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Seadler BD, Melamed J, Sow M, Rogers AL, Syed A, Linsky PL, Ubert HA, Schena S, Durham LA, Almassi GH. A model for delivery of extracorporeal life support in a stand-alone veterans affairs medical center. Artif Organs 2024. [PMID: 38321771 DOI: 10.1111/aor.14722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 01/09/2024] [Accepted: 01/23/2024] [Indexed: 02/08/2024]
Abstract
INTRODUCTION For the Veterans Health Administration (VHA) to continue to perform complex cardiothoracic surgery, there must be an established pathway for providing urgent/emergent extracorporeal life support (ECLS). Partnership with a nearby tertiary care center with such expertise may be the most resource-efficient way to provide ECLS services to patients in post-cardiotomy cardiogenic shock or respiratory failure. The goal of this project was to assess the efficiency, safety, and outcomes of surgical patients who required transfer for perioperative ECLS from a single stand-alone Veterans Affairs Medical Center (VAMC) to a separate ECLS center. METHODS Cohort consisted of all cardiothoracic surgery patients who experienced cardiogenic shock or refractory respiratory failure at the local VAMC requiring urgent or emergent institution of ECLS between 2019 and 2022. The primary outcomes are the safety and timeliness of transport. RESULTS Mean time from the initial shock call to arrival at the ECLS center was 2.8 h. There were no complications during transfer. Six patients (86%) survived to decannulation. CONCLUSION These results suggest that complex cardiothoracic surgery can be performed within the VHA system and when there is an indication for ECLS, those services can be safely and effectively provided at an affiliated, properly equipped center.
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Affiliation(s)
- Benjamin D Seadler
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Cardiothoracic Surgery, Clement J Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Joshua Melamed
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Cardiothoracic Surgery, Clement J Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Mami Sow
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Austin L Rogers
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Cardiothoracic Surgery, Clement J Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Ali Syed
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Paul L Linsky
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Cardiothoracic Surgery, Clement J Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - H Adam Ubert
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stefano Schena
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Cardiothoracic Surgery, Clement J Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
| | - Lucian A Durham
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - G Hossein Almassi
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
- Cardiothoracic Surgery, Clement J Zablocki Veterans Affairs Medical Center, Milwaukee, Wisconsin, USA
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Sow M, Seadler BD, Chandratre SR, Koratala A, Carlson SF, Joyce LD, Kohmoto T, Durham LA, Joyce DL. Supporting the right ventricle in postcardiotomy renal dysfunction: A case series. Clin Case Rep 2023; 11:e7695. [PMID: 37465241 PMCID: PMC10350664 DOI: 10.1002/ccr3.7695] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 06/05/2023] [Accepted: 06/27/2023] [Indexed: 07/20/2023] Open
Abstract
Postcardiotomy RV dysfunction is an under-recognized cause of acute kidney injury (AKI). Insertion of a percutaneous right ventricular assist device (RVAD) reduces central venous hypertension and congestive nephropathy by augmenting cardiac output. In selected patients, percutaneous RVAD insertion may improve renal function and obviate the need for long-term dialysis.
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Affiliation(s)
- Mami Sow
- Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Benjamin D. Seadler
- Division of Cardiothoracic SurgeryFroedtert & Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Sonal R. Chandratre
- Department of Pediatric EndocrinologyAspirus HealthStevens PointWisconsinUSA
| | - Abhilash Koratala
- Division of NephrologyFroedtert & Medical College of WisconsinMilwaukeeWisconsinUSA
| | | | - Lyle D. Joyce
- Division of Cardiothoracic SurgeryFroedtert & Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Takushi Kohmoto
- Division of Cardiothoracic SurgeryFroedtert & Medical College of WisconsinMilwaukeeWisconsinUSA
| | - Lucian A. Durham
- Division of Cardiothoracic SurgeryFroedtert & Medical College of WisconsinMilwaukeeWisconsinUSA
| | - David L. Joyce
- Division of Cardiothoracic SurgeryFroedtert & Medical College of WisconsinMilwaukeeWisconsinUSA
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Kamalia MA, Carlson SF, Melamed J, Ubert A, Rossi PJ, Durham LA. Adhered ECMO cannula in COVID-19 related severe acute respiratory failure. J Cardiothorac Surg 2022; 17:263. [PMID: 36209244 PMCID: PMC9547677 DOI: 10.1186/s13019-022-02004-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 09/27/2022] [Indexed: 11/10/2022] Open
Abstract
Background Crescent cannula adhesion in the setting of COVID-19 respiratory failure requiring extracorporeal membrane oxygenation (ECMO) support is a novel complication. The objective of this case presentation is to highlight this rare complication and to explore potential predisposing factors and our management strategies. Case presentation We present the case of a 25 y.o. patient with COVID-19 respiratory failure requiring ECMO support for 16-days in which a 32 Fr crescent cannula became adherent to the SVC and proximal jugular vein. Attempts to remove the cannula at the bedside failed due to immobility of the cannula. Ultrasound of the right neck was unremarkable, so he was taken to the hybrid OR where both TEE and fluoroscopy were unrevealing. An upper sternotomy was performed, and the superior vena cava and proximal jugular vein were dissected revealing a 2 cm segment of the distal SVC and proximal jugular vein that was densely sclerosed and adherent to the cannula. The vessel was opened across the adherent area at the level of the innominate vein and the cannula was then able to be withdrawn. The patient suffered no ill effects and had an unremarkable recovery to discharge. Conclusions To date, there have been no reports of crescent cannula adhesion related complications. In patients with COVID-19 respiratory failure requiring ECMO, clinicians should be aware of widespread hypercoagulability and the potential of unprovoked, localized venous sclerosis and cannula adhesion. We report our technique of decannulation in the setting of cannula adhesion and hope that presentation will shed further light on this complication allowing clinicians to optimize patient care.
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Affiliation(s)
| | | | - Joshua Melamed
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, HUB for Collaborative Medicine, 5th Floor, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA.
| | - Adam Ubert
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, HUB for Collaborative Medicine, 5th Floor, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
| | - Peter J Rossi
- Department of Surgery, Division of Vascular and Endovascular Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Lucian A Durham
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, HUB for Collaborative Medicine, 5th Floor, 8701 Watertown Plank Rd., Milwaukee, WI, 53226, USA
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Smith NJ, Park S, Zundel MT, Dong H, Szabo A, Cain MT, Durham LA. Extracorporeal membrane oxygenation for COVID-19: an evolving experience through multiple waves. Artif Organs 2022; 46:2257-2265. [PMID: 35957490 PMCID: PMC9538401 DOI: 10.1111/aor.14381] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 07/28/2022] [Accepted: 07/29/2022] [Indexed: 12/12/2022]
Abstract
Background Extracorporeal membrane oxygenation (ECMO) has shown variable results in COVID‐19 pneumonia however, some evidence supports benefit. Here we compare our institution's ECMO outcomes across multiple waves of the COVID‐19 pandemic. Methods All patients who received ECMO for COVID‐19 between March 1, 2020, and March 1, 2021, were reviewed. Patients received venovenous (VV) or right ventricular assist device (RVAD/ECMO) ECMO. Early (March 1–July 6, 2020, Era 1) and late (July 7, 2020–March 1, 2021, Era 2) pandemic RVAD/ECMO patients were compared. Results Fifty‐four patients received ECMO of which 16 (29.6%) patients received VV ECMO and 38 (70.4%) RVAD/ECMO. Median age was 53.0 years, body mass index 36.1 kg/m2, 41.2% female, and 49% Caucasian. The most common pre‐cannulation treatments included steroids (79.6%) and convalescent plasma (70.4%). Median time from admission to cannulation was 7.0 days. Median support time was 30.5 days (VV ECMO 35.0 days, RVAD/ECMO 26.0 days). In‐ hospital mortality was 42.6% (39.5% RVAD/ECMO, 50.0% VV ECMO). Significant morbidities included infection (80.8%), bleeding events (74.5%), and renal replacement therapy (30.8%). Cumulative mortality 120‐days post‐cannulation was 45.7% (VV ECMO 60.8%, RVAD/ECMO 40.0%). RVAD/ECMO Era 1 demonstrated a significantly lower cumulative mortality (16.2%) compared to Era 2 (60.4%). Competing risk analysis found age (HR 0.95, [95% CI 0.92, 0.98] p = 0.005) to be a protective factor for survival. Conclusion ECMO support for COVID‐19 is beneficial but carries significant morbidity. RVAD/ECMO support demonstrated consistent advantages in survival to VV‐ECMO, but with declining efficacy across time during the COVID‐19 pandemic.
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Affiliation(s)
- Nathan J Smith
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Sarah Park
- Department of Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - M Tracy Zundel
- Department of Anesthesiology, Division of Critical Care Anesthesia, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Huaying Dong
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Aniko Szabo
- Department of Biostatistics, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Michael T Cain
- Department of Surgery, Division of Cardiothoracic Surgery, University of Colorado Anschutz School of Medicine, Aurora, CO, USA
| | - Lucian A Durham
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI, USA
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Park SY, Smith NJ, Dong H, Szabo A, Zundel T, Durham LA. COV8: Characterization, Contributing Factors, And Outcomes Of Bleeding Complication In Extracorporeal Membrane Oxygenation for SARS-CoV-2 Pneumonia: A Single-Institution Experience. ASAIO J 2022. [DOI: 10.1097/01.mat.0000841084.40700.8c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Abstract
Microaxial left ventricular assist devices (mLVADs) have traditionally been placed through a transfemoral or transaxillary arterial approach. Transfemoral access is restrictive, significantly limiting postoperative patient ambulation. Transaxillary placement is preferred but not feasible in a subset of patients due to small arterial diameter or tight angulation of the thoracic outlet. Transcarotid delivery has been utilized for other cardiovascular device deployment with good success; however, this approach has not been described for mLVAD support. We present a case series of transcarotid placement of mLVADs in cases where a transaxillary and transfemoral approach was not feasible. From May 2017 to April 2019, six patients in cardiogenic shock required mLVAD support achieved via a transcarotid approach. Technical success was achieved in all patients. One patient was directly weaned from mLVAD support and two patients died on mLVAD support. Escalation to venoarterial extracorporeal membrane oxygenation (VA-ECMO) was required for three patients, two of whom subsequently died. There were no bleeding or valvular complications related to device placement, and no obvious or known neurologic complications related to mLVAD support. Transcarotid placement of mLVADs expands the utility of these devices as an alternative to traditional support strategies or prohibitive arterial anatomy; however, further study is needed to determine its efficacy.
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Affiliation(s)
- Adhitya Ramamurthi
- From the Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael T Cain
- From the Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nathan Smith
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Angelia Espinal
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David L Joyce
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Asim Mohammed
- Lutheran Health Network, Advanced Heart Failure, Fort Wayne, Indiana
| | - Lyle D Joyce
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lucian A Durham
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Smith NJ, Nance BA, Durham LA, McAlarnen LA, Bishop EA, Zundel MT. Extracorporeal Membrane Oxygenator Failure in a Patient With Gestational Trophoblastic Neoplasm: Possible Mechanisms and Considerations in Critical Care. J Cardiothorac Vasc Anesth 2021; 36:2583-2587. [PMID: 34649807 DOI: 10.1053/j.jvca.2021.09.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Revised: 09/22/2021] [Accepted: 09/27/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Nathan J Smith
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI.
| | - Beth A Nance
- Department of Anesthesiology, Division of Critical Care Anesthesia, Medical College of Wisconsin, Milwaukee, WI
| | - Lucian A Durham
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Lindsey A McAlarnen
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - Erin A Bishop
- Department of Obstetrics and Gynecology, Division of Gynecologic Oncology, Medical College of Wisconsin, Milwaukee, WI
| | - M Tracy Zundel
- Department of Anesthesiology, Division of Critical Care Anesthesia, Medical College of Wisconsin, Milwaukee, WI
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Nelson DW, Sundararajan S, Klein E, Joyce LD, Durham LA, Joyce DL, Mohammed AA. Sustained Use of the Impella 5.0 Heart Pump Enables Bridge to Clinical Decisions in 34 Patients. Tex Heart Inst J 2021; 48:469168. [PMID: 34388239 DOI: 10.14503/thij-20-7260] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
We studied whether sustained hemodynamic support (>7 d) with the Impella 5.0 heart pump can be used as a bridge to clinical decisions in patients who present with cardiogenic shock, and whether such support can improve their outcomes. We retrospectively reviewed cases of patients who had Impella 5.0 support at our hospital from August 2017 through May 2019. Thirty-four patients (23 with cardiogenic shock and 11 with severely decompensated heart failure) underwent sustained support for a mean duration of 11.7 ± 9.3 days (range, ≤48 d). Of 29 patients (85.3%) who survived to next therapy, 15 were weaned from the Impella, 8 underwent durable left ventricular assist device placement, 4 were escalated to venoarterial extracorporeal membrane oxygenation support, and 2 underwent heart transplantation. The 30-day survival rate was 76.5% (26 of 34 patients). Only 2 patients had a major adverse event: one each had an ischemic stroke and flail mitral leaflet. None of the devices malfunctioned. Sustained hemodynamic support with the Impella 5.0 not only improved outcomes in patients who presented with cardiogenic shock, but also provided time for multidisciplinary evaluation of potential cardiac recovery, or the need for durable left ventricular assist device implantation or heart transplantation. Our study shows the value of using the Impella 5.0 as a bridge to clinical decisions.
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Affiliation(s)
- Daniel W Nelson
- Division of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sakthi Sundararajan
- Division of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Evan Klein
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lyle D Joyce
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lucian A Durham
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David L Joyce
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Asim A Mohammed
- Division of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
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Miles B, Durham LA, Kurman J, Joyce LD, Johnstone DW, Joyce D, Pearson PJ. Venovenous Extracorporeal Membrane Oxygenation to Facilitate Removal of Endobronchial Tumors. Tex Heart Inst J 2021; 48:467735. [PMID: 34243188 DOI: 10.14503/thij-19-7111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Short-term extracorporeal membrane oxygenation is a useful adjunct to thoracic procedures. We report the cases of 2 middle-aged men who were supported with venovenous extracorporeal membrane oxygenation to facilitate tumor debulking and recanalization of the carina and mainstem bronchi. Neither patient had major complications or adverse events. These cases suggest that short-term extracorporeal membrane oxygenation is safe in patients undergoing complex resection or debulking of endobronchial lesions.
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Affiliation(s)
- Bryan Miles
- School of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lucian A Durham
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Jonathan Kurman
- Division of Pulmonary Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lyle D Joyce
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David W Johnstone
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Joyce
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Paul J Pearson
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Cain MT, Smith NJ, Barash M, Simpson P, Durham LA, Makker H, Roberts C, Falcucci O, Wang D, Walker R, Ahmed G, Brown SA, Nanchal RS, Joyce DL. Extracorporeal Membrane Oxygenation with Right Ventricular Assist Device for COVID-19 ARDS. J Surg Res 2021; 264:81-89. [PMID: 33789179 PMCID: PMC7969863 DOI: 10.1016/j.jss.2021.03.017] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [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: 12/14/2020] [Revised: 03/02/2021] [Accepted: 03/10/2021] [Indexed: 01/08/2023]
Abstract
Background: Right ventricular failure is an underrecognized consequence of COVID-19 pneumonia. Those with severe disease are treated with extracorporeal membrane oxygenation (ECMO) but with poor outcomes. Concomitant right ventricular assist device (RVAD) may be beneficial. Methods: A retrospective analysis of intensive care unit patients admitted with COVID-19 ARDS (Acute Respiratory Distress Syndrome) was performed. Nonintubated patients, those with acute kidney injury, and age > 75 were excluded. Patients who underwent RVAD/ECMO support were compared with those managed via invasive mechanical ventilation (IMV) alone. The primary outcome was in-hospital mortality. Secondary outcomes included 30-d mortality, acute kidney injury, length of ICU stay, and duration of mechanical ventilation. Results: A total of 145 patients were admitted to the ICU with COVID-19. Thirty-nine patients met inclusion criteria. Of these, 21 received IMV, and 18 received RVAD/ECMO. In-hospital (52.4 versus 11.1%, P = 0.008) and 30-d mortality (42.9 versus 5.6%, P= 0.011) were significantly lower in patients treated with RVAD/ECMO. Acute kidney injury occurred in 15 (71.4%) patients in the IMV group and zero RVAD/ECMO patients (P< 0.001). ICU (11.5 versus 21 d, P= 0.067) and hospital (14 versus 25.5 d, P = 0.054) length of stay were not significantly different. There were no RVAD/ECMO device complications. The duration of mechanical ventilation was not significantly different (10 versus 5 d, P = 0.44). Conclusions: RVAD support at the time of ECMO initiation resulted in the no secondary end-organ damage and higher in-hospital and 30-d survival versus IMV in specially selected patients with severe COVID-19 ARDS. Management of severe COVID-19 ARDS should prioritize right ventricular support.
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Affiliation(s)
- Michael T Cain
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nathan J Smith
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
| | - Mark Barash
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Pippa Simpson
- Department of Pediatrics, Division of Quantitative Health Sciences, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lucian A Durham
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Hemanckur Makker
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Christopher Roberts
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Octavio Falcucci
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Dong Wang
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rebekah Walker
- Center for Advancing Population Science, Medical College of Wisconsin, Milwaukee, Wisconsin; Department of Medicine, Division of General Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gulrayz Ahmed
- Department of Medicine, Division of Hematology and Oncology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sherry-Ann Brown
- Cardio-Oncology Program, Division of Cardiovascular Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Rahul S Nanchal
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David L Joyce
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin.
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Smith NJ, Ramamurthi A, Joyce LD, Durham LA, Kohmoto T, Joyce DL. Temporary mechanical circulatory support prevents the occurrence of a low-output state in high-risk coronary artery bypass grafting: A case series. J Card Surg 2021; 36:864-871. [PMID: 33428241 DOI: 10.1111/jocs.15309] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 11/27/2020] [Accepted: 12/28/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is a durable treatment for coronary artery disease. Left ventricular dysfunction (LVD) (a division of cardiothoracic surgery) (ejection fraction < 35%) significantly elevates perioperative risk for patients pursuing surgical revascularization. Periprocedural support with temporary mechanical circulatory support (tMCS) has shown benefit in this patient population. METHODS Four patients with ischemic cardiomyopathy and LVD underwent CABG at our institution between 2017 and 2018. Each patient received perioperative ventricular support using a microaxial tMCS device (Impella 5.0®). The occurrence of a postoperative low-output state (LOS) was assessed for as well as postoperative morbidity and mortality, device-specific complications, and tMCS support duration. RESULTS All patients survived to device explant without device-related complications. Two patients required reoperation for nondevice-related bleeding. All patients were without an LOS at 24 h postoperatively with cardiac indices of 2.9-3.6 L/min/m2 , normalized serum lactate, and vasoactive-inotrope scores of 0-12.0. There was a notably high incidence of acute renal failure (50%), which was observed in patients with preoperative cardiogenic shock. One patient died 10 days after the device explant. Of the three patients that survived to discharge, two were alive at the most recent follow-up. Postoperative device support varied widely (0-500 h). CONCLUSION Perioperative tMCS may be a viable strategy for preventing postoperative LOS in high-risk CABG patients with a low complication rate and acceptable morbidity. The application of microaxial tMCS devices in CABG is an area that warrants further investigation to delineate its impact on perioperative outcomes and potentially expand the indications for such devices.
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Affiliation(s)
- Nathan J Smith
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Adhitya Ramamurthi
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lyle D Joyce
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lucian A Durham
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Takushi Kohmoto
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - David L Joyce
- Department of Surgery, Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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12
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Davis RC, Durham LA, Kiraly L, Patel JJ. Safety, Tolerability, and Outcomes of Enteral Nutrition in Extracorporeal Membrane Oxygenation. Nutr Clin Pract 2020; 36:98-104. [PMID: 33078433 DOI: 10.1002/ncp.10591] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 08/31/2020] [Accepted: 09/20/2020] [Indexed: 02/06/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a supportive care system for patients with respiratory or cardiac failure. Patients requiring ECMO are at risk for significant inflammation, prolonged hospitalization, and acquired malnutrition and sarcopenia. Societal guidelines recommend early enteral nutrition in critically ill patients; however, in this population, optimal timing and dose of nutrition remains unknown and fear of reduced splanchnic perfusion, delayed gastric emptying, and bowel ischemia poses a barrier to appropriate energy and protein intake. This narrative review intends to provide an overview of ECMO, highlight the rationale for nutrition support in this population, and review the safety, tolerability, and outcomes associated with enteral nutrition during ECMO.
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Affiliation(s)
- Robert C Davis
- Clinical Nutrition Services, Froedtert Hospital, Milwaukee, Wisconsin, USA
| | - Lucian A Durham
- Division of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Laszlo Kiraly
- Division of Trauma, Critical Care, and Acute Care Surgery, Oregon Health & Science University, Portland, Oregon, USA
| | - Jayshil J Patel
- Division of Pulmonary and Critical Care Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
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Badu B, Cain MT, Durham LA, Joyce LD, Sundararajan S, Gaglianello N, Ishizawar D, Saltzberg M, Mohammed A, Joyce DL. A Dual-Lumen Percutaneous Cannula for Managing Refractory Right Ventricular Failure. ASAIO J 2020; 66:915-921. [PMID: 32740352 DOI: 10.1097/mat.0000000000001099] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
A right ventricular assist device (RVAD) using a dual-lumen percutaneous cannula inserted through the right internal jugular vein (IJV) might improve weaning in patients with refractory right ventricular (RV) failure. However, the reported experience with this cannula is limited. We reviewed the records of all patients receiving RVAD support with this new dual-lumen cannula at our institution between April 2017 and February 2019. We recorded data on weaning, mortality, and device-specific complications. We compared outcomes among three subgroups based on the indications for RVAD support (postcardiotomy, cardiogenic shock, and primary respiratory failure) and against similar results in the literature. Mean (standard deviation [SD]) age of the 40 patients (29 men) was 53 (15.5) years. Indications for implantation were postcardiotomy support in 18 patients, cardiogenic shock in 12, and respiratory failure in 10. In all, 17 (94%) patients in the postcardiotomy group were weaned from RVAD support, five (42%) in the cardiogenic shock group, and seven (70%) in the respiratory failure group, overall higher than those reported in the literature (49% to 59%) for surgically placed RVADs. Whereas published in-hospital mortality rates range from 42% to 50% for surgically placed RVADs and from 41% to 50% for RVADs with percutaneous cannulas implanted through the right IJV, mortality was 11%, 58%, and 40% in our subgroups, respectively. There were no major device-related complications. This percutaneous dual-lumen cannula appears to be safe and effective for managing refractory RV failure, with improved weaning and mortality profile, and with limited device-specific adverse events.
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Affiliation(s)
- Bernice Badu
- From the Department of surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael T Cain
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lucian A Durham
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Lyle D Joyce
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Sakthi Sundararajan
- Department of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Nunzio Gaglianello
- Department of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David Ishizawar
- Department of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Mitchell Saltzberg
- Department of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Asim Mohammed
- Department of Cardiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David L Joyce
- Division of Cardiothoracic Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
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Schurman AM, Cain MT, Joyce DL, Durham LA, Ishizawar D, Mohammed A, Joyce LD. Minimally Invasive Mechanical Circulatory Support Through the Perioperative Pulmonary Thromboendarterectomy Period: A Case Report. Innovations�(Phila) 2020; 15:173-176. [DOI: 10.1177/1556984520904790] [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] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 64-year-old man being evaluated for pulmonary thromboendarterectomy (PTE) preoperatively experienced pulseless electrical activity secondary to right ventricular failure while undergoing bronchoscopy. After return of spontaneous circulation, a percutaneous right ventricular assist device (RVAD) was placed through the right internal jugular vein. He continued on right ventricular support with demonstration of right ventricular recovery over the following 8 days, and subsequently underwent PTE for treatment of his primary condition. He recovered and was weaned from his RVAD support uneventfully. The need for RVAD support has traditionally been a contraindication for PTE; however, circulatory assist devices have been used as a salvage procedure for right-heart failure after PTE. This case highlights the potential for percutaneous mechanical circulatory support in treating severe perioperative right ventricular dysfunction, and to facilitate successful recovery in patients undergoing PTE.
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Affiliation(s)
| | | | - David L. Joyce
- Division of Cardiothoracic, Department of Surgery, Medical College of Wisconsin, Wauwatosa, USA
| | - Lucian A. Durham
- Division of Cardiothoracic, Department of Surgery, Medical College of Wisconsin, Wauwatosa, USA
| | - David Ishizawar
- Division of Cardiology, Department of Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | - Asim Mohammed
- Division of Cardiology, Department of Medicine, Medical College of Wisconsin, Wauwatosa, USA
| | - Lyle D. Joyce
- Division of Cardiothoracic, Department of Surgery, Medical College of Wisconsin, Wauwatosa, USA
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Cain MT, Joyce LD, Pearson PJ, Durham LA, Rokkas CK, Mohammed A, Joyce DL. Surgical Outcomes of Minimally Invasive vs Sternotomy Approaches to Single-Vessel Coronary Artery Bypass Grafting: A Study from The Society of Thoracic Surgeons National Database. J Am Coll Surg 2019. [DOI: 10.1016/j.jamcollsurg.2019.08.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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16
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Hill GED, Traudt RJ, Durham LA, Pagel PS, Tawil JN. Successful Treatment of Refractory Status Asthmaticus Accompanied by Right Ventricular Dysfunction Using a Protek Duo Tandem Heart Device. J Cardiothorac Vasc Anesth 2019; 33:3085-3089. [PMID: 31076305 DOI: 10.1053/j.jvca.2019.03.031] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Revised: 03/12/2019] [Accepted: 03/14/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Graham E D Hill
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Ryan J Traudt
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
| | - Lucian A Durham
- Department of Cardiothoracic Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI.
| | - Justin N Tawil
- Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, WI
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Kaur R, Bhurtel D, Bielefeld MR, Morales JM, Durham LA. Cryopreserved Saphenous Vein Compared With PTFE Graft for Use as Modified Blalock-Taussig or Central Shunt in Cyanotic Congenital Heart Disease. World J Pediatr Congenit Heart Surg 2018; 9:509-512. [PMID: 30157727 DOI: 10.1177/2150135118776616] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Many infants with congenital heart disease undergo palliative shunt procedures. In our center, cryopreserved saphenous vein and polytetrafluoroethylene (PTFE) are used as grafts to construct these shunts. In this retrospective review, we compare morbidity, mortality, and freedom from reoperation associated with the use of these graft materials. We conducted a retrospective study of 136 consecutive patients who were palliated with shunts between 2006 and 2015. A total of 136 patients were identified, 9 had incomplete data; thus, 127 patients were included: 69 saphenous and 58 PTFE. The cohorts were matched with respect to birth weight, gestational age, age and weight at time of surgery, and underlying cardiac condition. There were 15 (12%) deaths in the study cohort with no intraoperative mortality. Thrombosis was seen in 5.2% (2/38) of the saphenous modified Blalock-Taussig shunt (mBTS) group and 20.6% (14/68) of those with PTFE mBTS. There was no thrombosis in the central shunt group. Freedom from reoperation was 83% in the saphenous vein group and 81% in the PTFE group. There was no difference in overall morbidity or mortality, although thrombosis was significantly less in the saphenous vein group. Cryopreserved saphenous vein is a safe alternative, either as a mBTS or as a central shunt.
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Affiliation(s)
- Resham Kaur
- 1 Department of Pediatrics, Driscoll Children's Hospital, Corpus Christi, TX, USA
| | - Dilli Bhurtel
- 1 Department of Pediatrics, Driscoll Children's Hospital, Corpus Christi, TX, USA
| | - Mark R Bielefeld
- 2 Division of Pediatric Cardiovascular Surgery, Driscoll Children's Hospital, Corpus Christi, TX, USA
| | - J Mark Morales
- 2 Division of Pediatric Cardiovascular Surgery, Driscoll Children's Hospital, Corpus Christi, TX, USA
| | - Lucian A Durham
- 2 Division of Pediatric Cardiovascular Surgery, Driscoll Children's Hospital, Corpus Christi, TX, USA
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Deo SV, Sharma V, Altarabsheh SE, Hasin T, Dillon J, Shah IK, Durham LA, Stulak JM, Daly RC, Joyce LD, Park SJ. Hepatic and renal function with successful long-term support on a continuous flow left ventricular assist device. Heart Lung Circ 2014; 23:229-33. [PMID: 23992754 DOI: 10.1016/j.hlc.2013.07.021] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [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: 04/27/2013] [Revised: 07/17/2013] [Accepted: 07/24/2013] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Data regarding the long-term clinical effects of a continuous flow left ventricular assist device (CF-LVAD) on hepato-renal function is limited. Hence our aim was to assess changes in hepato-renal function over a one-year period in patients supported on a CF-LVAD. METHODS During the study period 126 patients underwent CF-LVAD implant. Changes in hepato-renal laboratory parameters were studied in 61/126 patients successfully supported on a CF-LVAD for period of one year. A separate cohort of a high-risk group (HCrB) of patients (56/126) with a serum creat>1.9 mg/dL (168 μmol/L) (75th percentile) or a serum bil>1.5 mg/dL (25.65 μmol/L) (75th percentile) was created. Changes in serum creatinine and bilirubin were analysed at regular intervals for this group along with the need for renal replacement therapy. RESULTS Baseline creatinine and blood urea nitrogen (BUN) for the entire cohort was 1.4[1.2,1.9 mg/dL] [123.7(106,168) μmol/L) and 27[20,39.5 mg/dL] [9.6(7.1,14.1) mmol/L] respectively. After an initial reduction at the end of one month [1(0.8,1.2) mg/dL; 88(70,105) μmol/L] (p<0.0001), a gradual increase was noted over the study period to reach (1.25[1.1,1.5] mg/dL; 106(97.2,132.6) μmol/L] (p=0.0003). The serum bilirubin normalised from a [1(0.7,1.55) mg/dL] [17(18.8,25.7) μmol/L) to 0.9(0.6,1.2)mg/dL [15.4(10.2,20.5) μmol/L] (p=0.0005) and continued to decline over one year. Improvement in the synthetic function of the liver was demonstrated by a rise in the serum albumin levels to reach 4.3[4.1,4.5] [43(41,45) gm/L] at the end of one year (p<0.0001). The baseline serum creatinine and bilirubin for the high-risk cohort (HCrB) was 1.9(1.3,2.4) mg/dL [168(115,212) μmol/L] and 1.7(1.00,2.4) mg/dL [29(17.1,68.4) μmol/L] respectively. The high-risk cohort (HCrB) demonstrated a trend towards higher 30-day mortality (p=0.06). While the need for temporary renal replacement therapy was higher in this cohort (16% vs. 4%; p=0.03), only 3% need it permanently. A significant reduction in creatinine was apparent at the end of one month [1.1(0.8,1.4) mg/dL; 97(70.7,123.7) μmol/L] (p<0.0001) and then remained stable at [1.3(1.1,1.5) mg/dL; 115(97,132.6) μmol/L]. Bilirubin demonstrated a 30% decline over one month and then remained low at [0.7(0.5,0.8) mg/dL; 62(44,70) μmol/L] p=0.0005 compared to the pre-operative baseline. CONCLUSION Hepato-renal function demonstrates early improvement and then remains stable in the majority of patients on continuous flow left ventricular assist device support for one year. High-risk patients demonstrate a higher 30-day mortality and temporary need for renal replacement therapy. Yet even in this cohort, improvement is present over a period of one year on the device, with a minimal need for permanent haemodialysis.
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Affiliation(s)
- Salil V Deo
- Division of Cardiovascular Surgery, Mayo Clinic, United States
| | - Vikas Sharma
- Division of Cardiovascular Surgery, Mayo Clinic, United States
| | | | - Tal Hasin
- Department of Cardiovascular Diseases, Mayo Clinic, United States
| | - John Dillon
- Division of Nephrology and Hypertension, Mayo Clinic, United States
| | - Ishan K Shah
- Division of Cardiovascular Surgery, Mayo Clinic, United States
| | - Lucian A Durham
- Division of Cardiovascular Surgery, Mayo Clinic, United States
| | - John M Stulak
- Division of Cardiovascular Surgery, Mayo Clinic, United States
| | - Richard C Daly
- Division of Cardiovascular Surgery, Mayo Clinic, United States
| | - Lyle D Joyce
- Division of Cardiovascular Surgery, Mayo Clinic, United States
| | - Soon J Park
- Division of Cardiovascular Surgery, Mayo Clinic, United States.
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19
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Deo SV, Sharma V, Altarabsheh SE, Hasin T, Dillon J, Shah IK, Durham LA, Stulak JM, Daly RC, Joyce LD, Park SJ. Hepatic and renal function with successful long-term support on a continuous flow left ventricular assist device. Heart Lung Circ 2013. [PMID: 23992754 DOI: 10.1016/j.hlc.2013.07.021.] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Data regarding the long-term clinical effects of a continuous flow left ventricular assist device (CF-LVAD) on hepato-renal function is limited. Hence our aim was to assess changes in hepato-renal function over a one-year period in patients supported on a CF-LVAD. METHODS During the study period 126 patients underwent CF-LVAD implant. Changes in hepato-renal laboratory parameters were studied in 61/126 patients successfully supported on a CF-LVAD for period of one year. A separate cohort of a high-risk group (HCrB) of patients (56/126) with a serum creat>1.9 mg/dL (168 μmol/L) (75th percentile) or a serum bil>1.5 mg/dL (25.65 μmol/L) (75th percentile) was created. Changes in serum creatinine and bilirubin were analysed at regular intervals for this group along with the need for renal replacement therapy. RESULTS Baseline creatinine and blood urea nitrogen (BUN) for the entire cohort was 1.4[1.2,1.9 mg/dL] [123.7(106,168) μmol/L) and 27[20,39.5 mg/dL] [9.6(7.1,14.1) mmol/L] respectively. After an initial reduction at the end of one month [1(0.8,1.2) mg/dL; 88(70,105) μmol/L] (p<0.0001), a gradual increase was noted over the study period to reach (1.25[1.1,1.5] mg/dL; 106(97.2,132.6) μmol/L] (p=0.0003). The serum bilirubin normalised from a [1(0.7,1.55) mg/dL] [17(18.8,25.7) μmol/L) to 0.9(0.6,1.2)mg/dL [15.4(10.2,20.5) μmol/L] (p=0.0005) and continued to decline over one year. Improvement in the synthetic function of the liver was demonstrated by a rise in the serum albumin levels to reach 4.3[4.1,4.5] [43(41,45) gm/L] at the end of one year (p<0.0001). The baseline serum creatinine and bilirubin for the high-risk cohort (HCrB) was 1.9(1.3,2.4) mg/dL [168(115,212) μmol/L] and 1.7(1.00,2.4) mg/dL [29(17.1,68.4) μmol/L] respectively. The high-risk cohort (HCrB) demonstrated a trend towards higher 30-day mortality (p=0.06). While the need for temporary renal replacement therapy was higher in this cohort (16% vs. 4%; p=0.03), only 3% need it permanently. A significant reduction in creatinine was apparent at the end of one month [1.1(0.8,1.4) mg/dL; 97(70.7,123.7) μmol/L] (p<0.0001) and then remained stable at [1.3(1.1,1.5) mg/dL; 115(97,132.6) μmol/L]. Bilirubin demonstrated a 30% decline over one month and then remained low at [0.7(0.5,0.8) mg/dL; 62(44,70) μmol/L] p=0.0005 compared to the pre-operative baseline. CONCLUSION Hepato-renal function demonstrates early improvement and then remains stable in the majority of patients on continuous flow left ventricular assist device support for one year. High-risk patients demonstrate a higher 30-day mortality and temporary need for renal replacement therapy. Yet even in this cohort, improvement is present over a period of one year on the device, with a minimal need for permanent haemodialysis.
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Affiliation(s)
- Salil V Deo
- Division of Cardiovascular Surgery, Mayo Clinic, United States
| | - Vikas Sharma
- Division of Cardiovascular Surgery, Mayo Clinic, United States
| | | | - Tal Hasin
- Department of Cardiovascular Diseases, Mayo Clinic, United States
| | - John Dillon
- Division of Nephrology and Hypertension, Mayo Clinic, United States
| | - Ishan K Shah
- Division of Cardiovascular Surgery, Mayo Clinic, United States
| | - Lucian A Durham
- Division of Cardiovascular Surgery, Mayo Clinic, United States
| | - John M Stulak
- Division of Cardiovascular Surgery, Mayo Clinic, United States
| | - Richard C Daly
- Division of Cardiovascular Surgery, Mayo Clinic, United States
| | - Lyle D Joyce
- Division of Cardiovascular Surgery, Mayo Clinic, United States
| | - Soon J Park
- Division of Cardiovascular Surgery, Mayo Clinic, United States.
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Durham LA, Dearani JA, Burkhart HM, Joyce LD, Cetta F, Cabalka AK, Phillips SD, Sundareswaran K, Farrar D, Park SJ. Application of Computer Modeling in Systemic VAD Support of Failing Fontan Physiology. World J Pediatr Congenit Heart Surg 2013; 2:243-8. [PMID: 23804979 DOI: 10.1177/2150135110397386] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Although the Fontan procedure has been enormously successful in palliation of single-ventricle patients, many seem to experience progressive failure of the Fontan circulation over time. Ventricular assist devices (VADs) have developed into stable platforms for long-term support of adult patients with heart failure. Given the success of axial flow devices, it was hypothesized that the technology could provide clinical benefit to failing Fontan patients. The aim of this study was to use a computer model to evaluate VAD support in failing Fontan physiology. A computer model of Fontan circulation with heart failure was developed and the HeartMate II (HM II) (Thoratec Corp) axial flow ventricular assist device was connected to this model in a systemic configuration to examine its impact. Cardiac catheterization data from 7 patients (8 catheterization studies) with failing Fontan physiology were applied to this model to evaluate the impact of using the HM II in this manner. When the HM II was used in a systemic configuration at 8000 rpm, there was a 35% decrease in the systemic venous pressure in the Fontan circuit and a 63% decrease in pulmonary capillary wedge pressure with a resultant 41% increase in CI. The model also predicted patient-specific parameters where the VAD may not benefit the patient, such as fixed elevated pulmonary vascular resistance, low systemic ventricular end-diastolic pressure, and high unresponsive systemic vascular resistance. These data suggest a potential benefit from application of axial flow VAD technology in the management of failing Fontan physiology. Clinical correlation will allow for refinement of this model as a predictive tool in discerning which patients may benefit from placement of a VAD and what issues must be addressed prior to implanting the device.
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Affiliation(s)
- Lucian A Durham
- Division of Cardiovascular Surgery, The Mayo Clinic, Rochester, MN, USA
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21
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Raju V, Burkhart HM, Durham LA, Eidem BW, Phillips SD, Li Z, Schaff HV, Dearani JA. Reoperation After Arterial Switch: A 27-Year Experience. Ann Thorac Surg 2013; 95:2105-12; discussion 2112-3. [DOI: 10.1016/j.athoracsur.2013.02.040] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 02/11/2013] [Accepted: 02/15/2013] [Indexed: 10/26/2022]
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McKellar SH, Deo S, Daly RC, Durham LA, Joyce LD, Stulak JM, Park SJ. Durability of central aortic valve closure in patients with continuous flow left ventricular assist devices. J Thorac Cardiovasc Surg 2012; 147:344-8. [PMID: 23246052 DOI: 10.1016/j.jtcvs.2012.09.098] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2011] [Revised: 08/23/2012] [Accepted: 09/13/2012] [Indexed: 11/17/2022]
Abstract
BACKGROUND A competent aortic valve is essential to providing effective left ventricular assist device support. We have adopted a practice of central aortic valve closure by placing a simple coaptation stitch at left ventricular assist device implantation in patients with significant aortic insufficiency. We conducted a follow-up study to evaluate the efficacy and durability of this procedure. METHODS The study included patients who had undergone continuous flow left ventricular assist device implantation. The patients were divided into 2 groups, those who did not require any aortic procedure because the valve was competent and those who underwent central aortic valve closure for mild or greater aortic regurgitation. The clinical endpoints were mortality, progression or recurrence of aortic insufficiency, and reoperation for aortic valve pathologic features. Aortic insufficiency was measured qualitatively from mild to severe on a scale of 0 to 5. RESULTS A total of 123 patients received continuous flow left ventricular assist devices from February 2007 to August 2011. Of those, 18 (15%) underwent central aortic valve closure at left ventricular assist device implantation because of significant aortic insufficiency (1.8 ± 1.4) and 105 who did not (competent aortic valve, 0.15 ± 0.43; P < .01). At follow-up (median, 312 days; range, 0-1429 days), the mean aortic insufficiency score remained low for the patients with central aortic valve closure (0.27 ± 0.46) in contrast to those without central aortic valve closure who experienced aortic insufficiency progression (0.78 ± 0.89; P = .02). In addition, the proportion of patients with more than mild aortic insufficiency was significantly less in the central aortic valve closure group (0% vs 18%; P = .05). The patients in the central aortic valve closure group were significantly older and had a greater incidence of renal failure at baseline. The 30-day mortality was greater in the central aortic valve closure group, but the late survival was similar between the 2 groups. No reoperations were required for recurrent aortic insufficiency. CONCLUSIONS The results of our study have shown that repair of aortic insufficiency with a simple central coaptation stitch is effective and durable in left ventricular assist device-supported patients, with follow-up extending into 2 years. Although aortic insufficiency progressed over time in those with minimal native valve regurgitation initially, no such progression was noted in those with central aortic valve closure. Additional investigation is needed to evaluate whether prophylactic central aortic valve closure should be performed at left ventricular assist device implantation to avoid problematic aortic regurgitation developing over time, in particular in patients undergoing left ventricular assist device implantation for life-long (destination therapy) support.
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Affiliation(s)
- Stephen H McKellar
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Salil Deo
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minn
| | - Richard C Daly
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minn
| | - Lucian A Durham
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minn
| | - Lyle D Joyce
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minn
| | - John M Stulak
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minn
| | - Soon J Park
- Division of Cardiovascular Surgery, Department of Surgery, Mayo Clinic College of Medicine, Rochester, Minn.
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Sharma V, Deo SV, Stulak JM, Durham LA, Daly RC, Park SJ, Baddour LM, Mehra K, Joyce LD. Driveline Infections in Left Ventricular Assist Devices: Implications for Destination Therapy. Ann Thorac Surg 2012; 94:1381-6. [DOI: 10.1016/j.athoracsur.2012.05.074] [Citation(s) in RCA: 71] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2012] [Revised: 05/15/2012] [Accepted: 05/24/2012] [Indexed: 10/28/2022]
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Durham LA, Burkhart HM, Dearani JA, Puga FJ, O’Leary PW, Schaff HV. Mitral Annular Growth in Children Following Early Mechanical Mitral Valve Replacement. World J Pediatr Congenit Heart Surg 2010; 1:177-81. [DOI: 10.1177/2150135110371487] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Irreparable mitral pathology may lead to early mitral valve replacement (MVR) in children. Often, a small mechanical prosthesis (<23 mm) is required, raising concerns about annular growth in patients who may eventually require subsequent mitral valve re-replacement (MVRR). The aim of this study was to evaluate interval mitral annular growth in this cohort. Between January 1972 and December 2006, 164 children underwent MVR with a mechanical prosthesis; 110 of these children (median age, 4 years; range, 7 days to 14 years) received a small mechanical prosthesis (<23 mm). The most common diagnoses were congenital mitral stenosis (10%), regurgitation (46%), and left atrioventricular valve dysfunction after previous atrioventricular septal defect repair (44%). The cohort was analyzed for age, body surface area (BSA), prosthesis size, and Z score at the time of MVR and MVRR. At the time of MVR, 78 patients had a BSA of 0.77 ± 0.06 m2, had an annular size of 24 ± 0.62 mm ( Z score, 2.91 ± 0.23), and ultimately did not require MVRR. Another cohort, who eventually did require MVRR (n = 24), had an initial BSA at the time of MVR of 0.62 ± 0.05 m2 ( P = NS vs MVR only) and an annular size of 20 ± 0.49 mm ( Z score, 1.85 ± 0.22) ( P = .008 vs MVR only). In the interval between MVR and MVRR (7.8 ± 1.1 years), BSA increased to 1.12 ± 0.07 m2, and annulus size increased to 24 ± 0.47 mm ( Z score, 1.80 ± 0.28). These data suggest growth of the mitral annulus following MVR with a small mechanical prosthesis, as evidenced by an unchanged Z score in the setting of normal interval increase in BSA. Additionally, there was a statistically significant difference in initial Z scores between the cohorts requiring MVRR and those who have not needed re-replacement, suggesting that the feasibility of placement of a slightly larger prosthesis may be associated with a decreased need for MVRR.
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Affiliation(s)
- Lucian A. Durham
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Joseph A. Dearani
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - Francisco J. Puga
- Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
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Boilson BA, Schirger JA, Topilsky Y, Durham LA, Kushwaha SS, Joyce LD, Daly RC, Park SJ. HAVE LVADS RENDERED FIXED PULMONARY HYPERTENSION IN HEART FAILURE A VESTIGE OF THE PAST? J Am Coll Cardiol 2010. [DOI: 10.1016/s0735-1097(10)60174-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Abstract
Lung transplant is an effective treatment for patients with end-stage lung disease but is limited because of the shortage of acceptable donor organs. Organ donation after cardiac death is one possible solution to the organ shortage because it could expand the pool of potential donors beyond brain-dead and living donors. We report the preliminary experience of Mayo Clinic with donation after cardiac death, lung procurement, and transplant.
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Affiliation(s)
| | | | | | - Stephen D. Cassivi
- Individual reprints of this article are not available. Address correspondence to Stephen D. Cassivi, MD, Mayo Clinic Lung Transplant Program, William J. von Liebig Transplant Center, Mayo Clinic, 200 First St SW, Rochester, MN 55905 ()
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Abstract
OBJECTIVE The management of patients with multiple ventricular septal defects remains controversial. Primary closure, interventional catheter techniques, and palliative surgery all may have a role, and specific management guidelines remain undefined. METHODS We reviewed the records of all 33 patients with multiple ventricular septal defects undergoing repair between January 1988 and October 1996. Pulmonary artery hypertension was present in 21 patients (group 1), and pulmonary stenosis was present in the remaining 12 (group 2). Closure was accomplished from a right atriotomy alone in most patients, although an apical left ventriculotomy was used for apical defects. Among group 1 patients, the mean age at repair was 5.9 +/- 0.9 months. Major associated anomalies included coarctation (n = 6), straddling tricuspid valve (n = 1), and critical aortic stenosis (n = 1). Reoperation was performed in two patients for residual ventricular septal defects. Among group 2 patients, the mean age at repair was 6.6 +/- 3.2 years. Major associated anomalies included tetralogy of Fallot (n = 2), pulmonary stenosis (n = 4), double-outlet right ventricle with hypoplastic left ventricle (n = 1), and isolated left ventricular hypoplasia (n = 1). Three required reoperation for residual ventricular septal defect. RESULTS There were no early or late deaths, no episodes of heart block, and no significant residual ventricular septal defects among group 1 patients. All group 1 patients remain free of significant residual cardiovascular conditions at a mean of 23.4 +/- 5.1 months. Among group 2 patients, there was one early death in a patient with double-outlet right ventricle and left ventricular hypoplasia. Complete heart block occurred in two patients and one required late mitral valve replacement. There were no late deaths, seven remain alive without significant residual defects at a mean of 36.2 +/- 8.0 months, and two required transplantation for left ventricular failure. CONCLUSIONS Primary repair for infants with multiple ventricular septal defects is associated with good late outcomes. The right atrial approach is satisfactory for most muscular defects, although limited apical left ventriculotomy was used for apical defects. Pulmonary artery banding should be limited to patients with complex associated defects.
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Affiliation(s)
- T Kitagawa
- Section of Thoracic Surgery, Pediatric Cardiovascular Surgery, C. S. Mott Children's Hospital, The University of Michigan School of Medicine, Ann Arbor 48109, USA
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Abstract
BACKGROUND Aortic valve replacement with a pulmonary autograft (Ross procedure) is being applied more commonly in children. Although indications for this procedure have been expanded, the presence of a dilated aortic annulus has remained a relative contraindication. In this condition, the use of an undersized autograft in an enlarged aortic annulus may result in significant aortic regurgitation. METHODS Among 68 children and young adults undergoing the Ross procedure, 15 (age range, 8 to 24 years) with severe aortic regurgitation or stenosis and an aortic annulus diameter that was at least 2 mm larger than the pulmonary annulus had aortic root tailoring. In this group, the diameter of the aortic annulus measured 26.6 +/- 1.3 mm (mean +/- standard error of the mean), whereas that of the pulmonary annulus was 22 +/- 0.9 mm. The mean annular difference was 4.6 +/- 0.7 mm (range, 2 to 12 mm). The aortic annulus was reduced by excising a triangular wedge of tissue posteriorly from the aortic valve annulus at the level of the commissure between the left and noncoronary cusps extending into the anterior leaflet of the mitral valve. The edges were reapproximated over a calibrated dilator to adjust the final size of the aortic annulus to 2 mm smaller than that of the pulmonary autograft. Circumferential felt strips were not used in any patient. RESULTS All patients survived and morbidity was limited to one reoperation for bleeding. Doppler echocardiographic examination performed at discharge demonstrated that no patient had more than trace to 1+ aortic regurgitation and none had evidence of aortic stenosis. Over a mean follow-up period of 6.3 +/- 1.5 months (range, 1 to 16 months) there has been no late morbidity or mortality and no progression of aortic regurgitation. CONCLUSIONS Aortic root tailoring further extends the use of the Ross procedure to patients with excessive aortic annular dilation while maintaining the potential for growth, which is particularly important in the pediatric population.
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Affiliation(s)
- L A Durham
- Section of Thoracic Surgery, University of Michigan School of Medicine, Ann Arbor, USA
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Abstract
Emergency center thoracotomy was performed at our facility on 389 patients from 1984 through 1989. There were no patients excluded from the study, and survival for all patients was 8.3% with survival rates of 15.2% and 7.3% for stab and gunshot wounds, respectively. Emergency center thoracotomy was performed on 42 patients suffering from isolated extrathoracic injuries with 7% survival. There were no survivors of blunt trauma in this study. Fifty-three percent of the patients arrived with cardiopulmonary resuscitation (CPR) in progress. The average time of prehospital CPR for survivors was 5.1 minutes compared with 9.1 minutes for nonsurvivors. Of the survivors, prehospital endotracheal intubation prolonged successful toleration of CPR to 9.4 minutes compared with 4.2 minutes for nonintubated surviving patients (p less than 0.001). Emergency center thoracotomy is useful in the resuscitation of victims dying of penetrating truncal trauma. Prehospital endotracheal intubation significantly lengthened the time of successful CPR.
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Affiliation(s)
- L A Durham
- Cora and Webb Mading Department of Surgery, Baylor College of Medicine, Houston, Texas 77030
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Durham LA, Krummel TM, Cawthorn JW, Thomas BL, Diegelmann RF. Analysis of transforming growth factor beta receptor binding in embryonic, fetal, and adult rabbit fibroblasts. J Pediatr Surg 1989; 24:784-8. [PMID: 2549233 DOI: 10.1016/s0022-3468(89)80537-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Adult wound repair traits including inflammation, fibroplasia, and collagen deposition are not seen at fetal wound sites. This observation raised questions about regulatory mechanisms extant in fetal healing. Transforming growth factor beta (TGF-beta) is an important regulatory polypeptide known to orchestrate fibroplasia and collagen synthesis during adult wound repair. Previous studies have suggested that the wounded rabbit fetus is capable of responding with these adult characteristics if provided with exogenous TGF-beta. In order to test whether the observed in vivo effects of TGF-beta in the rabbit fetus might be due to a direct effect on the fibroblast, TGF-beta receptor binding characteristics of early passage cultured embryonic (14 days' gestation), fetal (24 days' gestation), and adult rabbit fibroblasts were studied by flow cytometry. Experiments were carried out using fluorescein-conjugated TGF-beta (F-TGF-beta) with analysis on an EPICS V flow cytometer. F-TGF-beta was incubated with each of the three fibroblast types at 37 degrees C after which time the cells were washed twice and analyzed with a minimum of 10(5) cells for each data point. F-TGF-beta bound rapidly and reversibly to the embryonic, fetal, and adult fibroblasts with saturation being achieved at 1 nmol/L for fetal and adult cells, and 8 nmol/L in the embryonic fibroblasts. Saturating concentrations of F-TGF-beta yielded mean channel numbers (a function of relative amounts of F-TGF-beta-bound) of 172, 114, and 97 for embryonic, fetal, and adult cells, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)
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Affiliation(s)
- L A Durham
- Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond
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DePalma RL, Krummel TM, Durham LA, Michna BA, Thomas BL, Nelson JM, Diegelmann RF. Characterization and quantitation of wound matrix in the fetal rabbit. Matrix 1989; 9:224-31. [PMID: 2779482 DOI: 10.1016/s0934-8832(89)80054-x] [Citation(s) in RCA: 102] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Fetal response to injury has been characterized by the deposition of a matrix that is not primarily collagen. This study was designed to identify this matrix, in order to better understand the fetal mechanism of tissue repair. Silastic/polyvinyl alcohol sponge (PVA) wound implants were placed paravertebrally in 24-day gestation (31 days = term) fetal (n = 65) and adult (n = 43) rabbits and then harvested from one hour to 6 days post-wounding. Histologic analysis of the fetal wound matrix deposited in the PVA implants suggested the presence of glycosaminoglycans (GAG) rather than the collagen found in adult wound implants. To further analyze the fetal wound matrix, the GAG content was quantitated using an Alcian Blue dye-binding assay. Results showed significantly increased (p less than 0.05) GAG deposition on days 2-6 in the fetal wound compared to the adult wound. Fetal GAG levels were approximately three times those of the adult during this period. Separation of individual GAG species by cellulose acetate electrophoresis demonstrated that the GAG matrix of the fetal wound was composed predominantly of hyaluronic acid. This finding was confirmed by selective enzymatic digestion of separated GAG species using highly specific polysaccharidases. These observations of hyaluronic acid deposition in the fetal wound may be ascribed an important physiologic role by providing a more fluid and malleable matrix rather than a restrictive matrix composed of collagen. This new evidence coupled with earlier findings of the lack of an acute inflammatory response in the fetus further supports the hypothesis that the fetal response to injury is significantly different from the adult response.
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Affiliation(s)
- R L DePalma
- Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond 23298
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Durham LA, Grogan WM. Characterization of multiple forms of cholesteryl ester hydrolase in the rat testis. J Biol Chem 1984; 259:7433-8. [PMID: 6429131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
Cholesterol ester hydrolase (EC 3.1.1.13) activity from the 104,000 X g supernatant of rat testis was fractionated into 28-kDa, 72-kDa, and 420-kDa molecular mass forms by high performance size exclusion chromatography. The 72-kDa and 420-kDa forms (temperature-labile) were completely inactivated by elevation of temperature from 32 to 37 degrees C. Apparent disaggregation of the 420-kDa form suggested that the 72-kDa and 420-kDa enzymes are monomeric and multimeric forms of the same enzyme. The 28-kDa form was shown to be a different enzyme (temperature-stable) which retained activity at 37 degrees C. In contrast, cholesteryl ester hydrolase activities from 104,000 X g supernatants of liver or adrenal gland were unaffected and increased 4-fold, respectively, by elevation of temperature from 32 to 37 degrees C. Both testicular enzymes exhibited pH optima at about 7.3, and were activated by sodium cholate at concentrations near the critical micellar concentration (0.03-0.07%), but inhibited by higher concentrations. The temperature-labile cholesteryl ester hydrolase exhibited a high specificity for cholesteryl esters of monoenoic fatty acids of 18-24 carbons, especially nervonate (24:1), whereas the temperature-stable cholesteryl ester hydrolase exhibited highest specificity for cholesteryl oleate and arachidonate. Neither enzyme hydrolyzed cholesteryl acetate, myristate, palmitate, linoleate, or docosahexaenoate . Both enzymes reached maximum rates of hydrolysis at 150 microM substrates, with each substrate and at both reaction temperatures. Substrate inhibition was observed at higher concentrations (200 microM). The temperature-labile cholesteryl ester hydrolase was induced 20-fold in hypophysectomized rats by injection of follicle-stimulating hormone (FSH) and was localized in Sertoli cells, the target cells for FSH, but was not induced by luteinizing hormone. The temperature-stable cholesteryl ester hydrolase was induced by both FSH and LH and was found in both Sertoli cells and Leydig cells, the respective target cells for FSH and luteinizing hormone. Neither form of the enzyme was present at detectable levels in the germinal cells. The unique properties, localization, and hormonal regulation of both temperature-labile and temperature-stable cholesterol ester hydrolases suggest important roles for these enzymes in the testis.
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Abstract
Thrombin digestion of bovine growth hormone (1-191) resulted in cleavage of the peptide bond between amino acid residues 133 and 134. Native growth hormone and purified peptides (1-133) and (134-191) were assayed for somatomedin-like activity. Peptide (1-133), ranging in concentration from 0.15-15 nmol/l, stimulated in-vitro uptake of [3H]thymidine by rat costal cartilage. None of the other peptides was biologically active.
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Abstract
Cholesteryl ester hydrolase (CEH) (EC 3.1.1.13) activity was assayed in the 104,000 X g supernatant (S104) of rat and mouse testes and livers at various temperatures between 27 C and 44 C. The CEH activity in the testis dropped from 44 pmol [4-14C] cholesteryl oleate hydrolyzed/hr/mg protein to 14 pmol hydrolyzed/hr/mg protein (a 68% decrease) between testicular and abdominal temperatures (32 C and 37 C, respectively) in the rat. This decrease in activity is essentially a reversible phenomenon. CEH from the testis S104 was stabilized in 10 mM EDTA and was purified by HPLC size exclusion. These steps did not alter the temperature effect previously noted. The temperature effect on the testicular CEH was demonstrated in vivo by assaying the enzyme following unilateral cryptorchidism. The HPLC purification yielded 3 peaks of CEH activity from the testicular S104. The 28,000 MW peak was found to be temperature insensitive while the 70,000 and 420,000 MW peaks were temperature labile. The liver CEH of both species remained relatively constant over the range 32-37 C. CEH is a potential regulator of both steroidogenesis and membrane composition in the testis and its temperature lability may suggest a unique regulatory mechanism responsible for impaired spermatogenesis seen with elevated testicular temperatures.
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