vemulapalli S. Long-term outcomes of phenoclusters in severe tricuspid regurgitation. Eur Heart J 2023:7078718. [PMID: 36924209 DOI: 10.1093/eurheartj/ehad133] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 01/24/2023] [Accepted: 02/20/2023] [Indexed: 03/18/2023] Open
Abstract
AIMS Severe tricuspid regurgitation (TR) exhibits high 1-year morbidity and mortality, yet long-term cardiovascular risk overall and by subgroups remains unknown. This study characterizes 5-year outcomes and identifies distinct clinical risk profiles of severe TR. METHODS AND RESULTS Patients were included from a large US tertiary referral center with new severe TR by echocardiography based on four-category American Society of Echocardiography grading scale between 2007 and 2018. Patients were categorized by TR etiology (with lead present, primary, and secondary) and by supervised recursive partitioning (survival trees) for outcomes of death and the composite of death or heart failure hospitalization. The Kaplan-Meier estimates and Cox regression models were used to evaluate any association by (i) TR etiology and (ii) groups identified by survival trees and outcomes over 5 years. Among 2379 consecutive patients with new severe TR, median age was 70 years, 61% were female, and 40% were black. Event rates (95% confidence interval) were 30.9 (29.0-32.8) events/100 patient-years for death and 49.0 (45.9-52.2) events/100 patient-years for the composite endpoint, with no significant difference by TR etiology. After applying supervised survival tree modeling, two separate groups of four phenoclusters with distinct clinical prognoses were separately identified for death and the composite endpoint. Variables discriminating both outcomes were age, albumin, blood urea nitrogen, right ventricular function, and systolic blood pressure (all P < 0.05). CONCLUSION Patients with newly identified severe TR have high 5-year risk for death and death or heart failure hospitalization. Partitioning patients using supervised survival tree models, but not TR etiology, discriminated clinical risk. These data aid in identifying relevant subgroups in clinical trials of TR and clinical risk/benefit analysis for TR therapies.
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Affiliation(s)
- Vishal N Rao
- Division of Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA.,Duke Clinical Research Institute, Duke University School of Medicine, 300 W Morgan Street, Durham, NC 27701, USA
| | - Anna Giczewska
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W Morgan Street, Durham, NC 27701, USA
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W Morgan Street, Durham, NC 27701, USA
| | - G Michael Felker
- Division of Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA.,Duke Clinical Research Institute, Duke University School of Medicine, 300 W Morgan Street, Durham, NC 27701, USA
| | - Andrew Wang
- Division of Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Donald D Glower
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
| | - Kishan S Parikh
- Division of Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA.,Duke Clinical Research Institute, Duke University School of Medicine, 300 W Morgan Street, Durham, NC 27701, USA
| | - Sreekanth Vemulapalli
- Division of Cardiology, Duke University Medical Center, 2301 Erwin Road, Durham, NC 27710, USA
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8
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Nellis JR, Daneshmand MA, Gaca JG, Andersen ND, Haney JC, Turek JW. A single center experience with minimally invasive approaches in congenital cardiac surgery. J Thorac Dis 2021; 13:5818-5825. [PMID: 34795930 PMCID: PMC8575860 DOI: 10.21037/jtd-21-836] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 07/14/2021] [Indexed: 11/24/2022]
Abstract
Background Cardiac surgery is a technically demanding field with an appreciable learning curve that extends beyond formal training. Minimally invasive congenital cardiac surgery has one of the steepest learning curves. Early complications often discourage surgeons, particularly those at lower volume centers, from pursuing innovative approaches. Over the past three years, we have utilized a number of minimally invasive approaches including pulmonary valve replacement, anomalous aortic origin coronary artery repair, atrial septal defect repair, epicardial lead placement, and partial anomalous pulmonary venous return. Herein we report on our experience performing minimally invasive congenital cardiac surgery, lessons learned, and how our approach has evolved. Methods We performed a single institution, retrospective review, wherein continuous variables were reported as median (interquartile range). Results Between September 2017 and May 2020, minimally invasive approaches were attempted on 49 patients with a median age of 19 years (14–47 years) for nine distinct congenital cardiac diagnoses. Seven patients (14%) required conversion to larger incisions, including four patients or 36% of those undergoing anomalous aortic origin of a coronary artery repair. Patients who were converted had a higher body mass index 33.1 (31.7–37.8) than those who were not (24.2, 20.8–29.3) (P=0.009). Conclusions Minimally invasive approaches for congenital cardiac conditions require a team approach. Patients with a body mass index greater than 30 should be counseled on the higher rate of conversion. We no longer perform minimally invasive anomalous aortic origin of a coronary artery repair given the high rate of conversions and complications. Surgeons attempting this procedure should do so cautiously.
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Affiliation(s)
- Joseph R Nellis
- Department of Surgery, Duke University, Durham, NC, USA.,Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA
| | - Mani A Daneshmand
- Department of Surgery, Duke University, Durham, NC, USA.,Division of Thoracic and Cardiovascular Surgery, Duke University, Durham, NC, USA
| | - Jeffrey G Gaca
- Department of Surgery, Duke University, Durham, NC, USA.,Division of Thoracic and Cardiovascular Surgery, Duke University, Durham, NC, USA
| | - Nicholas D Andersen
- Department of Surgery, Duke University, Durham, NC, USA.,Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA.,Division of Thoracic and Cardiovascular Surgery, Duke University, Durham, NC, USA.,Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC, USA
| | - John C Haney
- Department of Surgery, Duke University, Durham, NC, USA.,Division of Thoracic and Cardiovascular Surgery, Duke University, Durham, NC, USA
| | - Joseph W Turek
- Department of Surgery, Duke University, Durham, NC, USA.,Duke Congenital Heart Surgery Research & Training Laboratory, Durham, NC, USA.,Division of Thoracic and Cardiovascular Surgery, Duke University, Durham, NC, USA.,Pediatric & Congenital Heart Center, Duke Children's Hospital, Durham, NC, USA
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9
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Vekstein A, Amin K, Record S, Williams A, Plichta R, Wang A, Kiefer T, Harrison JK, Gaca JG, Hughes GC. TCT-269 Five-Year Outcomes After Valve-in-Valve Transcatheter Aortic Valve Replacement: Excellent Valve-Specific Outcomes but Poor Overall Survival. J Am Coll Cardiol 2021. [DOI: 10.1016/j.jacc.2021.09.1122] [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: 10/20/2022]
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10
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Vekstein AM, Yerokun BA, Jawitz OK, Doberne JW, Anand J, Karhausen J, Ranney DN, Benrashid E, Wang H, Keenan JE, Schroder JN, Gaca JG, Hughes GC. Does deeper hypothermia reduce the risk of acute kidney injury after circulatory arrest for aortic arch surgery? Eur J Cardiothorac Surg 2021; 60:314-321. [PMID: 33624004 DOI: 10.1093/ejcts/ezab044] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 12/18/2020] [Accepted: 12/29/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES The impact of hypothermic circulatory arrest (HCA) temperature on postoperative acute kidney injury (AKI) has not been evaluated. This study examined the association between circulatory arrest temperatures and AKI in patients undergoing proximal aortic surgery with HCA. METHODS A total of 759 consecutive patients who underwent proximal aortic surgery (ascending ± valve ± root) including arch replacement requiring HCA between July 2005 and December 2016 were identified from a prospectively maintained institutional aortic surgery database. The primary outcome was AKI as defined by Risk, Injury, Failure, Loss, End Stage Renal Disease (ESRD) criteria. The association between minimum nasopharyngeal (NP) and bladder temperatures during HCA and postoperative AKI was assessed, adjusting for patient-level factors using multivariable logistic regression. RESULTS A total of 85% (n = 645) of patients underwent deep hypothermia (14.1-20.0°C), 11% (n = 83) low-moderate hypothermia (20.1-24.0°C) and 4% (n = 31) high-moderate hypothermia (24.1-28.0°C) as classified by NP temperature. When analysed by bladder temperature, 59% (n = 447) underwent deep hypothermia, 22% (n = 170) low-moderate, 16% (n = 118) high-moderate and 3% mild (n = 24) (28.1-34.0°C) hypothermia. The median systemic circulatory arrest time was 17 min. The incidence of AKI did not differ between hypothermia groups, whether analysed using minimum NP or bladder temperature. In the multivariable analysis, the association between degree of hypothermia and AKI remained non-significant whether analysed as a categorical variable (hypothermia group) or as a continuous variable (minimum NP or bladder temperature) (all P > 0.05). CONCLUSIONS In patients undergoing proximal aortic surgery including arch replacement requiring HCA, degree of systemic hypothermia was not associated with the risk of AKI. These data suggest that moderate hypothermia does not confer increased risk of AKI for patients requiring circulatory arrest, although additional prospective data are needed.
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Affiliation(s)
- Andrew M Vekstein
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Babtunde A Yerokun
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Oliver K Jawitz
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Julie W Doberne
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jatin Anand
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jorn Karhausen
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - David N Ranney
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Ehsan Benrashid
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Hanghang Wang
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey E Keenan
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jacob N Schroder
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey G Gaca
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
| | - G Chad Hughes
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, NC, USA
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11
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Doberne JW, Downey PS, Vekstein AM, Halpern S, Weissler EH, Madou ID, Plichta RP, Williams A, Long CA, Gaca JG, Haney J, Hughes GC. Bilateral Thoracosternotomy (Clamshell Approach) for Complex Aortic Arch Surgery. J Vasc Surg 2021. [DOI: 10.1016/j.jvs.2021.06.187] [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: 11/26/2022]
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12
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Wojnarski CM, Chodavadia PA, Barac YD, Armstrong JL, Vekstein AM, Haney JC, Gaca JG, Chad Hughes G, Glower DD. Long-term outcomes of aortic root replacement for endocarditis. J Card Surg 2021; 36:1969-1978. [PMID: 33651483 DOI: 10.1111/jocs.15472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 01/08/2021] [Accepted: 01/09/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Infective endocarditis (IE) involving the aortic valve and root is associated with high risk requiring thoughtful surgical decision-making. The impact of valve and conduit choices and patient factors on long-term outcomes in this patient population is poorly documented. METHODS From January 1976 to December 2013, 485 patients underwent aortic root and valve replacement at a single institution. Cox's proportional hazard model identified predictors of long-term survival and cumulative incidence functions were compared to assess need for reoperation with death as a competing risk. RESULTS Median age at time of operation was 56.6 years (interquartile range: 23.1) with the indication for operation being endocarditis in 14.6% (n = 71). Stentless root replacement was used in 70% IE versus 34% non-IE (p < .001). Endocarditis at time of root replacement did not have a significant impact on survival through 15 years (IE: 37.3% vs. non-IE: 42.5%; log-rank; p = .13). After multivariable adjustment, survival was similar between patients with and without endocarditis (hazard ratio: 1.1; 95% confidence interval: [0.77, 1.62]; p = .57). Freedom from reoperation at 15 years did not vary significantly by endocarditis status (IE: 95.9% vs. non-IE: 73.6%; p = .07). Among endocarditis patients, freedom from reoperation at 10 years was similar between homograft and stentless bioprosthetic conduits (95.3% vs. 88.5%; log-rank; K-sample; p = .46). CONCLUSIONS In a sample with frequent use of stentless prostheses, aortic root replacement for infective endocarditis had acceptable risk and long-term survival similar to root replacement for other indications. In the setting of endocarditis, root replacement with homograft or stentless bioprosthetic root has excellent durability through 15 years.
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Affiliation(s)
- Charles M Wojnarski
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Yaron D Barac
- Division of Cardiovascular and Thoracic Surgery, Rabin Medical Center, Petah Tikva, Israel
| | | | - Andrew M Vekstein
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - John C Haney
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeffrey G Gaca
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - G Chad Hughes
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Donald D Glower
- Division of Thoracic and Cardiovascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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13
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Schwartz FR, Tailor T, Gaca JG, Kiefer T, Harrison K, Hughes GC, Ramirez-Giraldo JC, Marin D, Hurwitz LM. Impact of dual energy cardiac CT for metal artefact reduction post aortic valve replacement. Eur J Radiol 2020; 129:109135. [PMID: 32590257 DOI: 10.1016/j.ejrad.2020.109135] [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] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 06/12/2020] [Accepted: 06/15/2020] [Indexed: 11/28/2022]
Abstract
PURPOSE Assess image quality of dual-energy (DE) and single-energy (SE) cardiac multi-detector computed tomographic (MDCT) post aortic valve replacement (AVR) on a dual source MDCT scanner. METHODS Eighty patients with cardiac MDCT acquisitions (ECG gated, dual-source) post-surgical and transcatheter AVR were retrospectively identified. Forty DE (cohort 1) and 40 SE acquisitions (cohort 2; 100 or 120 kVp) were reviewed. Metal artefact at valve coaptation (VC) and valve insertion site (VIS), and contrast enhancement were assessed. Valve leaflet edge definition was graded on a 4-point scale by three radiologists. RESULTS The mean percentage valve area obscured by metal artifact differed between the cohorts; cohort 1 DE blended, high keV and low keV: 14.8 %, 11.1 % and 17.8 % at VC and 16.4 %, 13 %, 20.4 % at VIS respectively. Cohort 2: 25.8 % and 33.6 % (VC and VIS); each DE reconstruction vs SE: P < 0.0001. Average contrast opacification and coefficient of variance for cohort 1: 562.9 ± 144.7, 281.1 ± 60.3 and 1132.7 ± 300.8 Hounsfield Units (HU) and 9.6 %, 10 % and 8.9 %. For cohort 2: 437.2 ± 119.2 HU and 10.8 % (P < 0.01). Average leaflet edge definition cohort 1: 2.3 ± 0.4, 2.7 ± 0.2 and 2.3 ± 0.2, and cohort 2: 2.9 ± 0.2. CONCLUSION DE high keV renderings can result in up to 17.2 % less metal artefact compared to standard SE acquisition for cardiac CT. Contrast opacification and homogeneity is higher for DE blended and low keV renderings compared to SE acquisition with leaflet visibility preferred for low keV and blended DE renderings.
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Affiliation(s)
- Fides Regina Schwartz
- Department of Radiology, Duke University Medical Center, Durham, NC 27705, United States.
| | - Tina Tailor
- Department of Radiology, Duke University Medical Center, Durham, NC 27705, United States
| | - Jeffrey G Gaca
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC 27705, United States
| | - Todd Kiefer
- Department of Cardiology, Duke University Medical Center, Durham, NC 27705, United States
| | - Kevin Harrison
- Department of Cardiology, Duke University Medical Center, Durham, NC 27705, United States
| | - G Chad Hughes
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC 27705, United States
| | | | - Daniele Marin
- Department of Radiology, Duke University Medical Center, Durham, NC 27705, United States
| | - Lynne M Hurwitz
- Department of Radiology, Duke University Medical Center, Durham, NC 27705, United States
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14
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Madou ID, Williams AR, Gaca JG. Patch exclusion technique with Amplatzer septal occluder device for the treatment of postinfarction ventricular septal defect. JTCVS Tech 2020; 3:198-201. [PMID: 34317870 PMCID: PMC8302874 DOI: 10.1016/j.xjtc.2020.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 03/17/2020] [Revised: 03/17/2020] [Accepted: 04/02/2020] [Indexed: 10/25/2022] Open
Affiliation(s)
- Isidore Dinga Madou
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, NC
| | - Adam R Williams
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, NC
| | - Jeffrey G Gaca
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University, Durham, NC
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15
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Jawitz OK, Gulack BC, Brennan JM, Thibault DP, Wang A, O'Brien SM, Schroder JN, Gaca JG, Smith PK. Association of postoperative complications and outcomes following coronary artery bypass grafting. Am Heart J 2020; 222:220-228. [PMID: 32105988 DOI: 10.1016/j.ahj.2020.02.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 02/06/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND The long-term effects of postoperative complications following coronary artery bypass grafting (CABG) are unknown. METHODS Medicare-linked records from the Society of Thoracic Surgeons Adult Cardiac Surgery Database were queried for isolated CABG records from 2007 through 2012. Unadjusted and adjusted associations between individual postoperative complications and both mortality and all-cause rehospitalization were evaluated to 7 years using Cox proportional-hazards models and cumulative incidence functions. Because of nonproportional hazards, associations are presented as early (0 to 90 days) and late (90 days to 7 years). RESULTS Of the 294,533 isolated CABG patients who had records linked to Medicare for long-term follow-up (median age, 73 years; 30% female), 120,721 (41%) experienced at least 1 of the complications of interest, including new-onset atrial fibrillation (30.0%), prolonged ventilation (12.3%), renal failure (4.5%), reoperation (3.5%), stroke (1.9%), and sternal wound infection (0.4%). Each of the 6 postoperative complications was associated with a significantly increased risk of mortality and rehospitalization to 7 years despite adjustment for baseline characteristics and the presence of multiple complications. Although the predominant effect of postoperative complications was observed in the first 90 days, the increased risk-adjusted hazard for death and rehospitalization continued through 7 years. CONCLUSIONS Postoperative complications are associated with an increased risk of both early and late mortality and all-cause rehospitalization, particularly during the "value" window within 90 days of CABG. These findings underscore the need to develop avoidance strategies as well as cost-adjustment methods for each of these complications.
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Affiliation(s)
- Oliver K Jawitz
- Department of Surgery, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | - Brian C Gulack
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - J Matthew Brennan
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | | | - Alice Wang
- Department of Surgery, Duke University Medical Center, Durham, NC
| | | | - Jacob N Schroder
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Peter K Smith
- Department of Surgery, Duke University Medical Center, Durham, NC
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16
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Faure ME, Suchá D, Schwartz FR, Symersky P, Bogers AJJC, Gaca JG, Koweek LM, de Heer LM, Budde RPJ. Surgically implanted aortic valve bioprostheses deform after implantation: insights from computed tomography. Eur Radiol 2020; 30:2651-2657. [PMID: 32002643 DOI: 10.1007/s00330-019-06634-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/28/2019] [Accepted: 12/13/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Little is known about the prevalence and degree of deformation of surgically implanted aortic biological valve prostheses (bio-sAVRs). We assessed bio-sAVR deformation using multidetector-row computed tomography (MDCT). METHODS Three imaging databases were searched for patients with MDCT performed after bio-sAVR implantation. Minimal and maximal valve ring diameters were obtained in systole and/or diastole, depending on the acquired cardiac phase(s). The eccentricity index (EI) was calculated as a measure of deformation as (1 - (minimal diameter/maximal diameter)) × 100%. EI of < 5% was considered none or trivial deformation, 5-10% mild deformation, and > 10% non-circular. Indications for MDCT and implanted valve type were retrieved. RESULTS One hundred fifty-two scans of bio-sAVRs were included. One hundred seventeen measurements were performed in systole and 35 in diastole. None or trivial deformation (EI < 5%) was seen in 67/152 (44%) of patients. Mild deformation (EI 5-10%) was seen in 59/152 (39%) and non-circularity was found in 26/152 (17%) of cases. Overall, median EI was 5.5% (IQR 3.4-7.8). In 77 patients, both systolic and diastolic measurements were performed from the same scan. For these scans, the median EI was 6.5% (IQR 3.4-10.2) in systole and 5.1% (IQR3.1-7.6) in diastole, with a significant difference between both groups (p = 0.006). CONCLUSIONS Surgically implanted aortic biological valve prostheses show mild deformation in 39% of cases and were considered non-circular in 17% of studied valves. KEY POINTS • Deformation of surgically implanted aortic valve bioprostheses (bio-sAVRs) can be adequately assessed using MDCT. • Bio-sAVRs show at least mild deformation (eccentricity index > 5%) in 56% of studied cases and were considered non-circular (eccentricity index > 10%) in 17% of studied valves. • The higher deformity rate found in bio-sAVRs with (suspected) valve pathology could suggest that geometric deformity may play a role in leaflet malformation and thrombus formation similar to that of transcatheter heart valves.
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Affiliation(s)
- Marguerite E Faure
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Po Box 2040, 3000, CA, Rotterdam, The Netherlands. .,Department of Radiology, AZ Monica, Antwerp, Belgium.
| | - Dominika Suchá
- Department of Radiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Fides R Schwartz
- Department of Radiology, Duke University Medical Center, Durham, USA
| | - Petr Symersky
- Department of Cardiothoracic Surgery, VU Medical Center, Amsterdam, The Netherlands
| | - Ad J J C Bogers
- Department of Cardiothoracic Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jeffrey G Gaca
- Department of Cardiothoracic Surgery, Duke University Medical Center, Durham, USA
| | - Lynne M Koweek
- Department of Radiology, Duke University Medical Center, Durham, USA
| | - Linda M de Heer
- Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden, The Netherlands.,Department of Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ricardo P J Budde
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Po Box 2040, 3000, CA, Rotterdam, The Netherlands
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17
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Williams JB, Shah AA, Zhang S, Jung SH, Yerokun B, Vemulapalli S, Smith PK, Gammie JS, Gaca JG. Impact of Microbiological Organism Type on Surgically Managed Endocarditis. Ann Thorac Surg 2019; 108:1325-1329. [DOI: 10.1016/j.athoracsur.2019.04.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2018] [Revised: 03/21/2019] [Accepted: 04/07/2019] [Indexed: 12/14/2022]
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18
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Hashmi NK, Ghadimi K, Srinivasan AJ, Li YJ, Raiff RD, Gaca JG, Root AG, Barac YD, Ortel TL, Levy JH, Welsby IJ. Three-factor prothrombin complex concentrates for refractory bleeding after cardiovascular surgery within an algorithmic approach to haemostasis. Vox Sang 2019; 114:374-385. [PMID: 30937927 DOI: 10.1111/vox.12774] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2018] [Revised: 02/22/2019] [Accepted: 02/25/2019] [Indexed: 01/11/2023]
Abstract
BACKGROUND/OBJECTIVES Prothrombin complex concentrates (PCC) are increasingly administered off-label in the United States to treat bleeding in cardiovascular surgical patients and carry the potential risk for acquired thromboembolic side-effects after surgery. Therefore, we hypothesized that the use of low-dose 3-factor (3F) PCC (20-30 IU/kg), as part of a transfusion algorithm, reduces bleeding without increasing postoperative thrombotic/thromboembolic complications. MATERIALS/METHODS After IRB approval, we retrospectively analysed 114 consecutive, complex cardiovascular surgical patients (age > 18 years), between February 2014 and June 2015, that received low-dose 3F-PCC (Profilnine® ), of which seven patients met established exclusion criteria. PCC was dosed according to an institutional perioperative algorithm. Allogeneic transfusions were recorded before and after PCC administration (n = 107). The incidence of postoperative thromboembolic events was determined within 30 days of surgery, and Factor II levels were measured in a subset of patients (n = 20) as a quality control measure to avoid excessive PCC dosing. RESULTS Total allogeneic blood product transfusion reached a mean of 12·4 ± 9·9 units before PCC and 5·0 ± 6·3 units after PCC administration (P < 0·001). The mean PCC dose was 15·8 ± 7·1 IU/kg. Four patients (3·8%) each experienced an ischaemic stroke on postoperative day 1, 2, 4 and 27. Seven patients (6·5%) had acquired venous thromboembolic disease within 10 days of surgery. Median factor II level after transfusion algorithm adherence and PCC administration was 87%. CONCLUSIONS 3F-PCC use for refractory bleeding after cardiovascular surgery resulted in reduced transfusion of allogeneic blood and blood products. Adherence to this algorithmic approach was associated with an acceptable incidence of postoperative thrombotic/thromboembolic complications.
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Affiliation(s)
- Nazish K Hashmi
- Department of Anesthesiology & Critical Care, Divisions of Cardiothoracic Anaesthesia & Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Kamrouz Ghadimi
- Department of Anesthesiology & Critical Care, Divisions of Cardiothoracic Anaesthesia & Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Amudan J Srinivasan
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yi-Ju Li
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Robert D Raiff
- Center for Medication Policy, Department of Pharmacy, Duke University Hospital Durham, NC, USA
| | - Jeffrey G Gaca
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Adam G Root
- Center for Medication Policy, Department of Pharmacy, Duke University Hospital Durham, NC, USA
| | - Yaron D Barac
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Thomas L Ortel
- Departments of Pathology, Hematology, and Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jerrold H Levy
- Department of Anesthesiology & Critical Care, Divisions of Cardiothoracic Anaesthesia & Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA.,Department of Surgery, Division of Cardiothoracic Surgery, Duke University School of Medicine, Durham, NC, USA
| | - Ian J Welsby
- Department of Anesthesiology & Critical Care, Divisions of Cardiothoracic Anaesthesia & Critical Care Medicine, Duke University School of Medicine, Durham, NC, USA
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19
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Williams JB, Gaca JG. The Mind Is Your Best Muscle: TAVR/SAVR Outcomes in Patients With Cognitive Impairment. Semin Thorac Cardiovasc Surg 2019; 31:381-382. [PMID: 30735714 DOI: 10.1053/j.semtcvs.2019.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 02/01/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Judson B Williams
- WakeMed Health and Hospitals, Duke University School of Medicine, Cardiovascular and Thoracic Surgery, Raleigh, North Carolina.
| | - Jeffrey G Gaca
- Duke Health, Duke University School of Medicine, Cardiovascular and Thoracic Surgery, Durham, North Carolina.
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20
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Inohara T, Manandhar P, Kosinski AS, Matsouaka RA, Kohsaka S, Mentz RJ, Thourani VH, Carroll JD, Kirtane AJ, Bavaria JE, Cohen DJ, Kiefer TL, Gaca JG, Kapadia SR, Peterson ED, Vemulapalli S. Association of Renin-Angiotensin Inhibitor Treatment With Mortality and Heart Failure Readmission in Patients With Transcatheter Aortic Valve Replacement. JAMA 2018; 320:2231-2241. [PMID: 30512100 PMCID: PMC6583475 DOI: 10.1001/jama.2018.18077] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
IMPORTANCE Data are lacking on the effect of a renin-angiotensin system (RAS) inhibitor prescribed after transcatheter aortic valve replacement (TAVR). Treatment with a RAS inhibitor may reverse left ventricular remodeling and improve function. OBJECTIVE To investigate the association of prescription of a RAS inhibitor and outcomes after TAVR. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of TAVR procedures performed in the United States (using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry) between July 2014 and January 2016 that were linked to Medicare claims data (final date of follow-up: March 31, 2017). To account for differences in demographics, echocardiographic findings, and in-hospital complications, 1:1 propensity matching was performed. EXPOSURES Initial hospital discharge prescription of a RAS inhibitor after TAVR. MAIN OUTCOMES AND MEASURES Primary outcomes were all-cause death and readmission due to heart failure at 1 year after discharge, which were considered separately. The secondary outcome was health status assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ; score range: 0-100, with a higher score indicating less symptom burden and better quality of life; a small effect size was defined as 5 points) at 1 year. RESULTS Among 21 312 patients who underwent TAVR at 417 US sites, 8468 patients (39.7%) were prescribed a RAS inhibitor at hospital discharge. After propensity matching, 15 896 patients were included (mean [SD] age, 82.4 [6.8] years; 48.1% were women; mean [SD] left ventricular ejection fraction [LVEF], 51.9% [11.5%]). Patients with a prescription for a RAS inhibitor vs those with no prescription had lower mortality rates at 1 year (12.5% vs 14.9%, respectively; absolute risk difference [ARD], -2.4% [95% CI, -3.5% to -1.4%]; hazard ratio [HR], 0.82 [95% CI, 0.76 to 0.90]) and lower heart failure readmission rates at 1 year (12.0% vs 13.8%; ARD, -1.8% [95% CI, -2.8% to -0.7%]; HR, 0.86 [95% CI, 0.79 to 0.95]). When stratified by LVEF, having a prescription for a RAS inhibitor vs no prescription was associated with lower 1-year mortality among patients with preserved LVEF (11.1% vs 13.9%, respectively; ARD, -2.81% [95% CI, -3.95% to -1.67%]; HR, 0.78 [95% CI, 0.71 to 0.86]), but not among those with reduced LVEF (18.8% vs 19.5%; ARD, -0.68% [95% CI, -3.52% to 2.20%]; HR, 0.95 [95% CI, 0.81 to 1.12]) (P = .04 for interaction). Of 15 896 matched patients, 4837 (30.4%) were included in the KCCQ score analysis and improvements at 1 year were greater in patients with a prescription for a RAS inhibitor vs those with no prescription (median, 33.3 [interquartile range, 14.2 to 51.0] vs 31.3 [interquartile range, 13.5 to 51.1], respectively; difference in improvement, 2.10 [95% CI, 0.10 to 4.06]; P < .001), but the effect size was not clinically meaningful. CONCLUSIONS AND RELEVANCE Among patients who underwent TAVR, receiving a prescription for a RAS inhibitor at hospital discharge compared with no prescription was significantly associated with a lower risk of mortality and heart failure readmission. However, due to potential selection bias, this finding requires further investigation in randomized trials.
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Affiliation(s)
- Taku Inohara
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Pratik Manandhar
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Andrzej S. Kosinski
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Roland A. Matsouaka
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Robert J. Mentz
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Vinod H. Thourani
- Department of Cardiac Surgery, MedStar Heart and Vascular Institute and Georgetown University School of Medicine, Washington, DC
| | - John D. Carroll
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora
| | - Ajay J. Kirtane
- Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York
| | - Joseph E. Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia
| | - David J. Cohen
- Department of Medicine, Saint Luke’s Mid America Heart Institute, Kansas City, Missouri
- Department of Medicine, University of Missouri–Kansas City School of Medicine, Kansas City
| | - Todd L. Kiefer
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G. Gaca
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Samir R. Kapadia
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric D. Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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Affiliation(s)
- Andrew Wang
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Vivian H Chu
- Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina
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22
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Waldron NH, Cooter M, Haney JC, Schroder JN, Gaca JG, Lin SS, Sigurdsson MI, Fudim M, Podgoreanu MV, Stafford-Smith M, Milano CA, Piccini JP, Mathew JP. Temporary autonomic modulation with botulinum toxin type A to reduce atrial fibrillation after cardiac surgery. Heart Rhythm 2018; 16:178-184. [PMID: 30414840 DOI: 10.1016/j.hrthm.2018.08.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2018] [Indexed: 11/26/2022]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) frequently complicates cardiac surgery and is associated with worse outcomes. The cardiac autonomic nervous system is implicated in the pathogenesis of POAF. OBJECTIVE The purpose of this study was to determine the efficacy and safety of selective cardiac autonomic modulation in preventing POAF. METHODS In this randomized, double-blind, placebo-controlled trial, adults undergoing cardiac surgery were randomized 1:1 to intraoperative injection of 250 units onabotulinumtoxinA (botulinum toxin type A [BoNTA]) or placebo into epicardial fat pads. The study was powered to detect a 40% reduction in relative risk of POAF. Time to first episode of in-hospital POAF was the primary outcome, evaluated in patients receiving injection. Additionally, incidence of POAF, length of stay (LOS), and adverse events were examined. RESULTS The trial assigned 145 patients to injection, 15 of whom were dropped before treatment, leaving 130 patients for analysis. Overall, 36.5% (23/63) of BoNTA-treated patients developed POAF compared with 47.8% (32/67) of placebo-treated patients. The time-to-event analysis revealed a hazard ratio of 0.69 (95% confidence interval 0.41-1.19; P = .18) for the BoNTA vs placebo arm. There were no significant differences in postoperative hospital LOS (median [interquartile range] 6.0 [3.4] vs 6.2 [3.7] days; P = .51) or adverse events prolonging LOS (27/63 [42.9%] vs 30/67 [44.8%]; P = .83) in patients receiving BoNTA vs placebo. CONCLUSION Epicardial injection of onabotulinumtoxinA was without discernible adverse effects, but we failed to detect a significant difference in risk of POAF. Future large-scale studies of epicardial onabotulinumtoxinA injection as a potential POAF prevention strategy should be designed to study smaller, but clinically meaningful, treatment effects.
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Affiliation(s)
- Nathan H Waldron
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
| | - Mary Cooter
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - John C Haney
- Department of Surgery (Cardiothoracic Surgery), Duke University Medical Center, Durham, North Carolina
| | - Jacob N Schroder
- Department of Surgery (Cardiothoracic Surgery), Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Department of Surgery (Cardiothoracic Surgery), Duke University Medical Center, Durham, North Carolina
| | - Shu S Lin
- Department of Surgery (Cardiothoracic Surgery), Duke University Medical Center, Durham, North Carolina; Department of Immunology, Duke University Medical Center, Durham, North Carolina; Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Martin I Sigurdsson
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine (Cardiology), Duke University Medical Center, Durham, North Carolina
| | - Mihai V Podgoreanu
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Mark Stafford-Smith
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Carmelo A Milano
- Department of Surgery (Cardiothoracic Surgery), Duke University Medical Center, Durham, North Carolina
| | - Jonathan P Piccini
- Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine (Cardiology), Duke University Medical Center, Durham, North Carolina
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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23
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Smith PJ, Browndyke JN, Monge ZA, Harshbarger TB, James ML, Gaca JG, Alexander JH, Berger MM, Newman MF, Milano CA, Mathew JP. Longitudinal Changes in Regional Cerebral Perfusion and Cognition After Cardiac Operation. Ann Thorac Surg 2018; 107:112-118. [PMID: 30253158 DOI: 10.1016/j.athoracsur.2018.07.056] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 06/20/2018] [Accepted: 07/09/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND Cardiac operation has been associated with increased risk of postoperative cognitive decline, as well as dementia risk in the general population. Few studies, however, have examined the impact of coronary revascularization or valve replacement or repair operation on longitudinal cerebral perfusion changes or their association with cognitive function. METHODS We examined longitudinal changes in cerebral perfusion among 54 individuals with cardiac disease; 27 undergoing cardiac operation and 27 matched control patients. Arterial spin labeling magnetic resonance perfusion imaging was used to quantify cerebral blood flow within the anterior communicating artery, middle cerebral artery (MCA), and posterior communicating artery vascular territories before operation and postoperatively at 6 weeks and 1 year. Cognitive performance was examined during the same intervals by using a battery of tests that tapped memory, executive, information processing and upper extremity motor functions. Repeated measures, mixed models were used to examine for perfusion changes and the association between perfusion changes and cognition. RESULTS Significant postoperative increases in perfusion were observed at 6 weeks within the MCA vascular territory after cardiac operation (p = 0.035 for interaction). Perfusion changes were most notable in distal territories of the MCA and posterior communicating artery at 6 weeks, with no additional changes at 1 year. Postoperative increases in MCA perfusion at 6 weeks were associated with improved psychomotor speed (β = 0.35, p = 0.016), whereas no important differences were found between the groups in vascular territory perfusion and cognition at 1 year. CONCLUSIONS Cardiac operation is associated with important short-term increases in MCA perfusion with associated improvements in psychomotor speed.
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Affiliation(s)
- Patrick J Smith
- Division of Behavioral Medicine, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.
| | - Jeffrey N Browndyke
- Division of Geriatric Behavioral Health, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina; Duke Institute for Brain Sciences, Duke University, Durham, North Carolina; Duke Brain Imaging and Analysis Center, Duke University, Durham, North Carolina
| | - Zachary A Monge
- Duke Center for Cognitive Neuroscience, Duke University, Durham, North Carolina
| | - Todd B Harshbarger
- Duke Brain Imaging and Analysis Center, Duke University, Durham, North Carolina; Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Michael L James
- Division of Neuroanesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina; Division of Neurocritical Care, Department of Neurology, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - John H Alexander
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina
| | - Miles M Berger
- Duke Institute for Brain Sciences, Duke University, Durham, North Carolina; Division of Neuroanesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Mark F Newman
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Carmelo A Milano
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Joseph P Mathew
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Inohara T, Manandhar P, Kosinski A, Kohsaka S, Mentz RJ, Thourani VH, Carroll JD, Kirtane AJ, Bavaria JE, Cohen DJ, Kiefer TL, Gaca JG, Kapadia SR, Vemulapalli S. P6030Association of renin-angiotensin system inhibition with clinical outcomes in patients undergoing transcatheter aortic valve replacement: analysis from the STS/ACC TVT Registry. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p6030] [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] [Indexed: 11/14/2022] Open
Affiliation(s)
- T Inohara
- Duke Clinical Research Institute, Durham, United States of America
| | - P Manandhar
- Duke Clinical Research Institute, Durham, United States of America
| | - A Kosinski
- Duke Clinical Research Institute, Durham, United States of America
| | - S Kohsaka
- Keio University School of Medicine, Tokyo, Japan
| | - R J Mentz
- Duke University Medical Center, Durham, United States of America
| | - V H Thourani
- Medstar Washington Hospital Center, Washington, United States of America
| | - J D Carroll
- University of Colorado Denver, Aurora, United States of America
| | - A J Kirtane
- Columbia University Medical Center, New York, United States of America
| | - J E Bavaria
- University of Pennsylvania, Philadelphia, United States of America
| | - D J Cohen
- St. Luke's Mid America Heart Institute, Kansas City, United States of America
| | - T L Kiefer
- Duke University Medical Center, Durham, United States of America
| | - J G Gaca
- Duke University Medical Center, Durham, United States of America
| | - S R Kapadia
- Cleveland Clinic Foundation, Cleveland, United States of America
| | - S Vemulapalli
- Duke University Medical Center, Durham, United States of America
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Abstract
IMPORTANCE Infective endocarditis occurs in approximately 15 of 100 000 people in the United States and has increased in incidence. Clinicians must make treatment decisions with respect to prophylaxis, surgical management, specific antibiotics, and the length of treatment in the setting of emerging, sometimes inconclusive clinical research findings. OBSERVATIONS Community-associated infective endocarditis remains the predominant form of the disease; however, health care accounts for one-third of cases in high-income countries. As medical interventions are increasingly performed on older patients, the disease incidence from cardiac implanted electronic devices is also increasing. In addition, younger patients involved with intravenous drug use has increased in the past decade and with it the proportion of US hospitalization has increased to more than 10%. These epidemiological factors have led to Staphylococcus aureus being the most common cause in high-income countries, accounting for up to 40% of cases. The mainstays of diagnosis are still echocardiography and blood cultures. Adjunctive imaging such as cardiac computed tomographic and nuclear imaging can improve the sensitivity for diagnosis when echocardiography is not conclusive. Serological studies, histopathology, and polymerase chain reaction assays have distinct roles in the diagnosis of infective endocarditis when blood culture have tested negative with the highest yield obtained from serological studies. Increasing antibiotic resistance, particularly to S aureus, has led to a need for different antibiotic treatment options such as newer antibiotics and combination therapy regimens. Surgery can confer a survival benefit to patients with major complications; however, the decision to pursue surgery must balance the risks and benefits of operations in these frequently high-risk patients. CONCLUSIONS AND RELEVANCE The epidemiology and management of infective endocarditis are continually changing. Guidelines provide specific recommendations about management; however, careful attention to individual patient characteristics, pathogen, and risk of sequela must be considered when making therapeutic decisions.
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Affiliation(s)
- Andrew Wang
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Vivian H Chu
- Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina
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26
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McCartney SL, Gaca JG. Invited Commentary: A Case of Multiple Ventricular Gradients. J Cardiothorac Vasc Anesth 2018; 32:1833-1834. [PMID: 29503120 DOI: 10.1053/j.jvca.2018.01.039] [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: 01/18/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Sharon L McCartney
- Department of Anesthesiology, Divisions of Cardiothoracic and Critical Care Anesthesiology Duke University, Durham, NC
| | - Jeffrey G Gaca
- Department of Surgery, Division of Cardiothoracic Surgery, Duke University, Durham, NC
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27
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Friedman DJ, Piccini JP, Wang T, Zheng J, Malaisrie SC, Holmes DR, Suri RM, Mack MJ, Badhwar V, Jacobs JP, Gaca JG, Chow SC, Peterson ED, Brennan JM. Association Between Left Atrial Appendage Occlusion and Readmission for Thromboembolism Among Patients With Atrial Fibrillation Undergoing Concomitant Cardiac Surgery. JAMA 2018; 319:365-374. [PMID: 29362794 PMCID: PMC5833567 DOI: 10.1001/jama.2017.20125] [Citation(s) in RCA: 118] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE The left atrial appendage is a key site of thrombus formation in atrial fibrillation (AF) and can be occluded or removed at the time of cardiac surgery. There is limited evidence regarding the effectiveness of surgical left atrial appendage occlusion (S-LAAO) for reducing the risk of thromboembolism. OBJECTIVE To evaluate the association of S-LAAO vs no receipt of S-LAAO with the risk of thromboembolism among older patients undergoing cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of a nationally representative Medicare-linked cohort from the Society of Thoracic Surgeons Adult Cardiac Surgery Database (2011-2012). Patients aged 65 years and older with AF undergoing cardiac surgery (coronary artery bypass grafting [CABG], mitral valve surgery with or without CABG, or aortic valve surgery with or without CABG) with and without concomitant S-LAAO were followed up until December 31, 2014. EXPOSURES S-LAAO vs no S-LAAO. MAIN OUTCOMES AND MEASURES The primary outcome was readmission for thromboembolism (stroke, transient ischemic attack, or systemic embolism) at up to 3 years of follow-up, as defined by Medicare claims data. Secondary end points included hemorrhagic stroke, all-cause mortality, and a composite end point (thromboembolism, hemorrhagic stroke, or all-cause mortality). RESULTS Among 10 524 patients undergoing surgery (median age, 76 years; 39% female; median CHA2DS2-VASc score, 4), 3892 (37%) underwent S-LAAO. Overall, at a mean follow-up of 2.6 years, thromboembolism occurred in 5.4%, hemorrhagic stroke in 0.9%, all-cause mortality in 21.5%, and the composite end point in 25.7%. S-LAAO, compared with no S-LAAO, was associated with lower unadjusted rates of thromboembolism (4.2% vs 6.2%), all-cause mortality (17.3% vs 23.9%), and the composite end point (20.5% vs 28.7%) but no significant difference in rates of hemorrhagic stroke (0.9% vs 0.9%). After inverse probability-weighted adjustment, S-LAAO was associated with a significantly lower rate of thromboembolism (subdistribution hazard ratio [HR], 0.67; 95% CI, 0.56-0.81; P < .001), all-cause mortality (HR, 0.88; 95% CI, 0.79-0.97; P = .001), and the composite end point (HR, 0.83; 95% CI, 0.76-0.91; P < .001) but not hemorrhagic stroke (subdistribution HR, 0.84; 95% CI, 0.53-1.32; P = .44). S-LAAO, compared with no S-LAAO, was associated with a lower risk of thromboembolism among patients discharged without anticoagulation (unadjusted rate, 4.2% vs 6.0%; adjusted subdistribution HR, 0.26; 95% CI, 0.17-0.40; P < .001), but not among patients discharged with anticoagulation (unadjusted rate, 4.1% vs 6.3%; adjusted subdistribution HR, 0.88; 95% CI, 0.56-1.39; P = .59). CONCLUSIONS AND RELEVANCE Among older patients with AF undergoing concomitant cardiac surgery, S-LAAO, compared with no S-LAAO, was associated with a lower risk of readmission for thromboembolism over 3 years. These findings support the use of S-LAAO, but randomized trials are necessary to provide definitive evidence.
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Affiliation(s)
- Daniel J. Friedman
- Duke Clinical Research Institute, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
| | - Jonathan P. Piccini
- Duke Clinical Research Institute, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
| | - Tongrong Wang
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Jiayin Zheng
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | | | - David R. Holmes
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Rakesh M. Suri
- Thoracic and Cardiovascular Surgery, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Michael J. Mack
- Division of Cardiovascular Surgery, Baylor University, Dallas, Texas
| | - Vinay Badhwar
- Department of Cardiovascular and Thoracic Surgery, West Virginia University, Morgantown
| | | | - Jeffrey G. Gaca
- Division of Cardiovascular and Thoracic Surgery, Duke University, Durham, North Carolina
| | - Shein-Chung Chow
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Eric D. Peterson
- Duke Clinical Research Institute, Durham, North Carolina
- Duke University School of Medicine, Durham, North Carolina
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28
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Barac YD, Zwischenberger B, Schroder JN, Daneshmand MA, Haney JC, Gaca JG, Wang A, Milano CA, Glower DD. Using a Regent Aortic Valve in a Small Annulus Mitral Position Is a Viable Option. Ann Thorac Surg 2017; 105:1200-1204. [PMID: 29258732 DOI: 10.1016/j.athoracsur.2017.11.042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [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: 06/12/2017] [Revised: 11/09/2017] [Accepted: 11/10/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Outcome of mitral valve replacement in extreme scenarios of small mitral annulus with the use of the Regent mechanical aortic valve is not well documented. METHODS Records were examined in 31 consecutive patients who underwent mitral valve replacement with the use of the aortic Regent valve because of a small mitral annulus. RESULTS Mean age was 60 ± 14 years. Mitral stenosis or mitral annulus calcification was present in 30 of 31 patients (97%). Concurrent procedures were performed in 17 of 31 patients (55%). Median valve size was 23 mm. Mean mitral gradient coming out of the operating room was 4.2 ± 1.5 mm Hg and at follow-up echocardiogram performed at a median of 32 months after the procedure was 5.8 ± 2.4 mm Hg. CONCLUSIONS A Regent aortic mechanical valve can be a viable option with a larger orifice area than the regular mechanical mitral valve in a problematic situation of a small mitral valve annulus. Moreover, the pressure gradients over the valve are acceptable intraoperatively and over time.
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Affiliation(s)
- Yaron D Barac
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | | | - Jacob N Schroder
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Mani A Daneshmand
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - John C Haney
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Andrew Wang
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Carmelo A Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Donald D Glower
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, North Carolina.
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29
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Wang H, Wagner M, Benrashid E, Keenan J, Wang A, Ranney D, Yerokun B, Gaca JG, McCann RL, Hughes GC. Outcomes of Reoperation After Acute Type A Aortic Dissection: Implications for Index Repair Strategy. J Am Heart Assoc 2017; 6:JAHA.117.006376. [PMID: 28974497 PMCID: PMC5721847 DOI: 10.1161/jaha.117.006376] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The optimal surgical approach for management of acute type A aortic dissection remains controversial. This study aimed to assess outcomes of reoperation after acute type A dissection repair to help guide decision making around index operative strategy. Methods and Results All aortic reoperations (n=129) at a single referral institution from August 2005 to April 2016 after prior acute type A dissection repair were reviewed. The primary outcome was 30‐day or in‐hospital mortality. Secondary outcomes included organ‐specific morbidity and 1‐ and 5‐year outcomes as estimated using the Kaplan–Meier method. The majority of initial reoperations were proximal aortic (aortic valve, aortic root, or ascending) or aortic arch procedures (62.5%, n=55); most initial reoperations were performed in the elective setting (83.1%, n=74). Additional nonstaged second or more reoperations were required in 21 patients (23.6%) after the initial reoperation, during a median follow‐up of 2.5 years after the initial reoperation. Thirty‐day or in‐hospital mortality for all reoperations was 7.0% (elective: 6.3%; nonelective: 11.1%) with acceptable rates of organ‐specific morbidity, given the procedural complexity. One‐ and 5‐year overall survival after initial reoperation was 85.9% and 64.9%, respectively, with aorta‐specific survival of 88% at 5 years. Conclusions Reoperation after acute type A aortic dissection repair is associated with low rates of mortality and morbidity. These data support more limited index repair for acute type A dissection, especially for patients undergoing index repair in lower volume centers without expertise in extensive repair, because reoperations, if needed, can be performed safely in referral aortic centers.
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Affiliation(s)
- Hanghang Wang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Matthew Wagner
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Ehsan Benrashid
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Alice Wang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - David Ranney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Babatunde Yerokun
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Richard L McCann
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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Patel PA, Ackermann AM, Augoustides JG, Ender J, Gutsche JT, Giri J, Vallabhajosyula P, Desai ND, Kostibas M, Brady MB, Eoh EJ, Gaca JG, Thompson A, Fitzsimons MG. Anesthetic Evolution in Transcatheter Aortic Valve Replacement: Expert Perspectives From High-Volume Academic Centers in Europe and the United States. J Cardiothorac Vasc Anesth 2017; 31:777-790. [DOI: 10.1053/j.jvca.2017.02.051] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2017] [Indexed: 11/11/2022]
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31
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Wang A, McCartney SL, Williams JB, Ganapathi A, Glower DD, Nicoara A, Gaca JG. Use of Adjuncts Reduces Cardiopulmonary Bypass Time During Minimally Invasive Aortic Valve Replacement. J Heart Valve Dis 2017; 26:155-160. [PMID: 28820544] [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] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND Minimally invasive aortic valve replacement (MIAVR) through a mini-thoracotomy is comparable to AVR through a sternotomy, but may have increased surgical times. The development of adjuncts such as the automatic knot fastener and percutaneous coronary sinus (CS) catheter may reduce this disadvantage. METHODS A retrospective review conducted between 2002 and 2015 at a single institution revealed 78 patients who underwent MIAVR with adjuncts. The automatic knot fastener was used on all patients, and a successful CS catheter was placed and confirmed by echocardiography in 67 patients (86%). Patients were propensity matched against those who had MIAVR without adjuncts (n = 78) and through a median sternotomy (n = 78) for assessment of major morbidity. Variables were compared using an unpaired t-test, Wilcoxon rank sum test, chi-squared and Fisher's exact test where appropriate. RESULTS Patients who underwent MIAVR with adjuncts had shorter cross-clamp times (70.5 versus 108.1 and 84.4 min; p <0.0001) and cardiopulmonary bypass (CPB) times (101.1 versus 166.12 and 127.7 min; p <0.0001) than those who underwent MIAVR without adjuncts or through a median sternotomy. Patients who underwent MIAVR received fewer blood transfusions compared to those undergoing AVR via a median sternotomy (0.6 and 1.2 versus 2.5; p <0.012). Patients who underwent MIAVR with adjuncts had similar rates of new-onset atrial fibrillation (AF) than those undergoing MIAVR without adjuncts (33% versus 22%; p = 0.11), but had higher rates of AF compared to the sternotomy group (33% versus 17%; p = 0.02). Rates of in-hospital morbidity and mortality were similar between all groups. CONCLUSIONS The use of adjuncts during MIAVR led to a significant shortening of cross-clamp and CPB times, and to a requirement for fewer blood transfusions. Morbidity and mortality rates after MIAVR were similar to those in patients undergoing a median sternotomy.
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Affiliation(s)
- Alice Wang
- Division of General Surgery, Duke University Medical Center, NC, USA. Electronic correspondence:
| | - Sharon L McCartney
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, NC, USA
| | - Judson B Williams
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, NC, USA
| | - Asvin Ganapathi
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, NC, USA
| | - Donald D Glower
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, NC, USA
| | - Alina Nicoara
- Division of Cardiothoracic Anesthesiology, Duke University Medical Center, NC, USA
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, NC, USA
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Browndyke JN, Berger M, Harshbarger TB, Smith PJ, White W, Bisanar TL, Alexander JH, Gaca JG, Welsh-Bohmer K, Newman MF, Mathew JP. Resting-State Functional Connectivity and Cognition After Major Cardiac Surgery in Older Adults without Preoperative Cognitive Impairment: Preliminary Findings. J Am Geriatr Soc 2016; 65:e6-e12. [PMID: 27858963 DOI: 10.1111/jgs.14534] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [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: 01/26/2023]
Abstract
OBJECTIVES To look for changes in intrinsic functional brain connectivity associated with postoperative changes in cognition, a common complication in seniors undergoing major surgery, using resting-state functional magnetic resonance imaging. DESIGN Objective cognitive testing and functional brain imaging were prospectively performed at preoperative baseline and 6 weeks after surgery and at the same time intervals in nonsurgical controls. SETTING Academic medical center. PARTICIPANTS Older adults undergoing cardiac surgery (n = 12) and nonsurgical older adult controls with a history of coronary artery disease (n = 12); no participants had cognitive impairment at preoperative baseline (Mini-Mental State Examination score >27). MEASUREMENTS Differences in resting-state functional connectivity (RSFC) and global cognitive change relationships were assessed using a voxel-wise intrinsic connectivity method, controlling for demographic factors and pre- and perioperative cerebral white matter disease volume. Analyses were corrected for multiple comparisons (false discovery rate P < .01). RESULTS Global cognitive change after cardiac surgery was significantly associated with intrinsic RSFC changes in regions of the posterior cingulate cortex and right superior frontal gyrus-anatomical and functional locations of the brain's default mode network (DMN). No statistically significant relationships were found between global cognitive change and RSFC change in nonsurgical controls. CONCLUSION Clinicians have long known that some older adults develop postoperative cognitive dysfunction (POCD) after anesthesia and surgery, yet the neurobiological correlates of POCD are not well defined. The current results suggest that altered RSFC in specific DMN regions is positively correlated with global cognitive change 6 weeks after cardiac surgery, suggesting that DMN activity and connectivity could be important diagnostic markers of POCD or intervention targets for potential POCD treatment efforts.
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Affiliation(s)
- Jeffrey N Browndyke
- Geriatric Behavioral Health Division, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina.,Institute for Brain Sciences, Duke University, Durham, North Carolina.,Brain Imaging and Analysis Center, Duke University, Durham, North Carolina
| | - Miles Berger
- Division of Neuroanesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Todd B Harshbarger
- Brain Imaging and Analysis Center, Duke University, Durham, North Carolina.,Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - Patrick J Smith
- Behavioral Medicine Division, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - William White
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Tiffany L Bisanar
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - John H Alexander
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Kathleen Welsh-Bohmer
- Geriatric Behavioral Health Division, Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, North Carolina
| | - Mark F Newman
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina
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Iribarne A, Keenan J, Benrashid E, Wang H, Meza JM, Ganapathi A, Gaca JG, Kim HW, Hurwitz LM, Hughes GC. Imaging Surveillance After Proximal Aortic Operations: Is it Necessary? Ann Thorac Surg 2016; 103:734-741. [PMID: 27677566 DOI: 10.1016/j.athoracsur.2016.06.085] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2015] [Revised: 06/16/2016] [Accepted: 06/22/2016] [Indexed: 01/13/2023]
Abstract
BACKGROUND Current guidelines for imaging surveillance after proximal aortic repair are not evidence based. This study sought to characterize the incidence and causes of reintervention after proximal aortic operations to provide data to guide the frequency and duration of postoperative surveillance. METHODS Data on all patients undergoing proximal aortic operations (ascending, with or without root, with or without aortic valve replacement, or with or without arch) during a 9-year period (n = 869) at a single institution were prospectively collected. Patients who required reintervention on the proximal or distal aorta were identified and causes for reintervention determined. Planned two-stage repairs and index procedures done at other hospitals were excluded. The primary end point was the time to the first reintervention, and competing-risk Cox regression was used to model reintervention risk. RESULTS Reinterventions occurred in 4.3% of patients (n = 37), with 48.6% (n = 18) involving the proximal aorta and 51.4% (n = 19) the distal. Median time to reintervention was 2.8 years (interquartile range, 1.5 to 3.6 years). For index aneurysm cases, reintervention for aneurysm of the descending/thoracoabdominal aorta and root were most common. Of the 6 root aneurysms/pseudoaneurysms, 5 (83%) were due to degeneration of a stentless porcine aortic root. For index type A dissections, reintervention for aneurysm of the descending/thoracoabdominal aorta and arch were most common. The mean duration of follow up was 4.2 ± 2.5 years. The 9-year actuarial freedom from reintervention was 92.9%. Cox regression showed index type A dissection was a significant predictor of time to aortic reintervention (hazard ratio, 2.01; 95% confidence interval, 1.04 to 3.9; p = 0.038). CONCLUSIONS Reinterventions after proximal aortic operations are uncommon; most occur within 3 years of the index operation and involve the proximal and distal aorta nearly equally. Patients with type A dissection or stentless porcine roots require aggressive surveillance, whereas a more liberal approach is suitable for patients without such risk factors. This strategy may reduce the lifetime radiation burden and health care costs.
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Affiliation(s)
- Alexander Iribarne
- Section of Cardiac Surgery, Department of Surgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Jeffrey Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ehsan Benrashid
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Hanghang Wang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - James M Meza
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Asvin Ganapathi
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Han W Kim
- Division of Cardiology, Duke Cardiovascular Magnetic Resonance Center, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Lynne M Hurwitz
- Department of Radiology, Duke University Medical Center, Durham, North Carolina
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina.
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Shah AA, Glower DD, Gaca JG. Trans-aortic Alfieri stitch at the time of septal myectomy for hypertrophic obstructive cardiomyopathy. J Card Surg 2016; 31:503-6. [DOI: 10.1111/jocs.12804] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- Asad A. Shah
- Division of Cardiovascular and Thoracic Surgery; Duke University Medical Center; Durham North Carolina
| | - Donald D. Glower
- Division of Cardiovascular and Thoracic Surgery; Duke University Medical Center; Durham North Carolina
| | - Jeffrey G. Gaca
- Division of Cardiovascular and Thoracic Surgery; Duke University Medical Center; Durham North Carolina
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35
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Andersen ND, Benrashid E, Ross AK, Pickett LC, Smith PK, Daneshmand MA, Schroder JN, Gaca JG, Hughes GC. The utility of the aortic dissection team: outcomes and insights after a decade of experience. Ann Cardiothorac Surg 2016; 5:194-201. [PMID: 27386406 DOI: 10.21037/acs.2016.05.12] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Mortality rates following acute type A aortic dissection (ATAAD) repair are reduced when operations are performed by a high-volume acute aortic dissection (AAD) team, leading to efforts to centralize ATAAD care. Here, we describe our experience with ATAAD repair by our AAD team over the last 10 years, with a focus on patient selection, transfer protocols, operative approach, and volume trends over time. METHODS An AAD team was implemented at our institution in 2005, with dedicated high-volume AAD surgeons, a multidisciplinary approach to thoracic aortic disease management, and a standardized protocol for ATAAD repair. Further process improvements were made in 2013 to facilitate the rapid transfer of ATAAD patients to our institution using stream-lined triage, diagnostic, and transfer protocols for patients with suspected ATAAD (RACE-AD protocol). Volume trends and outcomes were assessed longitudinally over this period. RESULTS Institutional ATAAD repair volume remained constant at 12±2 cases per year from 2005-2013, but increased nearly two-fold to 22±6 cases per year (P=0.004) from 2013-2015 following implementation of the RACE-AD protocol. To accommodate this increased volume, two additional surgeons were added to the AAD team. Surgeon ATAAD repair volume was unchanged over the 10-year interval (7.9±3.9 cases per year from 2005-2013 versus 5.5±1.5 cases per year from 2013-2015; P=0.36), and all AAD team surgeons consistently met or exceeded the high-volume surgeon threshold of 5 ATAAD repairs per year. Thirty-day/in-hospital mortality rates of less than 10% were maintained over the study period. CONCLUSIONS Centralization of ATAAD care has begun to occur at our center, with maintenance of low mortality rates for ATAAD repair. These data confirm a net positive impact on regional ATAAD outcomes through transfer of patients to a high-volume center with dedicated AAD surgeons.
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Affiliation(s)
- Nicholas D Andersen
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Ehsan Benrashid
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Adia K Ross
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Lisa C Pickett
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Peter K Smith
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Mani A Daneshmand
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jacob N Schroder
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - Jeffrey G Gaca
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
| | - G Chad Hughes
- 1 Department of Surgery, 2 Department of Medicine, Duke University Medical Center, Durham, NC, USA
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Abstract
BACKGROUND Transcatheter valve-in-valve (VIV) procedures are an alternative to standard surgical valve replacement in high risk patients. METHODS Cases in which a commercially approved transcatheter aortic valve replacement (TAVR) device was used for a nonaortic VIV procedure between November 2013 and September 2015 are reviewed. Clinical, echocardiographic, and procedural details, patient survival, and symptom severity by NYHA class at follow-up were assessed. RESULTS All patients were heart-team determined high risk for conventional redo surgery (mean STS PROM = 6.8 ± 2.2%). Five patients underwent VIV replacement in the nonaortic position, four for bioprosthetic mitral valve dysfunction, and one for bioprosthetic tricuspid valve dysfunction. Bioprosthetic failure was due to stenosis in three patients and regurgitation in two others. A balloon-expandable device was used for all patients (Edwards Lifesciences, Irvine, CA, USA). Transcatheter VIV replacement was accomplished by the transapical (mitral) and transfemoral venous (tricuspid) approaches. Median postoperative length of stay was five days (range 3-12). No deaths occurred at a mean follow-up of 21 months. NYHA class at follow-up decreased from class IV at baseline to class I or II for all patients. No paravalvular leaks greater than trivial were encountered. Median mean gradient following mitral replacement was 6.5 mmHg (range 6-13 mmHg), and following tricuspid replacement was 4 mmHg. Postoperative complications included hematuria, epistaxis, acute kidney injury, and atrial fibrillation. CONCLUSIONS Transcatheter VIV implantation in the nonaortic position for dysfunctional bioprostheses can be performed safely with favorable clinical outcomes using a balloon expandable TAVR device. doi: 10.1111/jocs.12745 (J Card Surg 2016;31:282-288).
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Affiliation(s)
- David N Ranney
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Judson B Williams
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Andrew Wang
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Hanna JM, Keenan JE, Wang H, Andersen ND, Gaca JG, Lombard FW, Welsby IJ, Hughes GC. Use of human fibrinogen concentrate during proximal aortic reconstruction with deep hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2015; 151:376-82. [PMID: 26428473 DOI: 10.1016/j.jtcvs.2015.08.079] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Revised: 08/11/2015] [Accepted: 08/23/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Human fibrinogen concentrate (HFC) is approved by the Food and Drug Administration for use at 70 mg/kg to treat congenital afibrinogenemia. We sought to determine whether this dose of HFC increases fibrinogen levels in the setting of high-risk bleeding associated with aortic reconstruction and deep hypothermic circulatory arrest (DHCA). METHODS This was a prospective, pilot, off-label study in which 22 patients undergoing elective proximal aortic reconstruction with DHCA were administered 70 mg/kg HFC upon separation from cardiopulmonary bypass (CPB). Fibrinogen levels were measured at baseline, just before, and 10 minutes after HFC administration, on skin closure, and the day after surgery. The primary study outcome was the difference in fibrinogen level immediately after separation from CPB, when HFC was administered, and the fibrinogen level 10 minutes following HFC administration. Additionally, postoperative thromboembolic events were assessed as a safety analysis. RESULTS The mean baseline fibrinogen level was 317 ± 49 mg/dL and fell to 235 ± 39 mg/dL just before separation from CPB. After HFC administration, the fibrinogen level rose to 331 ± 41 mg/dL (P < .001) and averaged 372 ± 45 mg/dL the next day. No postoperative thromboembolic complications occurred. CONCLUSIONS Administration of 70 mg/kg HFC upon separation from CPB raises fibrinogen levels by approximately 100 mg/dL without an apparent increase in thrombotic complications during proximal aortic reconstruction with DHCA. Further prospective study in a larger cohort of patients will be needed to definitively determine the safety and evaluate the efficacy of HFC as a hemostatic adjunct during these procedures.
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Affiliation(s)
- Jennifer M Hanna
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey E Keenan
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Hanghang Wang
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Nicholas D Andersen
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Frederick W Lombard
- Division of Cardiac Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Ian J Welsby
- Division of Cardiac Anesthesiology, Department of Anesthesiology, Duke University Medical Center, Durham, NC.
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
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Tang P, Onaitis M, Gaca JG, Milano CA, Stafford-Smith M, Glower D. Right Minithoracotomy Versus Median Sternotomy for Mitral Valve Surgery: A Propensity Matched Study. Ann Thorac Surg 2015; 100:575-81. [DOI: 10.1016/j.athoracsur.2015.04.027] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2015] [Revised: 03/29/2015] [Accepted: 04/01/2015] [Indexed: 10/23/2022]
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Cherry AD, Nicoara A, McQuilkin SH, Gaca JG, Del Rio JM. Multimodal Evaluation of Aortic Regurgitation After Mitral and Tricuspid Valve Repairs. Anesth Analg 2015. [PMID: 26197369 DOI: 10.1213/ane.0000000000000739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Anne D Cherry
- From the *Department of Anesthesiology, and †Department of Surgery, Duke University, Durham, North Carolina
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40
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Ganapathi AM, Hirji SA, Wang A, Patel CB, Gaca JG, Schroder JN. Bridge to Long-Term Mechanical Circulatory Support With a Left Ventricular Assist Device: Novel Use of Transcatheter Aortic Valve Replacement. Ann Thorac Surg 2015; 99:e91-3. [DOI: 10.1016/j.athoracsur.2014.12.087] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 12/03/2014] [Accepted: 12/16/2014] [Indexed: 10/23/2022]
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Esper SA, Bottiger BA, Ginsberg B, Del Rio JM, Glower DD, Gaca JG, Stafford-Smith M, Neuburger PJ, Chaney MA. CASE 8--2015. Paravertebral Catheter-Based Strategy for Primary Analgesia After Minimally Invasive Cardiac Surgery. J Cardiothorac Vasc Anesth 2015; 29:1071-80. [PMID: 26070694 DOI: 10.1053/j.jvca.2015.02.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Stephen A Esper
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA.
| | - Brandi A Bottiger
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Brian Ginsberg
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - J Mauricio Del Rio
- Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Donald D Glower
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Department of Surgery, Duke University Medical Center, Durham, NC
| | | | - Peter J Neuburger
- Department of Anesthesiology, New York University Medical Center, New York, NY
| | - Mark A Chaney
- Department of Anesthesia and Critical Care, The University of Chicago, Chicago, IL
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DeLong MR, Hughes DB, Gaca JG, Fischer JP, Bond JE, Hargrove WC, Atluri P, Levin LS, Erdmann D. Sternal talon offers a solution for secondary sternum osteosynthesis in patients with nonunion. Ann Thorac Surg 2014; 98:1804-8. [PMID: 25240779 DOI: 10.1016/j.athoracsur.2014.06.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 06/12/2014] [Accepted: 06/13/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Median sternotomy may be associated with postoperative complications such as nonunion after conventional metal wire closure. The Sternal Talon device (KLS Martin, Jacksonville, FL) has recently been introduced as an alternative for osteosynthesis after median sternotomy and may also be beneficial for patients with persistent sternal nonunion. METHODS A consecutive series of 24 patients underwent Sternal Talon repair for sternal nonunion or acute mediastinitis, or both, after sternal wire closure. Patient data--including demographics, surgical history, and indication for operation, as well as outcomes--were obtained and analyzed by retrospective chart review. RESULTS The average patient age was 61.3 years and 23 patients were men (95.8%). The most common median sternotomy procedure was coronary artery bypass grafting (CABG) in 19 patients (79.2%). Secondary closure using the Sternal Talon was indicated for sternal nonunion or infection, or both, in all patients. Eight patients underwent simultaneous muscle flap procedures during the placement of the Sternal Talon (33.3%). Sternal union was eventually achieved in 23 of 24 patients (95.8%). Subsequent reoperation was required in 4 patients (16.7%). CONCLUSIONS The data presented suggest that the osteosynthesis using the Sternal Talon device is a safe and effective modality for treating symptomatic sternal nonunion or acute dehiscence associated with infection (mediastinitis.).
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Affiliation(s)
- Michael R DeLong
- Division of Plastic, Reconstructive, Maxillofacial, and Oral Surgery and Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Duncan B Hughes
- Division of Plastic, Reconstructive, Maxillofacial, and Oral Surgery and Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Division of Cardiothoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - John P Fischer
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer E Bond
- Division of Plastic, Reconstructive, Maxillofacial, and Oral Surgery and Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - W Clark Hargrove
- Division of Cardiovascular Surgery and Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Pavan Atluri
- Division of Cardiovascular Surgery and Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - L Scott Levin
- Division of Plastic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Orthopedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Detlev Erdmann
- Division of Plastic, Reconstructive, Maxillofacial, and Oral Surgery and Department of Surgery, Duke University Medical Center, Durham, North Carolina.
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Andersen ND, Keenan JE, Ganapathi AM, Gaca JG, McCann RL, Hughes GC. Current management and outcome of chronic type B aortic dissection: results with open and endovascular repair since the advent of thoracic endografting. Ann Cardiothorac Surg 2014; 3:264-74. [PMID: 24967165 DOI: 10.3978/j.issn.2225-319x.2014.05.07] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 05/20/2014] [Indexed: 11/14/2022]
Abstract
BACKGROUND Thoracic endovascular aortic repair (TEVAR) has become the preferred treatment for chronic type B aortic dissection (CTBAD) at our institution. However, it remains incapable of treating all patients with CTBAD. The present study aims to review our contemporary results with open and endovascular CTBAD repairs since the advent of thoracic endografting. METHODS The records of all patients undergoing index repair of CTBAD (chronic DeBakey type IIIA, IIIB and repaired type I) at our institution between June 2005 and December 2013, were retrospectively reviewed. RESULTS A total of 107 patients underwent CTBAD repair, of whom 70% (n=75) underwent endovascular-based procedures [44 TEVAR, 27 hybrid arch and four hybrid thoracoabdominal aortic aneurysm (TAAA) repair] and 30% (n=32) underwent open procedures (nine open descending and 23 open TAAA). Connective tissue disease (CTD), prior aortic surgery and DeBakey dissection type were strongly associated with the choice of operation. The rates of stroke, paraplegia and operative mortality following endovascular-based repairs were 0%, 0% and 4% (n=3), respectively. Adverse neurologic events were higher following open repair, and rates of stroke, paraplegia, and operative mortality were 16% (n=5), 9% (n=3), and 6% (n=2), respectively. However, 1- and 5-year survival rates were similar for endovascular-based repairs (86% and 65%, respectively), and open repairs (88% and 79%, respectively). Over a median follow-up interval of 34 months, the rate of descending aortic reintervention was 24% (n=18) following endovascular-based repairs and 0% following open repairs (P=0.001). Forty-four percent (n=8) of descending aortic reinterventions were required to treat stent graft complications (five endoleak, two stent graft collapse and one stent graft-induced new entry tear) and the remainder were required to treat metachronous pathology (n=2) or progressive aneurysmal disease related to persistent distal fenestrations (n=8). CONCLUSIONS Endovascular repair of CTBAD was associated with excellent procedural and survival outcomes, but at the expense of further reinterventions. Open repair remains relevant for patients who are not candidates for endovascular repair and was associated with higher procedural morbidity but similar overall survival and fewer reinterventions.
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Affiliation(s)
- Nicholas D Andersen
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeffrey E Keenan
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Asvin M Ganapathi
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Jeffrey G Gaca
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Richard L McCann
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - G Chad Hughes
- 1 Division of Cardiovascular and Thoracic Surgery, 2 Division of Vascular Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
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44
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Kiefer TL, Vavalle J, Halim S, Kaul P, Klein JL, Hurwitz LH, Gaca JG, Harrison JK. Anterograde percutaneous coronary-cameral fistula closure employing a guide-in-guide technique. JACC Cardiovasc Interv 2014; 6:1105-7. [PMID: 24156972 DOI: 10.1016/j.jcin.2013.03.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2013] [Accepted: 03/15/2013] [Indexed: 01/15/2023]
Affiliation(s)
- Todd L Kiefer
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina.
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45
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Ganapathi AM, Hanna JM, Schechter MA, Englum BR, Castleberry AW, Gaca JG, Hughes GC. Antegrade versus retrograde cerebral perfusion for hemiarch replacement with deep hypothermic circulatory arrest: does it matter? A propensity-matched analysis. J Thorac Cardiovasc Surg 2014; 148:2896-902. [PMID: 24908350 DOI: 10.1016/j.jtcvs.2014.04.014] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Revised: 03/17/2014] [Accepted: 04/08/2014] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The choice of cerebral perfusion strategy for aortic arch surgery has been debated, and the superiority of antegrade (ACP) or retrograde (RCP) cerebral perfusion has not been shown. We examined the early and late outcomes for ACP versus RCP in proximal (hemi-) arch replacement using deep hypothermic circulatory arrest (DHCA). METHODS A retrospective analysis of a prospectively maintained database was performed for all patients undergoing elective and nonelective hemiarch replacement at a single referral institution from June 2005 to February 2013. Total arch cases were excluded to limit the analysis to shorter DHCA times and a more uniform patient population for whom clinical equipoise regarding ACP versus RCP exists. A total of 440 procedures were identified, with 360 (82%) using ACP and 80 (18%) using RCP. The endpoints included 30-day/in-hospital and late outcomes. A propensity score with 1:1 matching of 40 pre- and intraoperative variables was used to adjust for differences between the 2 groups. RESULTS All 80 RCP patients were propensity matched to a cohort of 80 similar ACP patients. The pre- and intraoperative characteristics were not significantly different between the 2 groups after matching. No differences were found in 30-day/in-hospital mortality or morbidity outcomes. The only significant difference between the 2 groups was a shorter mean operative time in the RCP cohort (P = .01). No significant differences were noted in late survival (P = .90). CONCLUSIONS In proximal arch operations using DHCA, equivalent early and late outcomes can be achieved with RCP and ACP, although the mean operative time is significantly less with RCP, likely owing to avoidance of axillary cannulation. Questions remain regarding comparative outcomes with straight DHCA and lesser degrees of hypothermia.
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Affiliation(s)
- Asvin M Ganapathi
- Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jennifer M Hanna
- Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Matthew A Schechter
- Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Brian R Englum
- Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Anthony W Castleberry
- Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Duke Center for Aortic Disease, Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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46
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Affiliation(s)
- Donald D. Glower
- Department of Surgery, Duke University Medical Center, Durham, NC USA
| | - Bhargavi S. Desai
- Department of Surgery, Duke University Medical Center, Durham, NC USA
| | - G. Chad Hughes
- Department of Surgery, Duke University Medical Center, Durham, NC USA
| | - Carmelo A. Milano
- Department of Surgery, Duke University Medical Center, Durham, NC USA
| | - Jeffrey G. Gaca
- Department of Surgery, Duke University Medical Center, Durham, NC USA
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47
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Andersen ND, Ganapathi AM, Hanna JM, Williams JB, Gaca JG, Hughes GC. Outcomes of acute type a dissection repair before and after implementation of a multidisciplinary thoracic aortic surgery program. J Am Coll Cardiol 2014; 63:1796-803. [PMID: 24412454 DOI: 10.1016/j.jacc.2013.10.085] [Citation(s) in RCA: 140] [Impact Index Per Article: 14.0] [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: 06/04/2013] [Revised: 08/29/2013] [Accepted: 10/08/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The purpose of this study was to compare the results of acute type A aortic dissection (ATAAD) repair before and after implementation of a multidisciplinary thoracic aortic surgery program (TASP) at our institution, with dedicated high-volume thoracic aortic surgeons, a multidisciplinary approach to thoracic aortic disease management, and a standardized protocol for ATAAD repair. BACKGROUND Outcomes of ATAAD repair may be improved when operations are performed at specialized high-volume thoracic aortic surgical centers. METHODS Between 1999 and 2011, 128 patients underwent ATAAD repair at our institution. Records of patients who underwent ATAAD repair 6 years before (n = 56) and 6 years after (n = 72) implementation of the TASP were retrospectively compared. Expected operative mortality rates were calculated using the International Registry of Acute Aortic Dissection pre-operative prediction model. RESULTS Baseline risk profiles and expected operative mortality rates were comparable between patients who underwent surgery before and after implementation of the TASP. Operative mortality before TASP implementation was 33.9% and was statistically equivalent to the expected operative mortality rate of 26.0% (observed-to-expected mortality ratio 1.30; p = 0.54). Operative mortality after TASP implementation fell to 2.8% and was statistically improved compared with the expected operative mortality rate of 18.2% (observed-to-expected mortality ratio 0.15; p = 0.005). Differences in survival persisted over long-term follow-up, with 5-year survival rates of 85% observed for TASP patients compared with 55% for pre-TASP patients (p = 0.002). CONCLUSIONS ATAAD repair can be performed with results approximating those of elective proximal aortic surgery when operations are performed by a high-volume multidisciplinary thoracic aortic surgery team. Efforts to standardize or centralize care of patients undergoing ATAAD are warranted.
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Affiliation(s)
- Nicholas D Andersen
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Asvin M Ganapathi
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jennifer M Hanna
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Judson B Williams
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G Gaca
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina
| | - G Chad Hughes
- Department of Surgery, Division of Cardiovascular and Thoracic Surgery, Duke University Medical Center, Durham, North Carolina.
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48
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Gaca JG, Clare RM, Rankin JS, Daneshmand MA, Milano CA, Hughes GC, Wolfe WG, Glower DD, Smith PK. Risk-adjusted survival after tissue versus mechanical aortic valve replacement: a 23-year assessment. J Heart Valve Dis 2013; 22:810-816. [PMID: 24597402 PMCID: PMC4348365] [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] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY Detailed analyses of risk-adjusted outcomes after mitral valve surgery have documented significant survival decrements with tissue valves at any age. Several recent studies of prosthetic aortic valve replacement (AVR) also have suggested a poorer performance of tissue valves, although analyses have been limited to small matched series. The study aim was to test the hypothesis that AVR with tissue valves is associated with a lower risk-adjusted survival, as compared to mechanical valves. METHODS Between 1986 and 2009, primary isolated AVR, with or without coronary artery bypass grafting (CABG), was performed with currently available valve types in 2148 patients (1108 tissue valves, 1040 mechanical). Patients were selected for tissue valves to be used primarily in the elderly. Baseline and operative characteristics were documented prospectively with a consistent variable set over the entire 23-year period. Follow up was obtained with mailed questionnaires, supplemented by National Death Index searches. The average time to death or follow up was seven years, and follow up for survival was 96.2% complete. Risk-adjusted survival characteristics for the two groups were evaluated using a Cox proportional hazards model with stepwise selection of candidate variables. RESULTS Differences in baseline characteristics between groups were (tissue versus mechanical): median age 73 versus 61 years; non-elective surgery 32% versus 28%; CABG 45% versus 35%; median ejection fraction 55% versus 55%; renal failure 6% versus 1%; diabetes 18% versus 7% (p<0.01). Unadjusted Kaplan-Meier survival was significantly lower with tissue than mechanical valves; however, after risk adjustment for the adverse profiles of tissue valve patients, no significant difference was observed in survival after tissue or mechanical AVR. Thus, the hypothesis did not hold, and risk-adjusted survival was equivalent, of course qualified by the fact that selection bias was evident. CONCLUSION With selection criteria that employed tissue AVR more frequently in elderly patients, tissue and mechanical valves achieved similar survival characteristics across the spectrum of patient risk. Further studies of the relative outcomes of mechanical versus tissue valves across the spectrum of patient age seem indicated.
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Affiliation(s)
| | | | | | | | | | - G Chad Hughes
- Duke University Medical Center, Durham, NC 27710, USA
| | | | | | - Peter K Smith
- Duke University Medical Center, Durham, NC 27710, USA
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49
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Ganapathi AM, Englum BR, Hanna JM, Schechter MA, Gaca JG, Hurwitz LM, Hughes GC. Frailty and risk in proximal aortic surgery. J Thorac Cardiovasc Surg 2013; 147:186-191.e1. [PMID: 24183336 DOI: 10.1016/j.jtcvs.2013.09.011] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2013] [Revised: 08/20/2013] [Accepted: 09/04/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Although frailty has recently been examined in various populations as a predictor of morbidity and mortality, its effect on thoracic aortic surgery outcomes has not been studied. The objective of the present study was to evaluate the role of frailty in predicting postoperative morbidity and mortality in patients undergoing proximal aortic replacement surgery. METHODS A retrospective analysis of a prospectively maintained database was performed for all patients undergoing elective and nonelective proximal aortic operations (root, ascending aorta, and/or arch) at a single-referral institution from June 2005 to December 2012. A total of 581 patients underwent proximal aortic surgery, of whom 574 (98.8%) were included in the present analysis; 7 were excluded because of incomplete data. Frailty was evaluated using an index consisting of age >70 years, body mass index <18.5 kg/m(2), anemia, history of stroke, hypoalbuminemia, and total psoas volume in the bottom quartile of the population. One point was given for each criterion met to determine a frailty score of 0 to 6. Frailty was defined as a score of ≥2. Risk models for length of stay >14 days, discharge to other than home, 30-day composite major morbidity, 30-day composite major morbidity/mortality, and 30-day and 1-year mortality were calculated using multivariate regression modeling. RESULTS Of the 574 patients, 148 (25.7%) were defined as frail (frailty score ≥2). The unadjusted 30-day/in-hospital and long-term outcomes were significantly worse for the frail versus nonfrail patients in all but 1 of the outcomes analyzed; no difference was found in the 30-day readmission rates between the 2 groups. In the multivariate model, a frailty score of ≥2 was associated with discharge to other than home and 30-day and 1-year mortality. CONCLUSIONS Frailty, as defined using a 6-component frailty index, can serve as an independent predictor of discharge disposition and early and late mortality risk in patients undergoing proximal aortic surgery. These frailty markers, all of which are easily assessed preoperatively, could provide valuable information for patient counseling and risk stratification before proximal aortic replacement.
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Affiliation(s)
- Asvin M Ganapathi
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Brian R Englum
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jennifer M Hanna
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Matthew A Schechter
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Jeffrey G Gaca
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC
| | - Lynne M Hurwitz
- Department of Radiology, Duke University Medical Center, Durham, NC
| | - G Chad Hughes
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, NC.
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50
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Gaca JG, Sheng S, Daneshmand M, Rankin JS, Williams ML, O'Brien SM, Gammie JS. Current outcomes for tricuspid valve infective endocarditis surgery in North America. Ann Thorac Surg 2013; 96:1374-1381. [PMID: 23968767 DOI: 10.1016/j.athoracsur.2013.05.046] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2013] [Revised: 05/11/2013] [Accepted: 05/14/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Tricuspid valve (TV) infective endocarditis (IE) accounts for 15% of IE cases and usually is treated medically. Surgical intervention is rare, and understanding of treatment options is based on small series of patients. The purpose of this study was to describe the population and outcomes for isolated TV IE using The Society of Thoracic Surgeons Adult Cardiac Database. METHODS Between 2002 and 2009, 910 operations for TV IE were performed. Procedures included replacement, repair, and valvectomy. Healed IE was present in 31.4% (n = 286), and active IE, in 68.5% (n = 624). Baseline patient characteristics as well as operative mortality and morbidity were analyzed, and univariate statistical differences were evaluated by Kruskal-Wallis test and stratum-adjusted Mantel-Haenszel χ(2) tests. RESULTS The median age was 40 years, with 50.6% male. Replacement of the TV was the most common procedure (n = 490; 53.8%), followed by TV repair (n = 354; 38.9%) and valvectomy (n = 66; 7.2%). Overall operative mortality was 7.3%, with no significant difference in mortality among valvectomy 12%, repair 7.6%, and replacement 6.3% (p = 0.34). Compared with the active group, healed patients experienced a trend toward lower operative mortality (4.2% versus 8.6%; p = 0.06), lower complication rates (35.6% versus 51.4%; p = 0.0004), and shorter overall length of stay (12 versus 22 days; p < 0.0001). CONCLUSIONS Isolated TV operation for IE is a rare clinical entity with a similar operative mortality to left-sided IE operations. Repair and replacement of the TV had similar perioperative mortality. Patients in the healed TV IE group demonstrated lower complication rates, length of stay, and a trend toward decreased mortality.
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Affiliation(s)
| | - Shubin Sheng
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | - Sean M O'Brien
- Duke Clinical Research Institute, Durham, North Carolina
| | - James S Gammie
- University of Maryland School of Medicine, Baltimore, Maryland
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