1
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Hammer Y, Xie J, Yang G, Bitar A, Haft JW, Cascino TM, Likosky DS, Pagani FD, Zhang M, Aaronson KD. Gastrointestinal bleeding following Heartmate 3 left ventricular assist device implantation: The Michigan Bleeding Risk Model. J Heart Lung Transplant 2024; 43:604-614. [PMID: 38065237 DOI: 10.1016/j.healun.2023.11.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/21/2023] [Accepted: 11/27/2023] [Indexed: 12/25/2023] Open
Abstract
BACKGROUND Gastrointestinal bleeding (GIB) results in frequent hospitalizations and impairs quality of life in durable left ventricular assist device (LVAD) recipients. Anticipation of these events before implantation could have important implications for patient selection and management. METHODS The study population included all adult HeartMate 3 (HM3) primary LVAD recipients enrolled in the STS Intermacs registry from January 2017 to December 2020. Using multivariable modeling methodologies, we investigated the relationships between preimplantation characteristics and postimplant bleeding, bleeding and death, and additional bleeding episodes on subsequent bleeding episodes and created a risk score to predict the likelihood of post-LVAD GIB based solely on preimplantation factors. RESULTS Of 6,425 patients who received an HM3 LVAD, 1,010 (15.7%) patients experienced GIB. Thirteen preimplantation factors were independent predictors of post-LVAD GIB. A risk score was created from these factors and calculated for each patient. By 3 years postimplant, GIB occurred in 11%, 26%, and 43% of low-, medium- and high-risk patients, respectively. Experiencing 1 post-LVAD GIB event was associated with an increased risk for further GIB events, with 33.9% of patients experiencing at least 1 recurrence. While post-LVAD GIB was associated with mortality, there was no relationship between number of GIB events and death. CONCLUSIONS The Michigan Bleeding Risk Model is a simple tool, which facilitates the prediction of post-LVAD GIB in HM3 recipients using 13 preimplant variables. The implementation of this tool may help in the risk stratification process and may have therapeutic and clinical implications in HM3 LVAD recipients.
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Affiliation(s)
- Yoav Hammer
- Division of Cardiovascular Disease, Michigan Medicine - University of Michigan, Ann Arbor, Michigan.
| | - Jiaheng Xie
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Michigan
| | - Guangyu Yang
- Institute of Statistics and Big Data, Renmin University of China, Beijing, China
| | - Abbas Bitar
- Division of Cardiovascular Disease, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Jonathan W Haft
- Department of Cardiac Surgery, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Thomas M Cascino
- Division of Cardiovascular Disease, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Francis D Pagani
- Department of Cardiac Surgery, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
| | - Min Zhang
- Tsinghua Univeristy, Vanke School of Public Health, Beijing, China
| | - Keith D Aaronson
- Division of Cardiovascular Disease, Michigan Medicine - University of Michigan, Ann Arbor, Michigan
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2
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Yost G, Plott J, Angandi A, Locke C, Marten T, Haft JW. Mechanical Analysis of a Novel Sternal Closure System in Static Tensile Loading. ASAIO J 2024:00002480-990000000-00439. [PMID: 38467067 DOI: 10.1097/mat.0000000000002185] [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] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Abstract
The most common means of sternal closure after sternotomy is stainless steel wire cerclage. These wires, while inexpensive and simple in design, are known to be associated with low strength and sternal dehiscence. In this biomechanical analysis, we compare single sternal wires, double sternal wires, and a novel sternal closure device we have designed to mitigate sternal dehiscence. The device uses polymer grommets at the sternal interfaces to distribute load over a large surface area of bone. Samples of each closure device were installed in a bone model and distracted at a rate of 10 mm/min while tensile forces were continuously measured and compared. Single wires generated the lowest stiffness and strength values, followed by the double wires. The novel device demonstrated significantly higher stiffness and strength at all displacements compared with the single and double wires. Clinical use of this device may result in meaningful reduction in complications associated with the use of standard sternal wires such as sternal separation and fracture.
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Affiliation(s)
- Gardner Yost
- From the Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
- Department of Biomedical Engineering, Coulter Translational Research Partnership, University of Michigan, Ann Arbor, Michigan
| | - Jeffrey Plott
- Department of Biomedical Engineering, Coulter Translational Research Partnership, University of Michigan, Ann Arbor, Michigan
| | - Amogh Angandi
- Department of Biomedical Engineering, Coulter Translational Research Partnership, University of Michigan, Ann Arbor, Michigan
| | - Conor Locke
- Department of Orthopaedic Surgery, University of Michigan, Ann Arbor, Michigan
| | - Thomas Marten
- Department of Biomedical Engineering, Coulter Translational Research Partnership, University of Michigan, Ann Arbor, Michigan
| | - Jonathan W Haft
- From the Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
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3
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Sicim H, Noly PE, Naik S, Sood V, Ohye RG, Haft JW, Aaronson KD, Pagani FD, Si MS, Tang PC. Determinants of survival following heart transplantation in adults with congenital heart disease. J Cardiothorac Surg 2024; 19:83. [PMID: 38336724 PMCID: PMC10858543 DOI: 10.1186/s13019-024-02509-0] [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] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
BACKGROUND Adult patients surviving with congenital heart disease (ACHD) is growing. We examine the factors associated with heart transplant outcomes in this challenging population with complex anatomy requiring redo-surgeries. METHODS We reviewed the United Network for Organ Sharing-Standard Transplant Analysis and Research database and analyzed 35,952 heart transplants from January 1st, 2000, to September 30th, 2018. We compared transplant characteristics for ischemic cardiomyopathy (ICM) (n = 14,236), nonischemic cardiomyopathy (NICM) (n = 20,676), and ACHD (n = 1040). Mean follow-up was 6.20 ± 4.84 years. Kaplan-Meier survival curves and Cox-proportional hazards analysis were used to analyze survival data. RESULTS Multivariable analysis confirmed that ACHD was associated greater in-hospital death compared to ICM (HR = 0.54, P < 0.001) and NICM (HR = 0.46, P < 0.001). Notable factors associated with increased mortality were history of cerebrovascular disease (HR = 1.11, P = 0.026), prior history of malignancy (HR = 1.12, P = 0.006), pre-transplant biventricular support (HR = 1.12, P = 0.069), postoperative stroke (HR = 1.47, P < 0.001) and postoperative dialysis (HR = 1.71, P < 0.001). ACHD transplants had a longer donor heart ischemic time (P < 0.001) and trend towards more deaths from primary graft dysfunction (P = 0.07). In-hospital deaths were more likely with ACHD and use of mechanical support such as use of right ventricular assist device (HR = 2.20, P = 0.049), biventricular support (HR = 1.62, P < 0.001) and extracorporeal membrane oxygenation (HR = 2.36, P < 0.001). Conditional survival after censoring hospital deaths was significantly higher in ACHD (P < 0.001). CONCLUSION Heart transplant in ACHD is associated with a higher post-operative mortality given anatomical complexity but a better long-term conditional survival. Normothermic donor heart perfusion may improve outcomes in the ACHD population by reducing the impact of longer ischemic times.
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Affiliation(s)
- Hüseyin Sicim
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Suyash Naik
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Vikram Sood
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Richard G Ohye
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Keith D Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Ming-Sing Si
- Department of Surgery, Division of Cardiac Surgery, University of California Los Angeles, Los Angeles, CA, USA
| | - Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA.
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA.
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4
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Yang G, Zhang B, Haft JW, Hawkins RB, Sturmer D, Likosky DS, Zhang M. Modeling and estimating a threshold effect: An application to improving cardiac surgery practices. Stat Methods Med Res 2023; 32:2318-2330. [PMID: 38031434 DOI: 10.1177/09622802231211004] [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] [Indexed: 12/01/2023]
Abstract
Estimating thresholds when a threshold effect exists has important applications in biomedical research. However, models/methods commonly used in the biomedical literature may lead to a biased estimate. For patients undergoing coronary artery bypass grafting (CABG), it is thought that exposure to low oxygen delivery (DO2) contributes to an increased risk of avoidable acute kidney injury. This research is motivated by estimating the threshold of nadir DO2 for CABG patients to help develop an evidence-based guideline for improving cardiac surgery practices. We review several models (sudden-jump model, broken-stick model, and the constrained broken-stick model) that can be adopted to estimate the threshold and discuss modeling assumptions, scientific plausibility, and implications in estimating the threshold. Under each model, various estimation methods are studied and compared. In particular, under a constrained broken-stick model, a modified two-step Newton-Raphson algorithm is introduced. Through comprehensive simulation studies and an application to data on CABG patients from the University of Michigan, we show that the constrained broken-stick model is flexible, more robust, and able to incorporate scientific knowledge to improve efficiency. The two-step Newton-Raphson algorithm has good computational performances relative to existing methods.
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Affiliation(s)
- Guangyu Yang
- Institute of Statistics and Big Data, Renmin University of China, Beijing, China
| | - Baqun Zhang
- School of Statistics and Management, Shanghai University of Finance and Economics, Shanghai, China
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - David Sturmer
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Min Zhang
- Department of Biostatistics, Univeristy of Michigan, Ann Arbor, MI, USA
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5
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Haft JW. Commentary: The never-ending search for a decent night's sleep. J Thorac Cardiovasc Surg 2023:S0022-5223(23)01076-0. [PMID: 37951535 DOI: 10.1016/j.jtcvs.2023.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/04/2023] [Indexed: 11/14/2023]
Affiliation(s)
- Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
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6
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Haft JW, Yost G. Open Surgical Treatment of Acute and Chronic Pulmonary Embolism. Interv Cardiol Clin 2023; 12:339-347. [PMID: 37290838 DOI: 10.1016/j.iccl.2023.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Acute pulmonary embolism (PE) is a common cause of death and morbidity in the United States and the prevalence of chronic thromboembolic pulmonary hypertension (CTEPH), a possible sequela of PE, has increased during the past decade. The mainstay treatment of CTEPH is open pulmonary endarterectomy, a procedure performed under hypothermic circulatory arrest, which entails endarterectomy of the branch, segmental and subsegmental pulmonary arteries. Acute PE may be similarly be treated with an open embolectomy in certain select circumstances.
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Affiliation(s)
- Jonathan W Haft
- Cardiothoracic Surgery, University of Michigan, 1500 East Medical Center Drive 5144 CVC, Ann Arbor, MI 48109-5864, USA.
| | - Gardner Yost
- Cardiothoracic Surgery, University of Michigan, 1500 East Medical Center Drive 5144 CVC, Ann Arbor, MI 48109-5864, USA
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7
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Milewski RC, Chatterjee S, Merritt-Genore H, Hayanga JWA, Grant MC, Roy N, Hirose H, Moosdorf R, Whitman GJ, Haft JW, Hiebert B, Stead C, Rycus P, Arora RC. ECMO During COVID-19: A Society of Thoracic Surgeons/Extracorporeal Life Support Organization Survey. Ann Thorac Surg Short Rep 2023; 1:168-173. [PMID: 36545251 PMCID: PMC9618293 DOI: 10.1016/j.atssr.2022.10.017] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/18/2022] [Indexed: 04/27/2023]
Abstract
BACKGROUND The Society of Thoracic Surgeons Workforce on Critical Care and the Extracorporeal Life Support Organization sought to identify how the coronavirus disease 2019 (COVID-19) pandemic has changed the practice of venoarterial (VA) and venovenous (VV) extracorporeal membrane oxygenation (ECMO) programs across North America. METHODS A 26-question survey covering 6 categories (ECMO initiation, cannulation, management, anticoagulation, triage/protocols, and credentialing) was emailed to 276 North American Extracorporeal Life Support Organization centers. ECMO practices before and during the COVID-19 pandemic were compared. RESULTS Responses were received from 93 (34%) programs. The percentage of high-volume (>20 cases per year) VV ECMO programs increased during the pandemic from 29% to 41% (P < .001), as did institutions requiring multiple clinicians for determining initiation of ECMO (VV ECMO, 25% to 43% [P = .001]; VA ECMO, 20% to 32% [P = .012]). During the pandemic, more institutions developed their own protocols for resource allocation (23% before to 51%; P < .001), and more programs created sharing arrangements to triage patients and equipment with other centers (31% to 57%; P < .001). Direct thrombin inhibitor use increased for both VA ECMO (13% to 18%; P = .025) and VV ECMO (12% to 24%; P = .005). Although cardiothoracic surgeons remained the primary cannulating proceduralists, VV ECMO cannulations performed by pulmonary and critical care physicians increased (13% to 17%; P = .046). CONCLUSIONS The Society of Thoracic Surgeons/Extracorporeal Life Support Organization collaborative survey indicated that the pandemic has affected ECMO practice. Further research on these ECMO strategies and lessons learned during the COVID-19 pandemic may be useful in future global situations.
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Affiliation(s)
- Rita C Milewski
- Department of Surgery, Yale University, New Haven, Connecticut
| | - Subhasis Chatterjee
- Department of Surgery, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
| | | | - J W Awori Hayanga
- Department of Cardiovascular and Thoracic Surgery, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Nathalie Roy
- Department of Cardiac Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hitoshi Hirose
- Department of Surgery, Virtua Health, Our Lady of Lourdes Hospital, Camden, New Jersey
| | - Rainer Moosdorf
- Department for Cardiovascular Surgery, Philipps University, Marburg, Germany
| | - Glenn J Whitman
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Brett Hiebert
- Cardiac Sciences Program, Winnipeg Regional Health Authority, Winnipeg, Manitoba, Canada
| | - Christine Stead
- Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Peter Rycus
- Extracorporeal Life Support Organization, Ann Arbor, Michigan
| | - Rakesh C Arora
- University Hospitals Harrington Heart Vascular Institute, Case Western Reserve University, Cleveland Ohio
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8
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Sleasman JR, Hijawi U, Alsalemi A, Rabie M, Noorizadeh M, Stead A, Cooley C, Donnelly C, Haft JW, Abrams D, Stead C, Ryan KR, Rycus P, Fox AD, Ogino MT, Alexander PM. Foundations of a Life Support Equipment Exchange Platform: ELSO Supplies. J Extra Corpor Technol 2023; 55:39-43. [PMID: 37034103 PMCID: PMC10071502 DOI: 10.1051/ject/2023001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 12/12/2022] [Indexed: 02/05/2023]
Abstract
The ELSO Supplies Platform (Supplies.ELSO.org) was created out of Extracorporeal Membrane Oxygenation (ECMO) disposable product deficiency prior to and during the Coronavirus Disease 2019 (COVID-19) pandemic. This novel Platform supports Centers in obtaining disposables when alternative avenues are exhausted. Driven by the opportunity for increased patient care by using the product availability of the 962 ELSO centers worldwide was the motivation to form an efficient online supply sharing platform. The pandemic created by COVID-19, became a catalyst to further recognize the magnitude of the supply disruption on a global scale, impacting allocations and guidelines for institutions, practice, and patient care. Records kept on the platform website are helpful to industry by providing insights where difficulties exist in the supply chain for needed equipment. Yet, the common thread is awareness, how critical situations can stretch resources and challenge our resolve for best patient care. ELSO is proud to support member centers in these situations, by providing a means of attaining needed ECMO life support products to cover supply deficiencies.
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Affiliation(s)
- Justin R. Sleasman
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Lead Perfusionist, Stanford Medicine Children’s Health 725 Welch Road Palo Alto CA 94304 USA
- Corresponding author:
| | - Ula Hijawi
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Researcher and Project Team Leader, Qatar University Doha Qatar
| | | | - Mohamed Rabie
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Researcher and Project Team Leader, Qatar University Doha Qatar
| | | | - Aidan Stead
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Interns, Extracorporeal Life Support Organization Ann Arbor MI 48103 USA
| | - Christopher Cooley
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Interns, Extracorporeal Life Support Organization Ann Arbor MI 48103 USA
| | - Conor Donnelly
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Interns, Extracorporeal Life Support Organization Ann Arbor MI 48103 USA
| | - Jonathan W. Haft
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Department of Cardiac Surgery, University of Michigan Ann Arbor MI 48109 USA
| | - Darryl Abrams
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Division of Pulmonary and Critical Care Medicine, Columbia University Irving Medical Center New York NY 10032 USA
| | - Christine Stead
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CEO, Extracorporeal Life Support Organization and Adjunct Faculty, University of Michigan School of Public Health, Health Management and Policy Ann Arbor MI 48103 USA
| | - Kathleen R. Ryan
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Department of Pediatrics, Division of Cardiology, Stanford Medicine Children’s Health and Stanford University School of Medicine Palo Alto CA 94304 USA
| | - Peter Rycus
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Executive Director, Extracorporeal Life Support Organization Ann Arbor MI 48103 USA
| | - Alexander D. Fox
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Project Manager, Extracorporeal Life support Organization Ann Arbor MI 48103 USA
| | - Mark T. Ogino
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Pediatric Neonatal-Perinatal, Critical Care Service, Division of Neonatology Nemours/Alfred I. du Pont Hospital for Children Wilmington DE 19803 USA
| | - Peta M.A. Alexander
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Lead Perfusionist, Stanford Medicine Children’s Health 725 Welch Road Palo Alto CA 94304 USA
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Department of Cardiology, Boston Children’s Hospital and Department of Pediatrics Harvard Medical School Boston MA 02115 USA
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9
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Hayanga JWA, Chatterjee S, Kim BS, Merritt-Genore H, Karianna Milewski RC, Haft JW, Arora RC. Venovenous extracorporeal membrane oxygenation in patients with COVID-19 respiratory failure. J Thorac Cardiovasc Surg 2023; 165:212-217. [PMID: 34756623 PMCID: PMC8505026 DOI: 10.1016/j.jtcvs.2021.09.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Revised: 09/15/2021] [Accepted: 09/28/2021] [Indexed: 12/16/2022]
Affiliation(s)
- J W Awori Hayanga
- Department of Cardiothoracic and Vascular Surgery, West Virginia University Medicine, Morgantown, WVa.
| | - Subhasis Chatterjee
- Divisions of General and Cardiothoracic Surgery, Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Md
| | | | | | - Jonathan W Haft
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Mich
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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10
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Cascino TM, McCullough JS, Wu X, Pienta MJ, Stewart JW, Hawkins RB, Brescia AA, Abou el ala A, Zhang M, Noly PE, Haft JW, Cowger JA, Colvin M, Aaronson KD, Pagani FD, Likosky DS. Comparison of Evaluations for Heart Transplant Before Durable Left Ventricular Assist Device and Subsequent Receipt of Transplant at Transplant vs Nontransplant Centers. JAMA Netw Open 2022; 5:e2240646. [PMID: 36342716 PMCID: PMC9641540 DOI: 10.1001/jamanetworkopen.2022.40646] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 09/20/2022] [Indexed: 11/09/2022] Open
Abstract
Importance In 2020, the Centers for Medicare & Medicaid Services revised its national coverage determination, removing the requirement to obtain review from a Medicare-approved heart transplant center to implant a durable left ventricular assist device (LVAD) for bridge-to-transplant (BTT) intent at an LVAD-only center. The association between center-level transplant availability and access to heart transplant, the gold-standard therapy for advanced heart failure (HF), is unknown. Objective To investigate the association of center transplant availability with LVAD implant strategies and subsequent heart transplant following LVAD implant before the Centers for Medicare & Medicaid Services policy change. Design, Setting, and Participants A retrospective cohort study of the Society of Thoracic Surgeons Intermacs multicenter US registry database was conducted from April 1, 2012, to June 30, 2020. The population included patients with HF receiving a primary durable LVAD. Exposures LVAD center transplant availability (LVAD/transplant vs LVAD only). Main Outcomes and Measures The primary outcomes were implant strategy as BTT and subsequent transplant by 2 years. Covariates that might affect listing strategy and outcomes were included (eg, patient demographic characteristics, comorbidities) in multivariable models. Parameters for BTT listing were estimated using logistic regression with center-level random effects and for receipt of a transplant using a Cox proportional hazards regression model with death as a competing event. Results The sample included 22 221 LVAD recipients with a median age of 59.0 (IQR, 50.0-67.0) years, of whom 17 420 (78.4%) were male and 3156 (14.2%) received implants at LVAD-only centers. Receiving an LVAD at an LVAD/transplant center was associated with a 79% increased adjusted odds of BTT LVAD designation (odds ratio, 1.79; 95% CI, 1.35-2.38; P < .001). The 2-year transplant rate following LVAD implant was 25.6% at LVAD/transplant centers and 11.9% at LVAD-only centers. There was an associated 33% increased rate of transplant at LVAD/transplant centers compared with LVAD-only centers (adjusted hazard ratio, 1.33; 95% CI, 1.17-1.51) with a similar hazard for death at 2 years (adjusted hazard ratio, 0.99; 95% CI, 0.90-1.08). Conclusions and Relevance Receiving an LVAD at an LVAD-transplant center was associated with increased odds of BTT intent at implant and subsequent transplant receipt for patients at 2 years. The findings of this study suggest that Centers for Medicare & Medicaid Services policy change may have the unintended consequence of further increasing inequities in access to transplant among patients at LVAD-only centers.
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Affiliation(s)
- Thomas M. Cascino
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor
| | | | - Xiaoting Wu
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
| | - Michael J. Pienta
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - James W. Stewart
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - Robert B. Hawkins
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | | | - Ashraf Abou el ala
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor
| | | | - Jonathan W. Haft
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - Jennifer A. Cowger
- Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Monica Colvin
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor
| | - Keith D. Aaronson
- Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor
| | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
| | - Donald S. Likosky
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor
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11
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Noly PE, Duggal N, Jiang M, Nordsletten D, Bonini M, Lei I, Ela AAE, Haft JW, Pagani FD, Cascino TM, Tang PC. Role of the mitral valve in left ventricular assist device pathophysiology. Front Cardiovasc Med 2022; 9:1018295. [PMID: 36386343 PMCID: PMC9649705 DOI: 10.3389/fcvm.2022.1018295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 09/29/2022] [Indexed: 08/27/2023] Open
Abstract
Functional mitral regurgitation (MR) in the setting of heart failure results from progressive dilatation of the left ventricle (LV) and mitral annulus. This leads to leaflet tethering with posterior displacement. Contrary to common assumptions, MR often does not resolve with LVAD decompression of the LV alone. The negative impact of significant (moderate-severe) mitral regurgitation in the LVAD setting is becoming better recognized in terms of its harmful effect on right heart function, pulmonary vascular resistance and hospital readmissions. However, controversies remain regarding the threshold for intervention and management. At present, there are no consensus indications for the repair of significant mitral regurgitation at the time of LVAD implantation due to the conflicting data regarding potential adverse effects of MR on clinical outcomes. In this review, we summarize the current understanding of MR pathophysiology in patients supported with LVAD and potential future management strategies.
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Affiliation(s)
- Pierre-Emmanuel Noly
- Department of Cardiac Surgery, Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | - Neal Duggal
- Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Mulan Jiang
- Massachusetts Institute of Technology, Cambridge, MA, United States
| | - David Nordsletten
- Department of Biomedical Engineering and Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States
| | - Mia Bonini
- Department of Biomedical Engineering and Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States
| | - Ienglam Lei
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Ashraf Abou El Ela
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Jonathan W. Haft
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Francis D. Pagani
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Thomas M. Cascino
- Division of Cardiovascular Medicine, Department of Internal Medicine, School of Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, United States
| | - Paul C. Tang
- Department of Biomedical Engineering and Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, United States
- Department of Cardiac Surgery, School of Medicine, University of Michigan, Ann Arbor, MI, United States
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12
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Jones-Ungerleider KC, Rose A, Knott K, Comstock S, Haft JW, Pagani FD, Tang PC. Sex-based considerations for implementation of ventricular assist device therapy. Front Cardiovasc Med 2022; 9:1011192. [DOI: 10.3389/fcvm.2022.1011192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/13/2022] [Indexed: 11/13/2022] Open
Abstract
Women with advanced heart failure receive advanced surgical therapies such as durable left ventricular assist device (LVAD) implantation or heart transplantation at a rate much lower compared to males. Reasons for this discrepancy remain largely unknown. Much of what is understood reflects outcomes of those patients who ultimately receive device implant or heart transplantation. Females have been shown to have a higher mortality following LVAD implantation and experience higher rates of bleeding and clotting phenomena and right ventricular failure. Beyond outcomes, the literature is limited in the identification of pre-operative factors that drive lower than expected LVAD implant rates in this population. More focused research is needed to define the disparities in advance heart failure therapy delivery in women and other underserved populations.
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Tang PC, Haft JW, Lei I, Wang Z, Chen YE, Abou El Ela A, Wu X, Pitt B, Aaronson KD, Pagani FD. Impact of donor blood type on outcomes after prolonged allograft ischemic times. J Thorac Cardiovasc Surg 2022; 164:981-993.e8. [PMID: 33558115 DOI: 10.1016/j.jtcvs.2020.12.123] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 06/15/2020] [Revised: 11/29/2020] [Accepted: 12/23/2020] [Indexed: 12/26/2022]
Abstract
OBJECTIVE The study objective was to determine the influence of allograft ischemic time on heart transplant outcomes among ABO donor organ types given limited prior reports of its survival impact. METHODS We identified 32,454 heart transplants (2000-2016) from the United Network for Organ Sharing database. Continuous and categoric variables were analyzed by parametric and nonparametric testing. Survival was determined using log-rank or Cox regression tests. Propensity matching adjusted for preoperative variables. RESULTS By comparing allograft ischemic time less than 4 hours (n = 6579) with 4 hours or more (n = 25,875), the hazard ratios for death at 15 years after prolonged ischemic time (≥4 hours) for blood types O, A, B, and AB were 1.106 (P < .001), 1.062 (P < .001), 1.059 (P = .062), and 1.114 (P = .221), respectively. Unadjusted data demonstrated higher mortality for transplantation of O versus non-O donor hearts for ischemic time 4 hours or more (hazard ratio, 1.164; P < .001). After propensity matching, O donor hearts continued to have worse survival if preserved for 4 hours or more (hazard ratio, 1.137, P = .008), but not if ischemic time was less than 4 hours (hazard ratio, 1.042, P = .113). In a matched group with 4 hours or more of ischemic time, patients receiving O donor organs were more likely to experience death from primary graft dysfunction (2.5% vs 1.7%, P = .052) and chronic allograft rejection (1.9% vs 1.1%, P = .021). No difference in death from primary graft dysfunction or chronic allograft rejection was seen with less than 4 hours of ischemic time (P > .150). CONCLUSIONS Compared with non-O donor hearts, transplantation with O donor hearts with ischemic time 4 hours or more leads to worse survival, with higher rates of primary graft dysfunction and chronic rejection. Caution should be practiced when considering donor hearts with the O blood type when anticipating extended cold ischemic times.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich.
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Ienglam Lei
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Zhong Wang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Y Eugene Chen
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich; Division of Cardiovascular Medicine, Department of Internal Medicine, Ann Arbor, Mich
| | - Ashraf Abou El Ela
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Xiaoting Wu
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Bertram Pitt
- Division of Cardiovascular Medicine, Department of Internal Medicine, Ann Arbor, Mich
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, Ann Arbor, Mich
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
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14
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Schmitzberger FF, Haas NL, Coute RA, Bartos J, Hackmann A, Haft JW, Hsu CH, Hutin A, Lamhaut L, Marinaro J, Nagao K, Nakashima T, Neumar R, Pellegrino V, Shinar Z, Whitmore SP, Yannopoulos D, Peterson WJ. ECPR 2: Expert Consensus on PeRcutaneous Cannulation for Extracorporeal CardioPulmonary Resuscitation. Resuscitation 2022; 179:214-220. [PMID: 35817270 DOI: 10.1016/j.resuscitation.2022.07.003] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 06/16/2022] [Accepted: 07/04/2022] [Indexed: 12/22/2022]
Abstract
AIM Extracorporeal cardiopulmonary resuscitation (ECPR) has emerged as a promising resuscitation strategy for select patients suffering from refractory out-of-hospital cardiac arrest (OHCA), though limited data exist regarding the best practices for ECPR initiation after OHCA. METHODS We utilized a modified Delphi process consisting of two survey rounds and a virtual consensus meeting to systematically identify detailed best practices for ECPR initiation following adult non-traumatic OHCA. A modified Delphi process builds content validity and is an accepted method to develop consensus by eliciting expert opinions through multiple rounds of questionnaires. Consensus was achieved when items reached a high level of agreement, defined as greater than 80% responses for a particular item rated a 4 or 5 on a 5-point Likert scale. RESULTS Snowball sampling generated a panel of 14 content experts, composed of physicians from four continents and five primary specialties. Seven existing institutional protocols for ECPR cannulation following OHCA were identified and merged into a single comprehensive list of 207 items. The panel reached consensus on 101 items meeting final criteria for inclusion: Prior to Patient Arrival (13 items), Inclusion Criteria (8), Exclusion Criteria (7), Patient Arrival (8), ECPR Cannulation (21), Go On Pump (18), and Post-Cannulation (26). CONCLUSION We present a list of items for ECPR initiation following adult nontraumatic OHCA, generated using a modified Delphi process from an international panel of content experts. These findings may benefit centers currently performing ECPR in quality assurance and serve as a template for new ECPR programs.
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Affiliation(s)
| | - Nathan L Haas
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Department of Emergency Medicine, Division of Critical Care, Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
| | - Ryan A Coute
- Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine, Birmingham, AL, USA
| | - Jason Bartos
- Division of Cardiology, Department of Medicine, Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN, USA
| | - Amy Hackmann
- Department of Cardiovascular and Thoracic Surgery, UTSouthwestern, Parkland Hospital, Dallas, TX, USA
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Cindy H Hsu
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Department of Emergency Medicine, Division of Critical Care, Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
| | - Alice Hutin
- SAMU de Paris, Assistance Publique - Hôpitaux de Paris, Necker University Hospital, Paris, France
| | - Lionel Lamhaut
- SAMU de Paris, Assistance Publique - Hôpitaux de Paris, Necker University Hospital, Paris, France
| | - Jon Marinaro
- Department of Emergency Medicine, Division of Critical Care, University of New Mexico, Albuquerque, NM, USA
| | - Ken Nagao
- Department of Cardiology, Nihon University Hospital, Chiyoda-ku, Tokyo, Japan
| | - Takahiro Nakashima
- Department of Emergency Medicine, Division of Critical Care, Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
| | - Robert Neumar
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA; Department of Emergency Medicine, Division of Critical Care, Max Harry Weil Institute for Critical Care Research and Innovation, Ann Arbor, MI, USA
| | | | - Zack Shinar
- Department of Emergency Medicine, Sharp Memorial Hospital, San Diego CA, USA
| | - Sage P Whitmore
- Critical Care Medicine, TriStar Centennial Medical Center, Nashville, TN, USA
| | - Demetri Yannopoulos
- Division of Cardiology, Center for Resuscitation Medicine, University of Minnesota School of Medicine, Minneapolis, MN
| | - William J Peterson
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
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15
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Tang PC, Wu X, Zhang M, Likosky D, Haft JW, Lei I, Abou El Ela A, Si MS, Aaronson KD, Pagani FD. Determining optimal donor heart ischemic times in adult cardiac transplantation. J Card Surg 2022; 37:2042-2050. [PMID: 35488767 PMCID: PMC9325483 DOI: 10.1111/jocs.16558] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/15/2022] [Accepted: 04/01/2022] [Indexed: 11/29/2022]
Abstract
Objectives Unsupervised statistical determination of optimal allograft ischemic time (IT) on heart transplant outcomes among ABO donor heart types. Methods We identified 36,145 heart transplants (2000–2018) from the United Network for Organ Sharing database. Continuous and categorical variables were analyzed with parametric and nonparametric testing. Determination of IT cutoffs for survival analysis was performed using Contal and O'Quigley univariable method and Vito Muggeo multivariable segmented modeling. Results Univariable and multivariable IT threshold determination revealed a cutoff at about 3 h. The hourly increase in survival risk with ≥3 h IT is asymmetrically experienced at the early 90 days (hazard ratio [HR] = 1.29, p < .001) and up to 1‐year time point (HR = 1.16, p < .001). Beyond 1 year the risk of prolonged IT is less impactful (HR = 1.04, p = .022). Longer IT was associated with more postoperative complications such as stroke (2.7% vs. 2.3, p = .042), dialysis (11.6% vs. 9.1%, p < .001) and death from primary graft dysfunction (1.8% vs. 1.2%, p < .001). O blood type donor hearts with IT ≥ 3 h has significantly increased hourly mortality risk at 90 days (HR = 1.27, p < .001), 90 days to 1 year (HR = 1.22, p < .001) and >1 year (HR = 1.05, p = .041). For non‐O blood types with ≥3 h IT hourly mortality risk was increased at 90 days (HR = 1.33, p < .001), but not at 90 days to 1 year (HR = 1.09, p = .146) nor ≥1 year (HR = 1.08, p = .237). Conclusions The donor heart IT threshold for survival determined from unbiased statistical modeling occurs at 3 h. With longer preservation times, transplantation with O donor hearts was associated with worse survival.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Xiaoting Wu
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Min Zhang
- Department of Biostatistics, School of Public Health, University of Michigan, Ann Arbor, Ann Arbor, Michigan, USA
| | - Donald Likosky
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Ienglam Lei
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Ashraf Abou El Ela
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Ming-Sing Si
- Division of Cardiac Surgery, Department of Surgery, University of California, Los Angeles, California, USA
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
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16
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Bergquist CS, Wu X, McLaughlin VV, Rosati CM, Pretorius V, Likosky DS, Haft JW. Pulmonary Endarterectomy for Chronic Thromboembolic Pulmonary Hypertension: A STS Database Analysis. Ann Thorac Surg 2021; 114:2157-2162. [PMID: 34838740 DOI: 10.1016/j.athoracsur.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 10/03/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Chronic thromboembolic pulmonary hypertension (CTEPH) is optimally treated by pulmonary thromboendarterectomy (PEA). Treatment effectiveness has been evaluated principally using single-center series. Data from the Society of Thoracic Surgeons Adult Cardiac Surgery Database were used to evaluate a volume-outcomes relationship for PEA. METHODS Circulatory arrest procedures performed between 2012-2018 were identified through an STS-ACSD Participant User File. For descriptive purposes, total center procedural volume categories were computed: low (0-75th percentile, <16); medium (76-95th percentile, 16-100); high (>95th percentile, >100). Mixed effect modeling was used to evaluate the effect of center procedural volume (modeled continuously) on operative mortality, adjusting for preoperative risk factors, with centers as a random effect. RESULTS There were 1,358 cases performed across 64 centers [n/N: low (49/172); medium (12/527); high (3/659)], with 42 centers performing <10 operations during the period. Procedural volume increased 2.6-fold between 2012-2018 (94 versus 339), with 79% of the change in volume accounted for by 4 centers. The mean (IQR) preoperative pulmonary artery systolic value was 74 mmHg (57-88), with no difference (p=0.55) by center volume categories. In unadjusted analysis, patients at high volume centers required fewer transfusions, had shorter ventilator and intensive care unit (ICU) duration, lower frequency of postoperative extracorporeal membrane oxygenation (ECMO), and trended lower mortality (2.1% vs 5.2%, p=0.051). Operative mortality was lower at higher volume centers (ORadjusted,1-case-increase: 0.997; CI95%: 0.994-1.0; p=0.025). CONCLUSIONS Most PEA procedures are performed among a small number of centers, with high-volume hospitals having favorable outcomes. These data suggest a potential role for PEA regionalization.
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Affiliation(s)
- Curtis S Bergquist
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Xiaoting Wu
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Vallerie V McLaughlin
- Division of Cardiovascular Medicine, Department of Internal Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Carlo M Rosati
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Victor Pretorius
- Sulpizio Cardiovascular Center, University of California at San Diego, La Jolla, CA 92037
| | - Donald S Likosky
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109
| | - Jonathan W Haft
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI 48109.
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Swol J, Brodie D, Willers A, Zakhary B, Belezzo J, Shinar Z, Weingart SD, Haft JW, Lorusso R, Peek GJ. Human factors in ECLS - A keystone for safety and quality - A narrative review for ECLS providers. Artif Organs 2021; 46:40-49. [PMID: 34738639 PMCID: PMC9298045 DOI: 10.1111/aor.14095] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 08/12/2021] [Accepted: 10/20/2021] [Indexed: 12/13/2022]
Abstract
INTRODUCTION Although the technology used for extracorporeal life support (ECLS) has improved greatly in recent years, the application of these devices to the patient is quite complex and requires extensive training of team members both individually and together. Human factors is an area that addresses the activities, contexts, environments, and tools which interact with human behavior in determining overall system performance. HYPOTHESIS Analyses of the cognitive behavior of ECLS teams and individual members of these teams with respect to the occurrence of human errors may identify additional opportunities to enhance safety in delivery of ECLS. RESULTS The aim of this article is to support health-care practitioners who perform ECLS, or who are starting an ECLS program, by establishing standards for the safe and efficient use of ECLS with a focus on human factor issues. Other key concepts include the importance of ECLS team leadership and management, as well as controlling the environment and the system to optimize patient care. CONCLUSION Expertise from other industries is extrapolated to improve patient safety through the application of simulation training to reduce error propagation and improve outcomes.
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Affiliation(s)
- Justyna Swol
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Paracelsus Medical University, Nuremberg, Germany
| | - Daniel Brodie
- Department of Medicine and Center for Acute Respiratory Failure, Columbia University College of Physicians and Surgeons/New York-Presbyterian Hospital, New York, New York, USA
| | - Anne Willers
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Bishoy Zakhary
- Division of Pulmonary and Critical Care Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Joseph Belezzo
- Emergency Room Sharp Memorial Hospital, San Diego, California, USA
| | - Zachary Shinar
- Emergency Room Sharp Memorial Hospital, San Diego, California, USA
| | - Scott D Weingart
- Department of Emergency Medicine, Division of Emergency Critical Care, Resuscitation and Acute Critical Care Unit, Stony Brook Hospital, Stony Brook, New York, USA
| | - Jonathan W Haft
- Department of Surgery, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Roberto Lorusso
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Giles J Peek
- UF Health Shands Children's Hospital, UF Health Congenital Heart Center, Gainesville, Florida, USA
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18
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Tang PC, Duggal NM, Haft JW, Romano MA, Bolling SF, Abou El Ela A, Wu X, Colvin MM, Aaronson KD, Pagani FD. Left Ventricular Assist Device Implantation in Patients with Preoperative Severe Mitral Regurgitation. ASAIO J 2021; 67:1139-1147. [PMID: 34570728 DOI: 10.1097/mat.0000000000001379] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We examined cardiac features associated with residual mitral regurgitation (MR) following continuous-flow left ventricular assist device (cfLVAD) implant. From 2003 to 2017, 134 patients with severe MR underwent cfVLAD implant without mitral valve (MV) intervention. Echocardiographic (echo) assessment occurred pre-cfLVAD, early post-cfLVAD, and at last available echo. Ventricular and atrial volumes were calculated from established formulas and normalized to be predicted. Cluster analysis based on preoperative normalized left ventricular and atrial volumes, and MV height identified grades 1, 2, and 3 with progressively larger cardiac chamber sizes. Median early echo follow-up was 0.92 (0.55, 1.45) months and the last follow-up was 15.12 (5.28, 38.28) months. Mitral regurgitation improved early after cfLVAD by 2.10 ± 1.16 grades (p < 0.01). Mitral regurgitation severity at the last echocardiogram positively correlated with the preoperative left ventricular volume (p = 0.014, R = 0.212), left atrial volume (p = 0.007, R = 0.233), MV anteroposterior height (p = 0.032, R = 0.185), and MV mediolateral diameter (p = 0.043, R = 0.175). Morphologically, smaller grade 1 hearts were correlated with MR resolution at the late follow-up (p = 0.023). Late right ventricular failure (RVF) at the last clinical follow-up was less in grade 1 (4/48 [8.3%]) compared with grades 2 and 3 (26/86 [30.2%]), p = 0.004). Grade 1 cardiac dimensions correlates with improvement in severe MR and had less late RVF.
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Affiliation(s)
| | | | | | | | | | | | | | - Monica M Colvin
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Keith D Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
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Tang PC, Lei I, Pagani FD, Haft JW. Response to letter by Miyauchi et al. J Card Surg 2021; 36:3987-3988. [PMID: 34232522 DOI: 10.1111/jocs.15790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 06/26/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Ienglam Lei
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
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20
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Tang PC, Lei I, Chen YE, Wang Z, Ailawadi G, Romano MA, Salvi S, Aaronson KD, Si MS, Pagani FD, Haft JW. Risk factors for heart transplant survival with greater than 5 h of donor heart ischemic time. J Card Surg 2021; 36:2677-2684. [PMID: 34018246 DOI: 10.1111/jocs.15621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/01/2021] [Accepted: 03/09/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Implantation of donor hearts with prolonged ischemic times is associated with worse survival. We sought to identify risk factors that modulate the effects of prolonged preservation. METHODS Retrospective review of the United Network for Organ Sharing database (2000-2018) to identify transplants with >5 (n = 1526) or ≤5 h (n = 35,733) of donor heart preservation. In transplanted hearts preserved for >5 h, Cox-proportional hazards identify modifiers for survival. RESULTS Compared to ≤5 h, transplanted patients with >5 h of preservation spent less time in status 1B (76 ± 160 vs. 85 ± 173 days, p = .027), more commonly had ischemic cardiomyopathy (42.3% vs. 38.3%, p = .002), and less commonly received a blood type O heart (45.4% vs. 50.8%, p < .001). Longer heart preservation time was associated with a higher incidence of postoperative stroke (4.5% vs. 2.5%, p < .001), and dialysis (16.4% vs. 10.6%, p < .001). Prolonged preservation was associated with a greater likelihood of death from primary graft dysfunction (2.8% vs. 1.5%, p < .001) but there was no difference in death from acute (2.0% vs. 1.7%, p = .402) or chronic rejection (2.0% vs. 1.9%, p = .618). In transplanted patients with >5 h of heart preservation, multivariable analysis identified greater mortality with ischemic cardiomyopathy etiology (hazard ratio [HR] = 1.36, p < 0.01), pre-transplant dialysis (HR = 1.84, p < .01), pre-transplant extracorporeal membrane oxygenation (ECMO, HR = 2.36, p = .09), and O blood type donor hearts (HR = 1.35, p < .01). CONCLUSION Preservation time >5 h is associated with worse survival. This mortality risk is further amplified by preoperative dialysis and ECMO, ischemic cardiomyopathy etiology, and use of O blood type donor hearts.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Ienglam Lei
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Y E Chen
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Zhong Wang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Shachi Salvi
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Keith D Aaronson
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Ming-Sing Si
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
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21
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Hsu CH, Meurer WJ, Domeier R, Fowler J, Whitmore SP, Bassin BS, Gunnerson KJ, Haft JW, Lynch WR, Nallamothu BK, Havey RA, Kidwell KM, Stacey WC, Silbergleit R, Bartlett RH, Neumar RW. Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest (EROCA): Results of a Randomized Feasibility Trial of Expedited Out-of-Hospital Transport. Ann Emerg Med 2021; 78:92-101. [PMID: 33541748 PMCID: PMC8238799 DOI: 10.1016/j.annemergmed.2020.11.011] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 11/08/2020] [Accepted: 11/16/2020] [Indexed: 01/14/2023]
Abstract
STUDY OBJECTIVE Outcomes of extracorporeal cardiopulmonary resuscitation (ECPR) for out-of-hospital cardiac arrest depend on time to therapy initiation. We hypothesize that it would be feasible to select refractory out-of-hospital cardiac arrest patients for expedited transport based on real-time estimates of the 911 call to the emergency department (ED) arrival interval, and for emergency physicians to rapidly initiate ECPR in eligible patients. METHODS In a 2-tiered emergency medical service with an ECPR-capable primary destination hospital, adults with refractory shockable or witnessed out-of-hospital cardiac arrest were randomized 4:1 to expedited transport or standard care if the predicted 911 call to ED arrival interval was less than or equal to 30 minutes. The primary outcomes were the proportion of subjects with 911 call to ED arrival less than or equal to 30 minutes and ED arrival to ECPR flow less than or equal to 30 minutes. RESULTS Of 151 out-of-hospital cardiac arrest 911 calls, 15 subjects (10%) were enrolled. Five of 12 subjects randomized to expedited transport had an ED arrival time of less than or equal to 30 minutes (overall mean 32.5 minutes [SD 7.1]), and 5 were eligible for and treated with ECPR. Three of 5 ECPR-treated subjects had flow initiated in less than or equal to 30 minutes of ED arrival (overall mean 32.4 minutes [SD 10.9]). No subject in either group survived with a good neurologic outcome. CONCLUSION The Extracorporeal Cardiopulmonary Resuscitation for Refractory Out-of-Hospital Cardiac Arrest trial did not meet predefined feasibility outcomes for selecting out-of-hospital cardiac arrest patients for expedited transport and initiating ECPR in the ED. Additional research is needed to improve the accuracy of predicting the 911 call to ED arrival interval, optimize patient selection, and reduce the ED arrival to ECPR flow interval.
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Affiliation(s)
- Cindy H Hsu
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI; Department of Surgery, University of Michigan Medical School, Ann Arbor, MI.
| | - William J Meurer
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI; Department of Neurology, University of Michigan Medical School, Ann Arbor, MI
| | - Robert Domeier
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Saint Joseph Hospital, University of Michigan Medical School, Ann Arbor, MI
| | - Jennifer Fowler
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Sage P Whitmore
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Benjamin S Bassin
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI
| | - Kyle J Gunnerson
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - William R Lynch
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI
| | - Brahmajee K Nallamothu
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Renee A Havey
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Kelley M Kidwell
- Department of Biostatistics, University of Michigan Medical School, Ann Arbor, MI
| | - William C Stacey
- Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Robert Silbergleit
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI
| | - Robert H Bartlett
- Department of Surgery, University of Michigan Medical School, Ann Arbor, MI; Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
| | - Robert W Neumar
- Department of Emergency Medicine, University of Michigan Medical School, Ann Arbor, MI; Michigan Center for Integrative Research in Critical Care, University of Michigan Medical School, Ann Arbor, MI; Extracorporeal Life Support Laboratory, University of Michigan Medical School, Ann Arbor, MI
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22
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Tang PC, Duggal NM, Haft JW, Aaronson KD, Pagani FD. Fate of preoperative moderate mitral regurgitation following left ventricular assist device implantation. J Card Surg 2021; 36:1843-1849. [PMID: 33604994 DOI: 10.1111/jocs.15428] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Accepted: 02/04/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We examined for improvements in preoperative moderate mitral regurgitation following continuous-flow left ventricular assist device (cfLVAD) implantation. METHODS From 2006 to 2020, 190 patients with moderate MR underwent cfVLAD implant without concomitant mitral valve (MV) surgery. Cardiac dimensions and contractility, as well as valve function, were assessed with an echocardiogram (echo) pre-cfLVAD, and at approximately 1 month post-cfLVAD. Outcomes were determined by retrospective chart review. RESULTS Median echo follow-up was 0.94 (0.53, 1.38) months. Residual significant moderate or greater MR was present in 30/190 (15.8%) on follow-up. Patients with significant residual MR had larger preoperative left ventricular internal diameters in diastole (74.4 ± 8.7 vs. 71.1.0 ± 9.1 mm, p = .034). Significant residual MR was associated with higher preoperative mean pulmonary artery pressures (OR = 1.055, p = .035) and pulmonary capillary wedge pressures (OR = 1.060, p = .034). Significant residual MR on echo was not associated with any survival difference (p = .325). The 1, 5, and 10 year survival were 89.9%, 55.2%, and 34.2%, respectively. CONCLUSIONS For patients with moderate MR undergoing LVAD implantation, the likelihood of significant residual MR is low and mitral intervention in this population is not recommended. However, select patients with larger preoperative left heart dimensions and pulmonary vascular pressures may be at risk for persistent residual MR.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Neal M Duggal
- Department of Anesthesiology, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Keith D Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
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23
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Carr BD, Johnson TJ, Gomez-Rexrode A, Mohammed A, Coughlin M, Toomasian JM, Rojas-Pena A, Bartlett RH, Haft JW. Inflammatory Effects of Blood-Air Interface in a Porcine Cardiopulmonary Bypass Model. ASAIO J 2020; 66:72-78. [PMID: 30585871 DOI: 10.1097/mat.0000000000000938] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Cardiopulmonary bypass (CPB) causes a systemic inflammatory response syndrome (SIRS) associated with multiorgan injury. A model was developed to test whether a blood-air interface (BAI) in the CPB circuit causes blood element activation and inflammation. Ten healthy swine were placed on partial CPB for 2 hours via the cervical vessels and monitored for 96 hours postoperatively. Five pigs (control group) had minimal air exposure in the circuit, while five were exposed to a BAI simulating cardiotomy suction. There were no significant differences in bypass flow or hemodynamics between the groups. In the BAI group, there was an increase in hemolysis after bypass (plasma-free hemoglobin 5.27 ± 1.2 vs. 0.94 ± 0.8 mg/dl; p = 0.01), more aggressive platelet consumption (28% vs. 83% of baseline; p = 0.009), leukocyte consumption (71% vs. 107% of baseline; p = 0.02), and increased granulocyte CD11b expression (409% vs. 106% of baseline; p = 0.009). These data suggest the inflammatory pattern responsible for the CPB-SIRS phenomenon may be driven by blood-air interaction. Future efforts should focus on BAI-associated mechanisms for minimizing blood trauma and inflammation during CPB.
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Affiliation(s)
- Benjamin D Carr
- From the Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Thomas J Johnson
- From the Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Amalia Gomez-Rexrode
- From the Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Azmath Mohammed
- From the Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Megan Coughlin
- From the Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - John M Toomasian
- From the Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Alvaro Rojas-Pena
- From the Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Robert H Bartlett
- From the Extracorporeal Life Support Laboratory, Department of Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Jonathan W Haft
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
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24
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Arora RC, Hassan A, Haft JW. Reply: Have we done the best that we could have done? J Thorac Cardiovasc Surg 2020; 160:e149-e151. [PMID: 32800268 PMCID: PMC7423581 DOI: 10.1016/j.jtcvs.2020.05.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/18/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Rakesh C Arora
- Department of Surgery, Max Rady College of Medicine, University of Manitoba, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Canada
| | - Ansar Hassan
- Department of Cardiac Surgery, New Brunswick Heart Centre, Saint John, New Brunswick, Canada
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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25
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Engelman DT, Lother S, George I, Funk DJ, Ailawadi G, Atluri P, Grant MC, Haft JW, Hassan A, Legare JF, Whitman GJR, Arora RC. Adult Cardiac Surgery and the COVID-19 Pandemic: Aggressive Infection Mitigation Strategies Are Necessary in the Operating Room and Surgical Recovery. Ann Thorac Surg 2020; 110:707-711. [PMID: 32353440 PMCID: PMC7185911 DOI: 10.1016/j.athoracsur.2020.04.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 04/16/2020] [Indexed: 01/08/2023]
Abstract
The COVID-19 pandemic necessitates aggressive infection mitigation strategies to reduce the risk to patients and healthcare providers. This document is intended to provide a framework for the adult cardiac surgeon to consider in this rapidly changing environment. Preoperative, intraoperative, and postoperative detailed protective measures are outlined. These are guidance recommendations during a pandemic surge to be used for all patients while local COVID-19 disease burden remains elevated.
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Affiliation(s)
- Daniel T Engelman
- Heart and Vascular Program, Baystate Health, and University of Massachusetts Medical School-Baystate, Springfield, Massachusetts.
| | - Sylvain Lother
- Sections of Critical Care and Infectious Diseases, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Isaac George
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York, New York
| | - Duane J Funk
- Section of Critical Care, Departments of Anesthesiology and Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gorav Ailawadi
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Ansar Hassan
- New Brunswick Heart Centre, Saint John, New Brunswick, Canada
| | | | - Glenn J R Whitman
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
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26
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Engelman DT, Lother S, George I, Ailawadi G, Atluri P, Grant MC, Haft JW, Hassan A, Legare JF, Whitman G, Arora RC. Ramping Up Delivery of Cardiac Surgery During the COVID-19 Pandemic: A Guidance Statement From The Society of Thoracic Surgeons COVID-19 Task Force. Ann Thorac Surg 2020; 110:712-717. [PMID: 32407853 PMCID: PMC7215160 DOI: 10.1016/j.athoracsur.2020.05.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 11/24/2022]
Abstract
The coronavirus disease 2019 (COVID-19) pandemic has had a profound global impact. Its rapid transmissibility has transformed healthcare delivery and forced countries to adopt strict measures to contain its spread. The vast majority of the United States cardiac surgical programs have deferred all but truly emergent/urgent operative procedures in an effort to reduce the burden on the healthcare system and to mobilize resources to combat the pandemic surge. While the number of COVID-19 cases continue to increase worldwide, the incidence of new cases has begun to decline in many North American cities. This "flattening of the curve" has prompted interest in reopening the economy, relaxing public health restrictions, and resuming nonurgent healthcare delivery. The following document provides a template whereby adult cardiac surgical programs may begin to ramp-up the care delivery in a deliberate and graded fashion as the COVID-19 pandemic burden begins to ease. "Resuscitating" the timely delivery of care is guided by three principles: (1) Collaborate to permit increased case volumes, balancing the clinical needs of patients awaiting surgical procedures with the local resources available within each healthcare system. (2) Prioritize patients awaiting elective procedures while proactively engaging all stakeholders, focusing on those with high-risk anatomy, changing/symptomatic clinical status, and, once these variables have been addressed, prioritizing by waiting times. (3) Reevaluate local conditions continuously to assess for any increase in admissions due to a recrudescence of cases, to assure adequate resources to care for patients, and to monitor in-hospital infectious transmissions to both patients and healthcare workers.
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Key Words
- as, aortic stenosis
- asd, atrial septal defect
- cabg, coronary artery bypass grafting
- cad, coronary artery disease
- chf, congestive heart failure
- covid-19, coronavirus disease 2019
- ecmo, extracorporeal membrane oxygenation
- ef, ejection fraction
- elso, extracorporeal life support organization
- icu, intensive care unit
- lad, left anterior descending artery
- lm, left main artery
- los, length of stay
- mr, mitral regurgitation
- naat, nucleic acid amplification testing
- pcr, polymerase chain reaction
- pfo, patent foramen ovale
- ppe, personal protective equipment
- tavr, transcatheter aortic valve replacement
- vad, ventricular assist device
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Affiliation(s)
- Daniel T Engelman
- Heart and Vascular Program, Baystate Health and University of Massachusetts Medical School-Baystate, Springfield, Massachusetts.
| | - Sylvain Lother
- Sections of Critical Care and Infectious Diseases, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Isaac George
- Division of Cardiothoracic Surgery, New York Presbyterian Hospital-Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York, New York
| | - Gorav Ailawadi
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Ansar Hassan
- New Brunswick Heart Centre, Saint John, New Brunswick, Canada
| | | | - Glenn Whitman
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
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27
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Mathis MR, Likosky DS, Haft JW, Maile MD, Blank RS, Colquhoun DA, Janda AM, Kheterpal S, Engoren MC. Lung-protective Ventilation in Cardiac Surgery: Reply. Anesthesiology 2020; 132:1611-1613. [PMID: 32287045 PMCID: PMC7774650 DOI: 10.1097/aln.0000000000003294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Engelman DT, Lother S, George I, Funk DJ, Ailawadi G, Atluri P, Grant MC, Haft JW, Hassan A, Legare JF, Whitman GJR, Arora RC. Adult cardiac surgery and the COVID-19 pandemic: Aggressive infection mitigation strategies are necessary in the operating room and surgical recovery. J Thorac Cardiovasc Surg 2020; 160:447-451. [PMID: 32689700 PMCID: PMC7185923 DOI: 10.1016/j.jtcvs.2020.04.059] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 04/16/2020] [Indexed: 12/15/2022]
Abstract
The COVID-19 pandemic necessitates aggressive infection mitigation strategies to reduce the risk to patients and healthcare providers. This document is intended to provide a framework for the adult cardiac surgeon to consider in this rapidly changing environment. Preoperative, intraoperative, and postoperative detailed protective measures are outlined. These are guidance recommendations during a pandemic surge to be used for all patients while local COVID-19 disease burden remains elevated.
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Affiliation(s)
- Daniel T Engelman
- Heart and Vascular Program, Baystate Health, and University of Massachusetts Medical School-Baystate, Springfield, Massachusetts.
| | - Sylvain Lother
- Sections of Critical Care and Infectious Diseases, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Isaac George
- Division of Cardiothoracic Surgery, Columbia University College of Physicians and Surgeons, New York Presbyterian Hospital, New York, New York
| | - Duane J Funk
- Section of Critical Care, Departments of Anesthesiology and Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Gorav Ailawadi
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Ansar Hassan
- New Brunswick Heart Centre, Saint John, New Brunswick, Canada
| | | | - Glenn J R Whitman
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada
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29
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Haft JW, Atluri P, Ailawadi G, Engelman DT, Grant MC, Hassan A, Legare JF, Whitman GJR, Arora RC. Adult Cardiac Surgery During the COVID-19 Pandemic: A Tiered Patient Triage Guidance Statement. Ann Thorac Surg 2020; 110:697-700. [PMID: 32305286 PMCID: PMC7161520 DOI: 10.1016/j.athoracsur.2020.04.003] [Citation(s) in RCA: 85] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/08/2020] [Indexed: 12/21/2022]
Abstract
In the setting of the current novel coronavirus pandemic, this document has been generated to provide guiding statements for the adult cardiac surgeon to consider in a rapidly evolving national landscape. Acknowledging the risk for a potentially prolonged need for cardiac surgery procedure deferral, we have created this proposed template for physicians and interdisciplinary teams to consider in protecting their patients, institution, and their highly specialized cardiac surgery team. In addition, recommendations on the transition from traditional in-person patient assessments and outpatient follow-up are provided. Lastly, we advocate that cardiac surgeons must continue to serve as leaders, experts, and relevant members of our medical community, shifting our role as necessary in this time of need.
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Affiliation(s)
- Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gorav Ailawadi
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Daniel T Engelman
- University of Massachusetts Medical School-Baystate, Springfield, Massachusetts
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ansar Hassan
- New Brunswick Heart Centre, Saint John, New Brunswick, Canada
| | | | - Glenn J R Whitman
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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30
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Haft JW, Atluri P, Ailawadi G, Engelman DT, Grant MC, Hassan A, Legare JF, Whitman GJR, Arora RC. Adult cardiac surgery during the COVID-19 pandemic: A tiered patient triage guidance statement. J Thorac Cardiovasc Surg 2020; 160:452-455. [PMID: 32689701 PMCID: PMC7161470 DOI: 10.1016/j.jtcvs.2020.04.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 04/08/2020] [Indexed: 01/19/2023]
Abstract
In the setting of the current novel coronavirus pandemic, this document has been generated to provide guiding statements for the adult cardiac surgeon to consider in a rapidly evolving national landscape. Acknowledging the risk for a potentially prolonged need for cardiac surgery procedure deferral, we have created this proposed template for physicians and interdisciplinary teams to consider in protecting their patients, institution, and their highly specialized cardiac surgery team. In addition, recommendations on the transition from traditional in-person patient assessments and outpatient follow-up are provided. Lastly, we advocate that cardiac surgeons must continue to serve as leaders, experts, and relevant members of our medical community, shifting our role as necessary in this time of need.
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Affiliation(s)
- Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Pavan Atluri
- Division of Cardiovascular Surgery, Department of Surgery, University of Pennsylvania, Philadelphia, Pa
| | - Gorav Ailawadi
- Department of Surgery, University of Virginia, Charlottesville, Va
| | - Daniel T Engelman
- University of Massachusetts Medical School-Baystate, Springfield, Mass
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, Md
| | - Ansar Hassan
- New Brunswick Heart Centre, Saint John, New Brunswick, Canada
| | | | - Glenn J R Whitman
- Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, Md
| | - Rakesh C Arora
- Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
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31
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Mokbel M, Zamani H, Lei I, Chen YE, Romano MA, Aaronson KD, Haft JW, Pagani FD, Tang PC. Histidine-Tryptophan-Ketoglutarate Solution for Donor Heart Preservation Is Safe for Transplantation. Ann Thorac Surg 2020; 109:763-770. [PMID: 31470011 DOI: 10.1016/j.athoracsur.2019.07.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Revised: 05/16/2019] [Accepted: 07/01/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Various solutions are used for donor heart preservation. We examined the outcomes in our heart transplant population where histidine-tryptophan-ketoglutarate (HTK) solution has been used for heart preservation since 2004. METHODS This was a retrospective review of the United Network for Organ Sharing (UNOS) database (2004-2016) comparing our heart transplant outcomes with other national centers. Propensity matching in a 1:3 ratio was performed to adjust for preoperative recipient variables. RESULTS After propensity matching comparing UNOS outcomes (n = 1080) with our institutional data (n = 360), there was no difference in matched preoperative variables. Donor hearts were similar for donor age, sex, donor-to-recipient size ratio, LVEF, and ischemic time. Our HTK cohort had a larger proportion with donor cardiac arrest (26.3% vs 6.1%, P < .001) and longer cardiac arrest duration (22.1 ± 16.0 vs 17.2 ± 14.0 minutes, P = .052). Our primary graft dysfunction (PGD) rate requiring mechanical support was 4.2% (n = 1). Postoperative mechanical support use for PGD included extracorporeal membrane oxygenation in 9 (60.0%), intraaortic balloon pump in 4 (26.7%), right ventricular assist device in 3 (20%), and biventricular assist device in 3 (20%). Overall survival at our institution was similar to the national average (P = .649). Survival at 1, 5, and 10 years with HTK was 92.2%, 81.3%, and 70.8%, and for the UNOS population was 91.6%, 80.3%, and 62.0%, respectively. CONCLUSIONS Use of HTK solution for donor hearts was associated with a low rate of severe PGD. Overall survival was not significantly different from other institutions using a variety of preservation solutions in the UNOS database during the same period. HTK solution is efficacious for preservation of donor hearts.
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Affiliation(s)
| | | | | | | | | | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
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Tang PC, Sarsour N, Haft JW, Romano MA, Konerman M, Colvin M, Koelling T, Aaronson KD, Pagani FD. Aortic Valve Repair Versus Replacement Associated With Durable Left Ventricular Assist Devices. Ann Thorac Surg 2020; 110:1259-1264. [PMID: 32105716 DOI: 10.1016/j.athoracsur.2020.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 12/16/2019] [Accepted: 01/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Aortic valve (AV) repair (AVr) using a central coaptation stitch or bioprosthetic AV replacement (AVR) are most commonly performed at the time of durable left ventricular assist device implant to address AV insufficiency (AI). METHODS Prospective data collection on 46 patients undergoing left ventricular assist device implant from 2007 through 2018 who received concomitant AVr (n = 40) or AVR (n = 6) was retrospectively analyzed to assess freedom from recurrent aortic insufficiency. Paired Wilcoxon rank-sum test was used to compare echocardiographic findings. Mantel-Cox statistics were used to analyze survival. RESULTS For AVr, central coaptation led to a mean decrease in AI severity by 2.1 ± 1.0 grades (P < .001). Three patients (7.5%) had recurrence of at least moderate AI by 3 years. In comparison, all patients in the AVR group had mild or less AI on subsequent follow-up. Success of AVr in downgrading AI severity was associated with a smaller aortic root diameter (P = .011) and sinotubular junction diameter (P = .003). An aortic root diameter greater than 3.5 cm was predictive of less improvement in AI severity compared with 3.5 cm or less (1.83 ± 1.03 versus 2.47 ± 0.80 grades of improvement; P = .038). Duration of cardiopulmonary bypass was 32 minutes longer and duration of aortic cross-clamp was 38 minutes longer for AVR versus AVr cohorts. No difference in 30-day (P = .418) or overall survival (P = .572) between the AVr and AVR groups was seen. CONCLUSIONS Aortic valve repair for addressing AI has a recurrence rate of 7.5% at 3 years. Success in downgrading AI is more likely with a smaller aortic root. No difference in survival was observed between AVr and AVR.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan.
| | - Nadeen Sarsour
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Matthew Konerman
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Monica Colvin
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Todd Koelling
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Keith D Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
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Haft JW. Commentary: Can we finally move the needle in organ donation? J Thorac Cardiovasc Surg 2019; 159:514. [PMID: 31420146 DOI: 10.1016/j.jtcvs.2019.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 07/05/2019] [Indexed: 11/19/2022]
Affiliation(s)
- Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
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Whitmore SP, Gunnerson KJ, Haft JW, Lynch WR, VanDyck T, Hebert C, Waldvogel J, Havey R, Weinberg A, Cranford JA, Rooney DM, Neumar RW. Simulation training enables emergency medicine providers to rapidly and safely initiate extracorporeal cardiopulmonary resuscitation (ECPR) in a simulated cardiac arrest scenario. Resuscitation 2019; 138:68-73. [PMID: 30862530 DOI: 10.1016/j.resuscitation.2019.03.002] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/23/2019] [Accepted: 03/04/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Extracorporeal cardiopulmonaryresuscitation (ECPR) is emerging as a viable rescue strategy for refractory out-of-hospital cardiac arrest. In the U.S., limited training of emergency medicine providers is a barrier to widespread implementation. AIMS Test the hypothesis that emergency medicine physicians and nurses can acquire and retain the skills to rapidly and safely initiate ECPR using high-fidelity simulation. STUDY DESIGN Prospective interventional study. SETTING U.S. tertiary academic medical center. SUBJECTS Emergency medicine physicians and nurses with no prior ECPR/ECMO experience. METHODS Teams of three physicians and three nurses underwent a two-day ECPR training course including didactics, hands-on training, and simulation. Teams were videotaped initiating ECPR in a high-fidelity simulation scenario before and after simulation training. The primary outcome was the proportion of simulations in which full ECPR support was achieved within 30 min of patient arrival. RESULTS Five teams completed the entire study. Full ECPR support was achieved within 30 min of patient arrival in 11/15, 15/15, and 15/15 attempts at baseline (B), post-testing (PT) and 3-month post-testing (3-PT), respectively (p = 0.06). Intervals (mean ± sd) required to achieve full ECPR support at B, PT, and 3-PT were 25.8±5.3, 17.2±4.6, and 19.2±1.9 min respectively (p < 0.05 for B vs. PT and 3-PT). CONCLUSION High fidelity simulation training is effective in preparing emergency medicine physicians and nurses to rapidly and safely initiate ECPR in a simulated cardiac arrest scenario, and should be considered when implementing an ED-based ECPR program.
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Affiliation(s)
- Sage P Whitmore
- Department of Emergency Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA; The Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Kyle J Gunnerson
- Department of Emergency Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA; The Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA; The Extracorporeal Life Support Program, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - William R Lynch
- Department of Surgery, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA; The Extracorporeal Life Support Program, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Tyler VanDyck
- Department of Emergency Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Christopher Hebert
- Department of Emergency Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - John Waldvogel
- The Extracorporeal Life Support Program, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Renee Havey
- Department of Emergency Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Allison Weinberg
- The Extracorporeal Life Support Program, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - James A Cranford
- Department of Psychiatry, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Deborah M Rooney
- Department of Learning Health Sciences, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Robert W Neumar
- Department of Emergency Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA; The Michigan Center for Integrative Research in Critical Care (MCIRCC), University of Michigan Medical School, Michigan Medicine, Ann Arbor, Michigan, USA.
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Tang PC, Haft JW, Romano MA, Bitar A, Hasan R, Palardy M, Aaronson KD, Pagani FD. Right ventricular failure following left ventricular assist device implantation is associated with a preoperative pro-inflammatory response. J Cardiothorac Surg 2019; 14:80. [PMID: 31023326 PMCID: PMC6482580 DOI: 10.1186/s13019-019-0895-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 01/22/2019] [Accepted: 04/01/2019] [Indexed: 01/20/2023] Open
Abstract
Background Systemic inflammation during implant of a durable left ventricular assist device (LVAD) may contribute to adverse outcomes. We investigated the association of the preoperative inflammatory markers with subsequent right ventricular failure (RVF). Materials and methods Prospective data was collected on 489 patients from 2003 through 2017 who underwent implantation of a durable LVAD. Uni- and multivariable correlation with leukocytosis was determined using linear and binary logistic regression. The population was also separated into low (< 10.5 K/ul, n = 362) and high (> 10.5 K/ul, n = 127) white blood cell count (WBC) groups. Mantel-Cox statistics was used to analyze survival data. Results Postop RVF was associated with a higher preop WBC (11.3 + 5.7 vs 8.7 + 3.1) and C-reactive protein (CRP, 5.6 + 4.4 vs 3.3 + 4.7) levels. Multivariable analysis identified an independent association between increased WBC preoperatively with increased lactate dehydrogenase (LDH, P < 0.001), heart rate (P < 0.001), CRP (P = 0.006), creatinine (P = 0.048), and INR (P = 0.049). The high WBC group was more likely to be on preoperative temporary circulatory support (17.3% vs 6.4%, P < 0.001) with a trend towards greater use of an intra-aortic balloon pump (55.9% vs 47.2%, P = 0.093). The high WBC group had poorer mid-term survival (P = 0.042). Conclusions Postop RVF is associated with a preoperative pro-inflammatory environment. This may be secondary to the increased systemic stress of decompensated heart failure. Systemic inflammation in the decompensated heart failure may contribute to RVF after LVAD implant.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, 5158 Cardiovascular Center, SPC 5864, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5864, USA.
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, 5158 Cardiovascular Center, SPC 5864, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5864, USA
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, 5158 Cardiovascular Center, SPC 5864, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5864, USA
| | - Abbas Bitar
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Reema Hasan
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Maryse Palardy
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, 5158 Cardiovascular Center, SPC 5864, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5864, USA
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Tang PC, Haft JW, Romano MA, Bitar A, Hasan R, Palardy M, Wu X, Aaronson KD, Pagani FD. Right ventricular function and residual mitral regurgitation after left ventricular assist device implantation determines the incidence of right heart failure. J Thorac Cardiovasc Surg 2019; 159:897-905.e4. [PMID: 31101350 DOI: 10.1016/j.jtcvs.2019.03.089] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 02/19/2019] [Accepted: 03/26/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The effect of significant mitral regurgitation (MR) on outcomes after continuous flow left ventricular assist device (cfLVAD) implantation remains unclear. METHODS We performed a retrospective review of prospectively collected data from 159 patients with preoperative severe MR who underwent cfLVAD implantation (2003-2017). Two-step cluster analysis using the log-likelihood distance for post-cfLVAD implantation parameters, which included right ventricular (RV) dysfunction, MR severity, and tricuspid regurgitation (TR) severity. Post-cfLVAD implantation echocardiographic parameters were obtained within the first month. RESULTS Cluster analysis resulted in 3 groups. Group 1 (n = 67) had mild or less MR with moderate-severe RV dysfunction (RVD). Group 2 (n = 43) had moderate-severe MR with moderate-severe RVD. Group 3 (n = 49) had moderate MR with mild RVD. Group 2 had the largest proportion with Interagency Registry for Mechanically Assisted Circulatory Support score of 1 (30.2%) and 2 (41.9%). They were more likely to undergo temporary mechanical circulatory support (18.6%) and tricuspid valve procedure (62.8%). Group 2 had the highest rate of stroke (30.2%; P = .02), hemolysis (39.5%; P = .01), device thrombosis (30%; P = .01), and worst survival (46.5%; P = .01). Survival at 5 years for groups 1, 2, and 3 were 56.0%, 17.6%, and 55.8%. Regression analysis of the entire population showed that greater MR severity after cfLVAD was associated with RV failure (P < .05; odds ratio, 1.6) and RV assist device use (P = .09; odds ratio, 1.6). After excluding tricuspid valve repairs, MR severity had a positive correlation with TR severity (R = 0.33; P < .01). CONCLUSIONS After cfLVAD implantation, moderate-severe MR and RVD predicted RV failure. Patients with preoperative moderate-severe MR and TR coupled with moderate-severe RVD might benefit the most from mitral and tricuspid valve intervention.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich.
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Abbas Bitar
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Reema Hasan
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Maryse Palardy
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Xiaoting Wu
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
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Stojanovska J, Lumeng CN, Griffin C, Hernando D, Hoffmann U, Haft JW, Kim KM, Burant CF, Singer K, Tsodikov A, Long BD, Romano MA, Tang PC, Yang B, Chenevert TL. Water-fat magnetic resonance imaging quantifies relative proportions of brown and white adipose tissues: ex-vivo experiments. J Med Imaging (Bellingham) 2018; 5:024007. [PMID: 30137870 PMCID: PMC6025480 DOI: 10.1117/1.jmi.5.2.024007] [Citation(s) in RCA: 2] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 06/08/2018] [Indexed: 12/12/2022] Open
Abstract
Quantifying the amount of brown adipose tissue (BAT) within white adipose tissue (WAT) in human depots may serve as a target to combat obesity. We aimed to quantify proton density fat fraction (PDFF) of BAT and WAT in relatively pure and in mixed preparation using water–fat imaging. Three ex-vivo experiments were performed at 3 T using excised interscapular BAT and inguinal/subcutaneous WAT from mice. The first two experiments consisted of BAT and WAT in separate tubes, and the third used mixed preparation with graded quantities of BAT and WAT. To investigate the influence of partial volume on PDFF metrics, low (2.66 mm3) and high spatial resolution (0.55 mm3 acquired voxels) in two orthogonal three-dimensional sections were compared. The low-resolution acquisitions are corrected for T2* and multipeak lipid spectrum, thus considered “quantitative,” whereas the high-resolution acquisitions are not corrected but were performed to better spatially segment BAT from WAT zones. As potential BAT metrics, we quantified the average PDFF and the volume of tissue having PDFF ≤50% (VOLPDFF≤50%) based on the PDFF histogram. In the first experiment, the average PDFF of BAT was 23±6% and 21±7.6% and the average PDFF of WAT was 76±7% and 87±7% using high- and low-resolution techniques, respectively. A similar trend with excellent reproducibility in average PDFF of BAT and WAT was observed in the second experiment. In the third experiment over the four acquisitions, the BAT-dominant tube demonstrated lower PDFF (mean ± SD) of 55±2% than WAT-dominant (69±4%) and WAT-only tubes (88±4%). Estimating VOLPDFF≤50%, the BAT-dominant tube demonstrated higher volume of 0.26 cm3 than WAT-dominant (0.16 cm3) and WAT-only tubes (0.01 cm3). The presence of BAT exhibits a lower PDFF relative to WAT, thus allowing segmentation of low PDFF tissue for quantification of volume representative of BAT. Future studies will determine the clinical relevance of BAT volume within human depots.
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Affiliation(s)
- Jadranka Stojanovska
- Michigan Medicine, Division of Cardiothoracic Radiology, Department of Radiology, Ann Arbor, Michigan, United States
| | - Carey N Lumeng
- Michigan Medicine, Department of Pediatrics and Molecular Physiology, Ann Arbor, Michigan, United States
| | - Cameron Griffin
- Michigan Medicine, Division of Pediatric Endocrinology, Ann Arbor, Michigan, United States
| | - Diego Hernando
- University of Wisconsin, Wisconsin Institutes for Medical Research, Medical Physics Department, Madison, Wisconsin, United States
| | - Udo Hoffmann
- Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts, United States
| | - Jonathan W Haft
- Michigan Medicine, Frankel Cardiovascular Center, Department of Cardiac Surgery, Ann Arbor, Michigan, United States
| | - Karen M Kim
- Michigan Medicine, Frankel Cardiovascular Center, Department of Cardiac Surgery, Ann Arbor, Michigan, United States
| | | | - Kanakadurga Singer
- Michigan Medicine, Division of Pediatric Endocrinology, Department of Pediatrics and Communicable Diseases, Ann Arbor, Michigan, United States
| | - Alex Tsodikov
- School of Public Health, Ann Arbor, Michigan, United States
| | - Benjamin D Long
- University of Michigan Medical School, Cardiovascular Center, Ann Arbor, Michigan, United States
| | - Matthew A Romano
- Michigan Medicine, Cardiovascular Center, Ann Arbor, Michigan, United States
| | - Paul C Tang
- Michigan Medicine, Cardiovascular Center, Ann Arbor, Michigan, United States
| | - Bo Yang
- Michigan Medicine, Cardiovascular Center, Ann Arbor, Michigan, United States
| | - Thomas L Chenevert
- Michigan Medicine, Department of Radiology-MRI, Ann Arbor, Michigan, United States
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38
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Haft JW. What is the best tool for rescue? J Thorac Cardiovasc Surg 2018; 155:1069-1070. [PMID: 29452459 DOI: 10.1016/j.jtcvs.2017.12.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2017] [Accepted: 12/04/2017] [Indexed: 11/13/2022]
Affiliation(s)
- Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
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Peer SM, Deatrick KB, Johnson TJ, Haft JW, Pagani FD, Ohye RG, Bove EL, Rojas-Peña A, Si MS. Mechanical Circulatory Support for the Failing Fontan: Conversion to Assisted Single Ventricle Circulation—Preliminary Observations. World J Pediatr Congenit Heart Surg 2018; 9:31-37. [DOI: 10.1177/2150135117733968] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background: Mechanical circulatory support (MCS) of a failing Fontan circulation remains challenging. We hypothesized that MCS can be provided by converting the Fontan circulation into a mechanically assisted single ventricle parallel circulation (MASVC). Methods: A porcine model of functionally univentricular circulation was created under cardiopulmonary bypass (CPB) by performing an atrial septectomy, tricuspid valvectomy, and interrupting antegrade pulmonary blood flow. A centrifugal flow pump was placed with inflow from the common atrium. Eight millimeter Dacron grafts anastomosed to the ascending aorta and main pulmonary artery supplied systemic (Qs) and pulmonary (Qp) blood flow. Ultrasonic flow probes were used to measure Qs and Qp after weaning from CPB. The Qp/Qs ratio was regulated using an adjustable clamp. Hemodynamic and laboratory data were recorded. Results: All four animals were successfully weaned from CPB onto the MASVC for a duration of two hours. Mechanically assisted single ventricle parallel circulation achieved satisfactory hemodynamics. As anticipated, the arterial oxygen saturation and partial pressure of oxygen in arterial blood were lower in the MASVC compared to baseline biventricular circulation. At the conclusion of the study, there was a trend towards a decrease in the mixed venous saturation with increasing oxygen extraction compared to the baseline. Serum lactate levels increased after weaning from CPB and did not return to baseline after two hours of support. Conclusion: Mechanically assisted single ventricle parallel circulation can be established in a single ventricle animal model. This strategy could potentially provide MCS of a single ventricle circulation. Studies with longer duration of support are required to assess adequacy of support and long-term sustainability.
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Affiliation(s)
- Syed M. Peer
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
- Department of Pediatric Cardiac Surgery, University of Minnesota, Minneapolis, MN, USA
| | - Kristopher B. Deatrick
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Thomas J. Johnson
- Department of Surgery-Section of Transplantation, ECMO Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Jonathan W. Haft
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Francis D. Pagani
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Richard G. Ohye
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Edward L. Bove
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Alvaro Rojas-Peña
- Department of Surgery-Section of Transplantation, ECMO Laboratory, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Ming-Sing Si
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, MI, USA
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Qin Y, Zajda J, Brisbois EJ, Ren H, Toomasian JM, Major TC, Rojas-Pena A, Carr B, Johnson T, Haft JW, Bartlett RH, Hunt AP, Lehnert N, Meyerhoff ME. Portable Nitric Oxide (NO) Generator Based on Electrochemical Reduction of Nitrite for Potential Applications in Inhaled NO Therapy and Cardiopulmonary Bypass Surgery. Mol Pharm 2017; 14:3762-3771. [DOI: 10.1021/acs.molpharmaceut.7b00514] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Affiliation(s)
- Yu Qin
- Department of Chemistry and ‡Department of
Surgery, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Joanna Zajda
- Department of Chemistry and ‡Department of
Surgery, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Elizabeth J. Brisbois
- Department of Chemistry and ‡Department of
Surgery, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Hang Ren
- Department of Chemistry and ‡Department of
Surgery, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - John M. Toomasian
- Department of Chemistry and ‡Department of
Surgery, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Terry C. Major
- Department of Chemistry and ‡Department of
Surgery, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Alvaro Rojas-Pena
- Department of Chemistry and ‡Department of
Surgery, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Benjamin Carr
- Department of Chemistry and ‡Department of
Surgery, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Thomas Johnson
- Department of Chemistry and ‡Department of
Surgery, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Jonathan W. Haft
- Department of Chemistry and ‡Department of
Surgery, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Robert H. Bartlett
- Department of Chemistry and ‡Department of
Surgery, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Andrew P. Hunt
- Department of Chemistry and ‡Department of
Surgery, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Nicolai Lehnert
- Department of Chemistry and ‡Department of
Surgery, University of Michigan, Ann Arbor, Michigan 48109, United States
| | - Mark E. Meyerhoff
- Department of Chemistry and ‡Department of
Surgery, University of Michigan, Ann Arbor, Michigan 48109, United States
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Engoren M, Maile MD, Heung M, Jewell ES, Vahabzadeh C, Haft JW, Kheterpal S. The Association Between Urine Output, Creatinine Elevation, and Death. Ann Thorac Surg 2017; 103:1229-1237. [DOI: 10.1016/j.athoracsur.2016.07.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 07/04/2016] [Accepted: 07/11/2016] [Indexed: 11/28/2022]
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Camaj A, Wu X, Zhang M, Engoren M, Haft JW, Likosky DS. Abstract 141: Increasing Storage Age of Transfused Red Blood Cell Units Is Not Associated with Cardiac Surgical Outcomes. Circ Cardiovasc Qual Outcomes 2017. [DOI: 10.1161/circoutcomes.10.suppl_3.141] [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] [Indexed: 11/16/2022]
Abstract
Introduction:
First-in, first-out institutional blood management practices are based on evidence associating increased risk of sequelae from exposure to older red blood cell (RBC) transfusions. Nonetheless, research to date within the setting of cardiac surgery has been limited by previously unmeasured confounding (i.e., use of leukoreduction, timing and volume transfused).
Hypothesis:
After accounting for exposure to leukoreduction and the timing and volume of RBC units, older RBC units will not increase a patient’s odds of developing post-operative sequelae following cardiac surgery.
Methods:
We reviewed 659 adult patients undergoing CABG and/or valve operations between January 1, 2008-December 31, 2015 at a tertiary center. During this time period, all RBCs given to cardiac surgery patients were leukoreduced. To address confounding by timing and volume of RBCs, we analyzed patients receiving 1 or 2 units of RBCs intraoperatively. Logistic regression was used to model the maximum storage age of RBCs against a composite endpoint (prolonged mechanical ventilation, pneumonia, renal failure, operative mortality). We further explored any differences when modeling age of RBCs as quintiles and dichotomously (≥14 vs. <14 days). We present our results using odds ratios and 95% confidence intervals.
Results:
The average maximum storage age of RBCs ranged from 5 to 42 days (mean 20.8, sd: 7.0). The primary endpoint occurred among 122 (18.5%) subjects. There was neither a significant association between increasing age of RBCs and our composite endpoint (OR 1.0; 95% CI 0.98, 1.04), nor evidence of confounding in univariate analysis. These findings were qualitatively unchanged when modeling age of RBCs as quintiles (Figure;
ptrend
=0.50) or dichotomously (OR 1.6; 95% CI 0.88, 2.79).
Conclusion:
In this single center study, we did not detect a significant adverse effect of increasing age of RBCs contrary to prior conclusions. Our findings suggest that current institutional RBC storage policies that prioritize distribution of older age RBC units may not adversely impact patient outcomes following cardiac surgery.
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Turer DM, Koch KL, Koelling TM, Wu AH, Pagani FD, Haft JW. Comparing the Effectiveness of an Axial and a Centrifugal Left Ventricular Assist Device in Ventricular Unloading. ASAIO J 2016; 62:652-656. [DOI: 10.1097/mat.0000000000000420] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Si MS, Pagani FD, Haft JW. Use of the total artificial heart as a bridge to transplant in a 13-year-old with congenitally corrected transposition of the great arteries. J Thorac Cardiovasc Surg 2016; 151:e71-3. [DOI: 10.1016/j.jtcvs.2015.11.049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 11/23/2015] [Accepted: 11/28/2015] [Indexed: 11/27/2022]
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Haft JW. Going the distance with success: An attempted argument that less is not always more. J Thorac Cardiovasc Surg 2015; 151:528-9. [PMID: 26586357 DOI: 10.1016/j.jtcvs.2015.10.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 10/17/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
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Seelhammer TG, Maile MD, Heung M, Haft JW, Jewell ES, Engoren M. Kinetic estimated glomerular filtration rate and acute kidney injury in cardiac surgery patients. J Crit Care 2015; 31:249-54. [PMID: 26700609 DOI: 10.1016/j.jcrc.2015.11.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 09/28/2015] [Accepted: 11/06/2015] [Indexed: 11/29/2022]
Abstract
PURPOSE To determine how a formula to estimate kinetically changing glomerular filtration rate (keGFR) relates to serum creatinine changes and to compare the discriminatory ability of keGFR to that of perioperative change in serum creatinine to predict acute kidney injury (AKI) and mortality. MATERIALS AND METHODS Retrospective cohort study at a single-tertiary-care Midwestern university hospital of 4022 patients admitted to the intensive care unit between January 2006 and January 2012 immediately after cardiac surgery. MEASUREMENTS AND MAIN RESULTS Of 4022 patients, 1031 (25.6%) developed at least AKI stage 1 and 1106 (27.5%) developed AKI-min. Patients who developed AKI stage 1 or AKI-min had a greater decrease in keGFR, both by absolute amounts and by percentage. After adjusting for other factors with logistic regression, keGFR had good discrimination (c statistic = 0.787 and 0.749, respectively) in predicting AKI and operative mortality. CONCLUSION Despite no change in immediate perioperative serum creatinine levels, keGFR fell and this predicted subsequent AKI. Using keGFR enables identification of patients who, despite unchanged postoperative creatinine, incur clinically significant kidney injury based on reduction in GFR and increased mortality.
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Affiliation(s)
| | | | - Michael Heung
- Anesthesiology & Critical Care, Mayo Clinic, Rochester, MN
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Hannawa KK, Good ED, Haft JW, Williams DM. Percutaneous Extraction of Embolized Intracardiac Inferior Vena Cava Filter Struts Using Fused Intracardiac Ultrasound and Electroanatomic Mapping. J Vasc Interv Radiol 2015; 26:1368-74. [DOI: 10.1016/j.jvir.2015.05.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2015] [Revised: 05/07/2015] [Accepted: 05/08/2015] [Indexed: 02/02/2023] Open
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Mazur DE, Bartlett RH, Haft JW. Reply: To PMID 24856794. Ann Thorac Surg 2015; 99:2256. [PMID: 26046900 DOI: 10.1016/j.athoracsur.2015.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 03/05/2015] [Accepted: 03/16/2015] [Indexed: 11/29/2022]
Affiliation(s)
- Daniel E Mazur
- Michigan Critical Care Consultants, Inc, Ann Arbor, Michigan
| | | | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Health System, 1500 E Medical Center Dr, SPC 5864, Ann Arbor, MI 48109.
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Haft JW. Are devices for temporary mechanical circulatory support getting safer? J Thorac Cardiovasc Surg 2015; 150:e43-4. [PMID: 26145766 DOI: 10.1016/j.jtcvs.2015.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2015] [Accepted: 06/03/2015] [Indexed: 11/18/2022]
Affiliation(s)
- Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
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Swol J, Belohlávek J, Haft JW, Ichiba S, Lorusso R, Peek GJ. Conditions and procedures for in-hospital extracorporeal life support (ECLS) in cardiopulmonary resuscitation (CPR) of adult patients. Perfusion 2015; 31:182-8. [PMID: 26081929 DOI: 10.1177/0267659115591622] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The use of extracorporeal life support (ECLS) in cardiopulmonary resuscitation (CPR; ECPR) has been repeatedly published as non-randomized studies, mainly case series and case reports. The aim of this article is to support physicians, perfusionists, nurses and extracorporeal membrane oxygenation (ECMO) specialists who regularly perform ECPR or are willing to start an ECPR program by establishing standards for safe and efficient ECPR procedures. This article represents the experience and recommendations of physicians who provide ECPR routinely. Based on its survival and outcome rates, ECPR can be considered when determining the optimal treatment of patients who require CPR. The successful performance of ECLS cannulation during CPR is a life-saving measure and has been associated with improved outcome (including neurological outcome) after CPR. We summarize the general structure of an ECLS team and describe the cannulation procedure and the approaches for post-resuscitation care. The differences in hospital organizations and their regulations may result in variations of this model.
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Affiliation(s)
- Justyna Swol
- Surgical Critical Care, Department of Surgery, Surgical Intensive Care Unit, University Hospital Bergmannsheil Bochum, Bochum, Germany
| | - Jan Belohlávek
- Coronary Care Unit, 2nd Department of Medicine, Cardiovascular Medicine, General Teaching Hospital, Charles University in Prague, Prague, Czech Republic
| | - Jonathan W Haft
- Department of Community and Emergency Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Shingo Ichiba
- Cardiac Surgery & Anesthesia, Extra Corporeal Life Support Program, Cardiovascular Intensive Care Units, University of Michigan Health System, Ann Arbor, MI, USA
| | - Roberto Lorusso
- U.O. Cardiochirugia-Spedali Civili, Piazzale Spedali Civili, Brescia, Italy
| | - Giles J Peek
- Cardiothoracic Surgery & ECMO, East Midlands Congenital Heart Centre, Paediatric & Adult ECMO Programme, Glenfield Hospital, Leicester, UK
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