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Sullivan AE, Levack MM, Barker CM, Goel K. Backed Against a Wall: Iatrogenic Type A Aortic Dissection Pinned by Transcatheter Aortic Valve. Struct Heart 2023; 7:100218. [PMID: 38046863 PMCID: PMC10692345 DOI: 10.1016/j.shj.2023.100218] [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] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 07/23/2023] [Accepted: 08/10/2023] [Indexed: 12/05/2023]
Affiliation(s)
- Alexander E. Sullivan
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Melissa M. Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Colin M. Barker
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kashish Goel
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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2
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Tipograf Y, McLaren T, Savoie B, Kumar A, Levack MM. The role of coronary CTA and CT-fractional flow reserve evaluating coronary artery disease in transcatheter aortic valve replacement. J Card Surg 2022; 37:4133-4137. [PMID: 36183383 DOI: 10.1111/jocs.16967] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 09/14/2022] [Indexed: 01/06/2023]
Affiliation(s)
- Yuliya Tipograf
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Thomas McLaren
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brent Savoie
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anupam Kumar
- Department of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Melissa M Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Col NF, Otero D, Lindman BR, Horne A, Levack MM, Ngo L, Goodloe K, Strong S, Kaplan E, Beaudry M, Coylewright M. What matters most to patients with severe aortic stenosis when choosing treatment? Framing the conversation for shared decision making. PLoS One 2022; 17:e0270209. [PMID: 35951553 PMCID: PMC9371337 DOI: 10.1371/journal.pone.0270209] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 06/06/2022] [Indexed: 11/18/2022] Open
Abstract
Background
Guidelines recommend including the patient’s values and preferences when choosing treatment for severe aortic stenosis (sAS). However, little is known about what matters most to patients as they develop treatment preferences. Our objective was to identify, prioritize, and organize patient-reported goals and features of treatment for sAS.
Methods
This multi-center mixed-methods study conducted structured focus groups using the nominal group technique to identify patients’ most important treatment goals and features. Patients separately rated and grouped those items using card sorting techniques. Multidimensional scaling and hierarchical cluster analyses generated a cognitive map and clusters.
Results
51 adults with sAS and 3 caregivers with experience choosing treatment (age 36–92 years) were included. Participants were referred from multiple health centers across the U.S. and online. Eight nominal group meetings generated 32 unique treatment goals and 46 treatment features, which were grouped into 10 clusters of goals and 11 clusters of features. The most important clusters were: 1) trust in the healthcare team, 2) having good information about options, and 3) long-term outlook. Other clusters addressed the need for and urgency of treatment, being independent and active, overall health, quality of life, family and friends, recovery, homecare, and the process of decision-making.
Conclusions
These patient-reported items addressed the impact of the treatment decision on the lives of patients and their families from the time of decision-making through recovery, homecare, and beyond. Many attributes had not been previously reported for sAS. The goals and features that patients’ value, and the relative importance that they attach to them, differ from those reported in clinical trials and vary substantially from one individual to another. These findings are being used to design a shared decision-making tool to help patients and their clinicians choose a treatment that aligns with the patients’ priorities.
Trial registration
ClinicalTrials.gov, Trial ID: NCT04755426, Trial URL https://clinicaltrials.gov/ct2/show/NCT04755426.
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Affiliation(s)
- Nananda F. Col
- Shared Decision Making Resources, Georgetown, ME and University of New England, Biddeford, Maine, United States of America
- * E-mail:
| | - Diana Otero
- Department of Cardiovascular Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States of America
| | - Brian R. Lindman
- Structural Heart and Valve Center, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Aaron Horne
- HeartCare Specialists, Medical City North Hills, North Richland Hills, Texas, United States of America
| | - Melissa M. Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, United States of America
| | - Long Ngo
- Harvard Medical School, Boston, Massachusetts, United States of America
| | - Kimberly Goodloe
- American Heart Association Ambassador, Atlanta, Georgia, United States of America
| | - Susan Strong
- Heart Valve Voice US, Washington DC, United States of America
| | - Elvin Kaplan
- Patient Collaborator, Brownsville, Vermont, United States of America
| | - Melissa Beaudry
- Central Vermont Medical Center, Berlin, Vermont, United States of America
| | - Megan Coylewright
- Department of Cardiovascular Medicine, The Erlanger Heart and Lung Institute, Chattanooga, Tennessee, United States of America
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Johannesen SL, Barker CM, Levack MM. Adjunctive Techniques for Repair of Ischaemic Mitral Regurgitation. Card Fail Rev 2021; 7:e20. [PMID: 34950510 PMCID: PMC8674630 DOI: 10.15420/cfr.2021.06] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 09/16/2021] [Indexed: 11/29/2022] Open
Abstract
Ischaemic mitral regurgitation is a complex process with debate in the literature as to the optimal treatment pathway. Multiple therapies are available to alleviate mitral regurgitation including medical management, transcatheter edge-to-edge repair, mitral valve repair and mitral valve replacement. Medical management with goal-directed therapy should be utilised in patients with heart failure and mild-to-moderate regurgitation. Transcatheter approaches are typically used in patients with prohibitive operative risk, although their use is expanding, especially in those with functional mitral regurgitation who are not responding to goal-directed medical therapy. It is generally accepted that patients with mild-to-moderate disease can avoid valve intervention if successful revascularisation is performed. A higher consideration should be given to valve replacement over repair in patients with severe mitral regurgitation in the setting of myocardial ischaemia. Operative course must be personalised to each patient, and continues to develop with improving technologies and ongoing research into optimal treatment.
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Affiliation(s)
- Sigrid L Johannesen
- Department of Cardiothoracic Surgery, Vanderbilt University Medical Centre Nashville, TN, US
| | - Colin M Barker
- Section of Interventional Cardiology, Vanderbilt University Medical Centre Nashville, TN, US
| | - Melissa M Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Centre Nashville, TN, US
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5
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Levack MM, Kindzelski BA, Miletic KG, Vargo PR, Bakaeen FG, Johnston DR, Rajeswaran J, Blackstone EH, Roselli EE. Adjunctive endovascular balloon fracture fenestration for chronic aortic dissection. J Thorac Cardiovasc Surg 2020; 164:2-10.e5. [DOI: 10.1016/j.jtcvs.2020.09.106] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 08/30/2020] [Accepted: 09/18/2020] [Indexed: 01/29/2023]
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Fiedler AG, Emerson D, Gillaspie EA, Hermsen JL, Levack MM, McCarthy DP, Sihag S, Worrell SG, Antonoff MB. Multi-institutional collaborative mock oral (mICMO) examination for cardiothoracic surgery trainees: Results from the pilot experience. ACTA ACUST UNITED AC 2020; 3:128-135. [PMID: 34173545 PMCID: PMC7381400 DOI: 10.1016/j.xjon.2020.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Revised: 07/18/2020] [Accepted: 07/21/2020] [Indexed: 11/24/2022]
Abstract
Objective The American Board of Thoracic Surgery–certifying examination is challenging for applicants. Single institutions have reported good results with a mock oral examination (MOE) for trainees. General surgery literature has demonstrated success with in-person multi-institutional MOE examinations. Due to small numbers of cardiothoracic training programs and significant geographic variability, we hypothesized that a multi-institutional, collaborative remotely administered MOE (mICMO) pairing faculty with trainees from different institutions would provide an important educational experience. Methods mICMOs were conducted via the Zoom virtual platform across 6 institutions. Descriptive results via post-experience survey were analyzed and reported. Results In total, 100% of trainees found mICMO useful. The majority would recommend to a peer, and 100% of faculty examiners found mICMO useful and would participate in another examination. Conclusions Faculty and trainees found the experience to be effective with respect to creating a high-stakes environment, educationally beneficial, and productive. These results support the continued use of mICMO and encourage expansion and collaboration with additional institutions across the country.
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Affiliation(s)
- Amy G Fiedler
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin, Madison, Wis
| | - Dominic Emerson
- Department of Cardiac Surgery, Cedars Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | | | - Joshua L Hermsen
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin, Madison, Wis
| | | | - Daniel P McCarthy
- Division of Cardiothoracic Surgery, Department of Surgery, University of Wisconsin, Madison, Wis
| | - Smita Sihag
- Department of Surgery, Memorial Sloan Kettering, Thoracic Service, New York, NY
| | - Stephanie G Worrell
- Division of Thoracic Surgery, Case Western Reserve University, Cleveland, Ohio
| | - Mara B Antonoff
- Department of Thoracic and Cardiovascular Surgery, UT MD Anderson Cancer Center, Houston, Tex
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7
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Levack MM, Mecozzi G, Jainandunsing JS, Bouma W, Jassar AS, Pouch AM, Yushkevich PA, Mariani MA, Jackson BM, Gorman JH, Gorman RC. Quantitative three-dimensional echocardiographic analysis of the bicuspid aortic valve and aortic root: A single modality approach. J Card Surg 2019; 35:375-382. [PMID: 31794089 DOI: 10.1111/jocs.14387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Patients with bicuspid aortic valves (BAV) are heterogeneous with regard to patterns of root remodeling and valvular dysfunction. Two-dimensional echocardiography is the standard surveillance modality for patients with aortic valve dysfunction. However, ancillary computed tomography or magnetic resonance imaging is often necessary to characterize associated patterns of aortic root pathology. Conversely, the pairing of three-dimensional (3D) echocardiography with novel quantitative modeling techniques allows for a single modality description of the entire root complex. We sought to determine 3D aortic valve and root geometry with this quantitative approach. METHODS Transesophageal real-time 3D echocardiography was performed in five patients with tricuspid aortic valves (TAV) and in five patients with BAV. No patient had evidence of valvular dysfunction or aortic root pathology. A customized image analysis protocol was used to assess 3D aortic annular, valvular, and root geometry. RESULTS Annular, sinus and sinotubular junction diameters and areas were similar in both groups. Coaptation length and area were higher in the TAV group (7.25 ± 0.98 mm and 298 ± 118 mm2 , respectively) compared to the BAV group (5.67 ± 1.33 mm and 177 ± 43 mm2 ; P = .07 and P = .01). Cusp surface area to annular area, coaptation height, and the sub- and supravalvular tenting indices did not differ significantly between groups. CONCLUSIONS Single modality 3D echocardiography-based modeling allows for a quantitative description of the aortic valve and root geometry. This technique together with novel indices will improve our understanding of normal and pathologic geometry in the BAV population and may help to identify geometric predictors of adverse remodeling and guide tailored surgical therapy.
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Affiliation(s)
- Melissa M Levack
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Gianclaudio Mecozzi
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jayant S Jainandunsing
- Department of Anesthesiology and Pain Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Wobbe Bouma
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Arminder S Jassar
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alison M Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul A Yushkevich
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Benjamin M Jackson
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Levack MM, Fiedler AG, Kaafarani H, King DR. Perforation of a mesenteric Meckel's diverticulum. J Surg Case Rep 2018; 2018:rjy126. [PMID: 29977514 PMCID: PMC6007423 DOI: 10.1093/jscr/rjy126] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 05/23/2018] [Indexed: 11/13/2022] Open
Abstract
Meckel’s diverticulum is a remnant of the embryologic omphalomeseteric duct and is a common congenital anomaly found in ~2% of the population. The clinical significance of this anomaly is that the persistent diverticulum can lead to intestinal obstruction or diverticulitis and may contain ectopic tissue which can lead to bleeding, ulceration or perforation. The classic location of a Meckel’s diverticulum has been described ~40 cm from the ileocecal valve on the antimesenteric side of the distal ileum. There have only been a few documented cases of a Meckel’s diverticulum found on the mesenteric border of the ileum. In this report, we describe a patient who presented with a perforated Meckel’s diverticulum which was found on the mesenteric border and performed a review to determine the significance of this finding.
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Affiliation(s)
- Melissa M Levack
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Amy G Fiedler
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Haytham Kaafarani
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - David R King
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
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9
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Levack MM, Keshavamurthy S, Schoenhagen P, Johnston DR. Management of a duplicated inferior vena cava in thoracoabdominal aortic aneurysm repair. J Thorac Cardiovasc Surg 2016; 153:e39-e41. [PMID: 27919457 DOI: 10.1016/j.jtcvs.2016.10.039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [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: 08/02/2016] [Revised: 10/05/2016] [Accepted: 10/13/2016] [Indexed: 10/20/2022]
Affiliation(s)
- Melissa M Levack
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Suresh Keshavamurthy
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Paul Schoenhagen
- Department of Radiology, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
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10
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Wijdh-den Hamer IJ, Bouma W, Lai EK, Levack MM, Shang EK, Pouch AM, Eperjesi TJ, Plappert TJ, Yushkevich PA, Hung J, Mariani MA, Khabbaz KR, Gleason TG, Mahmood F, Acker MA, Woo YJ, Cheung AT, Gillespie MJ, Jackson BM, Gorman JH, Gorman RC. The value of preoperative 3-dimensional over 2-dimensional valve analysis in predicting recurrent ischemic mitral regurgitation after mitral annuloplasty. J Thorac Cardiovasc Surg 2016; 152:847-59. [PMID: 27530639 DOI: 10.1016/j.jtcvs.2016.06.040] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 05/05/2016] [Accepted: 06/10/2016] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Repair for ischemic mitral regurgitation with undersized annuloplasty is characterized by high recurrence rates. We sought to determine the value of pre-repair 3-dimensional echocardiography over 2-dimensional echocardiography in predicting recurrence at 6 months. METHODS Intraoperative transesophageal 2-dimensional echocardiography and 3-dimensional echocardiography were performed in 50 patients undergoing undersized annuloplasty for ischemic mitral regurgitation. Two-dimensional echocardiography annular diameter and tethering parameters were measured in the apical 2- and 4-chamber views. A customized protocol was used to assess 3-dimensional annular geometry and regional leaflet tethering. Recurrence (grade ≥2) was assessed with 2-dimensional transthoracic echocardiography at 6 months. RESULTS Preoperative 2- and 3-dimensional annular geometry were similar in all patients with ischemic mitral regurgitation. Preoperative 2- and 3-dimensional leaflet tethering were significantly higher in patients with recurrence (n = 13) when compared with patients without recurrence (n = 37). Multivariate logistic regression revealed preoperative 2-dimensional echocardiography posterior tethering angle as an independent predictor of recurrence with an optimal cutoff value of 32.0° (area under the curve, 0.81; 95% confidence interval, 0.68-0.95; P = .002) and preoperative 3-dimensional echocardiography P3 tethering angle as an independent predictor of recurrence with an optimal cutoff value of 29.9° (area under the curve, 0.92; 95% confidence interval, 0.84-1.00; P < .001). The predictive value of the 3-dimensional geometric multivariate model can be augmented by adding basal aneurysm/dyskinesis (area under the curve, 0.94; 95% confidence interval, 0.87-1.00; P < .001). CONCLUSIONS Preoperative 3-dimensional echocardiography P3 tethering angle is a stronger predictor of ischemic mitral regurgitation recurrence after annuloplasty than preoperative 2-dimensional echocardiography posterior tethering angle, which is highly influenced by viewing plane. In patients with a preoperative P3 tethering angle of 29.9° or larger (especially when combined with basal aneurysm/dyskinesis), chordal-sparing valve replacement should be strongly considered.
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Affiliation(s)
- Inez J Wijdh-den Hamer
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Wobbe Bouma
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eric K Lai
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Melissa M Levack
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Eric K Shang
- Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Alison M Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Thomas J Eperjesi
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Theodore J Plappert
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa
| | - Paul A Yushkevich
- Department of Radiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Judy Hung
- Department of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kamal R Khabbaz
- Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | | | - Feroze Mahmood
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Michael A Acker
- Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Albert T Cheung
- Department of Anesthesia, Stanford University, Stanford, Calif
| | - Matthew J Gillespie
- Department of Cardiology, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Benjamin M Jackson
- Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pa; Department of Surgery, The Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pa.
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Bouma W, Lai EK, Levack MM, Shang EK, Pouch AM, Eperjesi TJ, Plappert TJ, Yushkevich PA, Mariani MA, Khabbaz KR, Gleason TG, Mahmood F, Acker MA, Woo YJ, Cheung AT, Jackson BM, Gorman JH, Gorman RC. Preoperative Three-Dimensional Valve Analysis Predicts Recurrent Ischemic Mitral Regurgitation After Mitral Annuloplasty. Ann Thorac Surg 2015; 101:567-75; discussion 575. [PMID: 26688087 DOI: 10.1016/j.athoracsur.2015.09.076] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 09/08/2015] [Accepted: 09/21/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Valve repair for ischemic mitral regurgitation (IMR) with undersized annuloplasty rings is characterized by high IMR recurrence rates. Patient-specific preoperative imaging-based risk stratification for recurrent IMR would optimize results. We sought to determine if prerepair three-dimensional (3D) echocardiography combined with a novel valve-modeling algorithm would be predictive of IMR recurrence 6 months after repair. METHODS Intraoperative transesophageal real-time 3D echocardiography was performed in 50 patients undergoing undersized ring annuloplasty for IMR and in 21 patients with normal mitral valves. A customized image analysis protocol was used to assess 3D annular geometry and regional leaflet tethering. IMR recurrence (≥ grade 2) was assessed with two-dimensional transthoracic echocardiography 6 months after repair. RESULTS Preoperative annular geometry was similar in all IMR patients, and preoperative leaflet tethering was significantly higher in patients with recurrent IMR (n=13) than in patients in whom IMR did not recur (n=37) (tethering index: 3.91 ± 1.01 vs 2.90 ± 1.17, p = 0.008; tethering angles of A3: 23.5° ± 8.9° vs 14.4° ± 11.4°, p = 0.012; P2: 44.4° ± 8.8° vs 28.2° ± 17.0°, p = 0.002; and P3: 35.2° ± 6.0° vs. 18.6° ± 12.7°, p < 0.001). Multivariate logistic regression analysis revealed the preoperative P3 tethering angle as an independent predictor of IMR recurrence with an optimal cutoff value of 29.9° (area under the curve, 0.92; 95% confidence interval, 0.84 to 1.00; p < 0.001). CONCLUSIONS 3D echocardiography combined with valve modeling is predictive of recurrent IMR. Preoperative regional leaflet tethering of segment P3 is a strong independent predictor of IMR recurrence after undersized ring annuloplasty. In patients with a preoperative P3 tethering angle of 29.9° or larger, chordal-sparing valve replacement rather than valve repair should be strongly considered.
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Affiliation(s)
- Wobbe Bouma
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Eric K Lai
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa M Levack
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Eric K Shang
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Alison M Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas J Eperjesi
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Theodore J Plappert
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Paul A Yushkevich
- Department of Radiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Massimo A Mariani
- Department of Cardiothoracic Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Kamal R Khabbaz
- Department of Cardiothoracic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Thomas G Gleason
- Department of Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Feroze Mahmood
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Michael A Acker
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Y Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, California
| | - Albert T Cheung
- Department of Anesthesia, Stanford University, Stanford, California
| | - Benjamin M Jackson
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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Levack MM, Madariaga ML, Kaafarani HMA. Non-operative successful management of a perforated small bowel diverticulum. World J Gastroenterol 2014; 20:18477-18479. [PMID: 25561819 PMCID: PMC4277989 DOI: 10.3748/wjg.v20.i48.18477] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Revised: 06/13/2014] [Accepted: 07/16/2014] [Indexed: 02/06/2023] Open
Abstract
Jejunoileal diverticula are rare and generally asymptomatic. In the few cases of patients who develop complications such as diverticulitis, perforation, obstruction, and/or hemorrhage, conventional treatment consists of surgical resection. We describe a case of perforated jejunoileal diverticulum with localized abscess and highlight the merits of surgical vs medical management. The patient is a 77-year-old male who presented with sharp, constant abdominal pain just inferior to the umbilicus. Administration of intravenous antibiotics results in complete and long-term resolution of the patient’s symptoms. In this report, we establish a framework for safely treating perforated small bowel diverticulum without surgical exploration.
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Jassar AS, Levack MM, Solorzano RD, Pouch AM, Ferrari G, Cheung AT, Ferrari VA, Gorman JH, Gorman RC, Jackson BM. Feasibility of in vivo human aortic valve modeling using real-time three-dimensional echocardiography. Ann Thorac Surg 2014; 97:1255-8. [PMID: 24518577 DOI: 10.1016/j.athoracsur.2013.12.017] [Citation(s) in RCA: 4] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2012] [Revised: 12/04/2013] [Accepted: 12/18/2013] [Indexed: 12/25/2022]
Abstract
BACKGROUND Surgical techniques for aortic valve (AV) repair are directed toward restoring normal structural relationships in the aortic root and rely on detailed assessment of root and valve anatomy. Noninvasive three-dimensional (3D) imaging and modeling may assist in patient selection and operative planning. METHODS Transesophageal real-time 3D echocardiographic images of 5 patients with normal AVs were acquired. The aortic root and the annulus were manually segmented at end diastole using a 36-point rotational template. The AV leaflets and the coaptation zone were manually segmented in parallel 1-mm cross sections. Quantitative 3D models of the AV and root were generated and used to measure standard anatomic parameters and were compared to conventional two-dimensional echocardiographic measurements. All measurements are given as mean±SD. RESULTS Annular, sinus, and sinotubular junction areas were 4.1±0.6 cm2, 7.5±1.2 cm2, and 3.9±1.0 cm2, respectively. Root diameters (measured in three locations) by 3D model inspection and two-dimensional echocardiography measurement correlated (R2=0.75). Noncoapted areas of the left, right, and noncoronary leaflets were 1.9±0.2 cm2, 1.6±0.3 cm2, and 1.6±0.3 cm2, respectively. Mean coaptation areas for the left-right, left-noncoronary, and right-noncoronary coaptation zones were 87.7±36.9 mm2, 69.9±20.7 mm2, and 114.2±23.0 mm2, respectively. The mean ratio of noncoapted leaflet area to annular area was 1.3±0.2. CONCLUSIONS High-resolution 3D models of the in vivo normal human aortic root and valve were generated using 3D echocardiography. Quantitative 3D models and analysis may assist in characterization of pathology and decision making for AV repair.
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Affiliation(s)
- Arminder S Jassar
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa M Levack
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania
| | - Ricardo D Solorzano
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania
| | - Alison M Pouch
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania
| | - Giovanni Ferrari
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Albert T Cheung
- Department of Anesthesiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Victor A Ferrari
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania; Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin M Jackson
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania.
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Ryan LP, Levack MM, Gorman JH, Gorman RC, Milewski RC, Bavaria JE. Quantitative analysis of 3-dimensional aortic annular geometry: implication for aortic root reimplantation. J Thorac Cardiovasc Surg 2013; 147:1103-5. [PMID: 24332105 DOI: 10.1016/j.jtcvs.2013.03.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2012] [Revised: 03/06/2013] [Accepted: 03/15/2013] [Indexed: 10/25/2022]
Affiliation(s)
- Liam P Ryan
- Division of Cardiovascular Surgery, Sanger Heart and Vascular Institute, Carolinas Medical Center, Charlotte, NC
| | - Melissa M Levack
- Gorman Cardiovascular Research Group, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Joseph H Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Robert C Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Rita C Milewski
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa
| | - Joseph E Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania School of Medicine, Philadelphia, Pa.
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Levack MM, Bavaria JE, Gorman RC, Gorman JH, Ryan LP. Rapid Aortic Arch Debranching Using the Gore Hybrid Vascular Graft. Ann Thorac Surg 2013; 95:e163-5. [DOI: 10.1016/j.athoracsur.2013.01.078] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2012] [Revised: 12/13/2012] [Accepted: 01/07/2013] [Indexed: 10/26/2022]
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Contijoch F, Witschey WR, McGarvey JR, Levack MM, Ferrari VA, Kondo N, Takebayashi S, Shimaoka T, Aoki C, Zsido GA, Gorman JH, Gorman RC, Pilla JJ. Real time MRI of border zone end-systolic regional work. J Cardiovasc Magn Reson 2013. [PMCID: PMC3559805 DOI: 10.1186/1532-429x-15-s1-p191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Vergnat M, Levack MM, Jackson BM, Bavaria JE, Herrmann HC, Cheung AT, Weiss SJ, Gorman JH, Gorman RC. The effect of surgical and transcatheter aortic valve replacement on mitral annular anatomy. Ann Thorac Surg 2012; 95:614-9. [PMID: 23245440 DOI: 10.1016/j.athoracsur.2012.10.026] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Revised: 10/04/2012] [Accepted: 10/10/2012] [Indexed: 11/24/2022]
Abstract
BACKGROUND The effect of aortic valve replacement on three-dimensional mitral annular geometry has not been well described. Emerging transcatheter approaches for aortic valve replacement employ fundamentally different mechanical techniques for achieving fixation and seal of the prosthetic valve than standard surgical aortic valve replacement. This study compares the immediate impact of transcatheter aortic valve replacement (TAVR) and standard surgical aortic valve replacement (AVR) on mitral annular anatomy. METHODS Real-time three-dimensional echocardiography was performed in patients undergoing TAVR using the Edwards Sapien valve (n = 10 [Edwards Lifesciences, Irvine, CA]) or AVR (n = 10) for severe aortic stenosis. Mitral annular geometric indexes were measured using Tomtec EchoView (Tomtec Imaging Systems, Munich, Germany) to assess regional and global annular geometry. RESULTS Mixed between-within analysis of variance showed no differences between TAVR and AVR groups in any of the mitral annular geometric indices preoperatively. However, postoperative analysis did demonstrate an effect of AVR on geometry. Patients undergoing open AVR had significant decrease in annular height, septolateral diameter, mitral valve transverse diameter, and mitral annular area after valve replacement (p ≤ 0.006). Similar changes were not noted in the TAVR group. CONCLUSIONS Mitral annular geometry is better preserved by TAVR than by AVR. Thus, TAVR may be a more physiologic approach to aortic replacement.
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Affiliation(s)
- Mathieu Vergnat
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Levack MM, Witschey WR, McGarvey JR, Kondo N, Zsido GA, Gorman JH, Pilla JJ, Gorman RC. Mitral leaflet dynamics in ischemic mitral regurgitation using high resolution MRI. J Cardiovasc Magn Reson 2012. [PMCID: PMC3305775 DOI: 10.1186/1532-429x-14-s1-w57] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Levack MM, Jassar AS, Shang EK, Vergnat M, Woo YJ, Acker MA, Jackson BM, Gorman JH, Gorman RC. Three-dimensional echocardiographic analysis of mitral annular dynamics: implication for annuloplasty selection. Circulation 2012; 126:S183-8. [PMID: 22965981 DOI: 10.1161/circulationaha.111.084483] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Proponents of flexible annuloplasty rings have hypothesized that such devices maintain annular dynamics. This hypothesis is based on the supposition that annular motion is relatively normal in patients undergoing mitral valve repair. We hypothesized that mitral annular dynamics are impaired in ischemic mitral regurgitation and myxomatous mitral regurgitation. METHODS AND RESULTS A Philips iE33 echocardiographic module and X7-2t probe were used to acquire full-volume real-time 3-dimensional transesophageal echocardiography loops in 11 normal subjects, 11 patients with ischemic mitral regurgitation and 11 patients with myxomatous mitral regurgitation. Image analysis was performed using Tomtec Image Arena, 4D-MV Assessment, 2.1 (Munich, Germany). A midsystolic frame was selected for the initiation of annular tracking using the semiautomated program. Continuous parameters were normalized in time to provide for uniform systolic and diastolic periods. Both ischemic mitral regurgitation (9.98 ± 155 cm(2)) and myxomatous mitral regurgitation annuli (13.29 ± 3.05 cm(2)) were larger in area than normal annuli (7.95 ± 1.40 cm(2)) at midsystole. In general, ischemic mitral regurgitation annuli were less dynamic than controls. In myxomatous mitral regurgitation, annular dynamics were also markedly abnormal with the mitral annulus dilating rapidly in early systole in response to rising ventricular pressure. CONCLUSIONS In both ischemic mitral regurgitation and myxomatous mitral regurgitation, annular dynamics and anatomy are abnormal. Flexible annuloplasty devices used in mitral valve repair are, therefore, unlikely to result in either normal annular dynamics or normal anatomy.
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Jassar AS, Minakawa M, Shuto T, Robb JD, Koomalsingh KJ, Levack MM, Vergnat M, Eperjesi TJ, Jackson BM, Gorman JH, Gorman RC. Posterior leaflet augmentation in ischemic mitral regurgitation increases leaflet coaptation and mobility. Ann Thorac Surg 2012; 94:1438-45. [PMID: 22795059 DOI: 10.1016/j.athoracsur.2012.05.025] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Revised: 05/02/2012] [Accepted: 05/03/2012] [Indexed: 01/09/2023]
Abstract
BACKGROUND Restoring leaflet coaptation is the primary objective in repair of ischemic mitral regurgitation (IMR). The common practice of placing an undersized annuloplasty ring partially achieves this goal by correcting annular dilation; however, annular reduction has been demonstrated to exacerbate posterior leaflet tethering. Using a sheep model of IMR, we tested the hypothesis that posterior leaflet augmentation (PLA) combined with standard annuloplasty sizing increases leaflet coaptation more effectively than undersized annuloplasty alone. METHODS Eight weeks after posterobasal myocardial infarction, 15 sheep with 2+ or greater IMR underwent annuloplasty with either a 24-mm annuloplasty ring (24-mm group, n = 5), 30-mm ring (30-mm group, n = 5), or 30-mm ring with concomitant augmentation of the posterior leaflet (PLA group, n = 5). Using three-dimensional echocardiography, postrepair coaptation zone and posterior leaflet mobility were assessed. RESULTS Leaflet coaptation length after repair was greater in the PLA group (4.1 ± 0.3 mm) and the 24-mm group (3.8 ± 0.5 mm) as compared with the 30-mm group (2.7 ± 0.6 mm, p < 0.01). Leaflet coaptation area was significantly greater in the PLA group (121.5 ± 6.6 mm(2)) as compared with the 30-mm group (77.5 ± 17.0 mm(2)) or the 24-mm group (92.5 ± 17.9 mm(2), p < 0.01). Posterior leaflet mobility was significantly greater in the PLA group as compared with the 30-mm group or the 24-mm group. CONCLUSIONS Posterior leaflet augmentation combined with standard-sized annuloplasty enhances leaflet coaptation more effectively than either standard-sized annuloplasty or undersized annuloplasty alone. Increased leaflet coaptation after PLA provides redundancy to IMR repair, and may decrease incidence of both recurrent IMR and mitral stenosis.
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Affiliation(s)
- Arminder S Jassar
- Department of Surgery, University of Pennsylvania, Philadelphia, PA 19036, USA
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Witschey WRT, Zsido GA, Koomalsingh K, Kondo N, Minakawa M, Shuto T, McGarvey JR, Levack MM, Contijoch F, Pilla JJ, Gorman JH, Gorman RC. In vivo chronic myocardial infarction characterization by spin locked cardiovascular magnetic resonance. J Cardiovasc Magn Reson 2012; 14:37. [PMID: 22704222 PMCID: PMC3461454 DOI: 10.1186/1532-429x-14-37] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2012] [Accepted: 06/15/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Late gadolinium enhanced (LGE) cardiovascular magnetic resonance (CMR) is frequently used to evaluate myocardial viability, estimate total infarct size and transmurality, but is not always straightforward is and contraindicated in patients with renal failure because of the risk of nephrogenic systemic fibrosis. T2- and T1-weighted CMR alone is however relatively insensitive to chronic myocardial infarction (MI) in the absence of a contrast agent. The objective of this manuscript is to explore T1ρ-weighted rotating frame CMR techniques for infarct characterization without contrast agents. We hypothesize that T1ρ CMR accurately measures infarct size in chronic MI on account of a large change in T1ρ relaxation time between scar and myocardium. METHODS 7Yorkshire swine underwent CMR at 8 weeks post-surgical induction of apical or posterolateral myocardial infarction. Late gadolinium enhanced and T1ρ CMR were performed at high resolution to visualize MI. T1ρ-weighted imaging was performed with a B₁ = 500 Hz spin lock pulse on a 3 T clinical MR scanner. Following sacrifice, the heart was excised and infarct size was calculated by optical planimetry. Infarct size was calculated for all three methods (LGE, T1ρ and planimetry) and statistical analysis was performed. T1ρ relaxation time maps were computed from multiple T1ρ-weighted images at varying spin lock duration. RESULTS Mean infarct contrast-to-noise ratio (CNR) in LGE and T1ρ CMR was 2.8 ± 0.1 and 2.7 ± 0.1. The variation in signal intensity of tissues was found to be, in order of decreasing signal intensity, LV blood, fat and edema, infarct and healthy myocardium. Infarct size measured by T1ρ CMR (21.1% ± 1.4%) was not significantly different from LGE CMR (22.2% ± 1.5%) or planimetry (21.1% ± 2.7%; p < 0.05).T1ρ relaxation times were T1ρinfarct = 91.7 ms in the infarct and T1ρremote = 47.2 ms in the remote myocardium. CONCLUSIONS T1ρ-weighted imaging using long spin locking pulses enables high discrimination between infarct and myocardium. T1ρ CMR may be useful to visualizing MI without the need for exogenous contrast agents for a wide range of clinical cardiac applications such as to distinguish edema and scar tissue and tissue characterization of myocarditis and ventricular fibrosis.
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Affiliation(s)
- Walter RT Witschey
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, University of Pennsylvania, 500 S Ridgeway Ave, Glenolden, PA 19036, USA
| | - Gerald A Zsido
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin Koomalsingh
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Norihiro Kondo
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Masahito Minakawa
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Takashi Shuto
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeremy R McGarvey
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Melissa M Levack
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Francisco Contijoch
- Department of Bioengineering, University of Pennsylvania, Philadelphia, PA, USA
| | - James J Pilla
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
- Department of Radiology, University of Pennsylvania, 500 S Ridgeway Ave, Glenolden, PA 19036, USA
| | - Joseph H Gorman
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert C Gorman
- Department of Surgery, University of Pennsylvania, Philadelphia, PA, USA
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Shang EK, Pouch AM, Xu C, Levack MM, Gorman RC, Barker CF, Sehgal CM, Jackson BM. PS66. Carotid Artery Segmentation and Wall Thickness Measurement Using CTA. J Vasc Surg 2012. [DOI: 10.1016/j.jvs.2012.03.126] [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: 11/28/2022]
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Xu C, Jassar AS, Nathan DP, Eperjesi TJ, Brinster CJ, Levack MM, Vergnat M, Gorman RC, Gorman JH, Jackson BM. Augmented mitral valve leaflet area decreases leaflet stress: a finite element simulation. Ann Thorac Surg 2012; 93:1141-5. [PMID: 22397985 PMCID: PMC3462015 DOI: 10.1016/j.athoracsur.2012.01.069] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2011] [Revised: 01/17/2012] [Accepted: 01/20/2012] [Indexed: 11/20/2022]
Abstract
BACKGROUND Using human mitral valve (MV) models derived from three-dimensional echocardiography, finite element analysis was used to predict mechanical leaflet and chordal stress. Subsequently, valve geometries were altered to examine the effects on stresses of the following: (1) varying coaptation area; (2) varying noncoapted leaflet tissue area; and (3) varying interleaflet coefficient of friction (μ). METHODS Three human MV models were loaded with a transvalvular pressure of 80 mm Hg using finite element analysis. Initially leaflet coaptation was set to 10%, 50%, or 100% of actual coaptation length to test the influence of coaptation length on stress distribution. Next, leaflet surface areas were augmented by 1% overall and by 2% in the noncoapted "belly" region to test the influence of increased leaflet billowing without changing the gross geometry of the MV. Finally, the coefficient of friction between the coapted leaflets was set to μ = 0, 0.05, or 0.3, to assess the influence of friction on MV function. RESULTS Leaflet coaptation length did not affect stress distribution in either the coapted or noncoapted leaflet regions; peak leaflet stress was 0.36 ± 0.17 MPa at 100%, 0.35 ± 0.14 MPa at 50%, and 0.35 ± 0.15 MPa at 10% coaptation lengths (p = 0.85). Similarly, coaptation length did not affect peak chordal tension (p = 0.74). Increasing the noncoapted leaflet area decreased the peak valvular stresses by 5 ± 2% (p = 0.02). Varying the coefficient of friction between leaflets did not alter leaflet or chordal stress distribution (p = 0.18). CONCLUSIONS Redundant MV leaflet tissue reduces mechanical stress on the noncoapted leaflets; the extent of coaptation or frictional interleaflet interaction does not independently influence leaflet stresses. Repair techniques that increase or preserve noncoapted leaflet area may decrease mechanical stresses and thereby enhance repair durability.
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Affiliation(s)
- Chun Xu
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania
| | - Arminder S. Jassar
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Derek P. Nathan
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Thomas J. Eperjesi
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania
| | - Clayton J. Brinster
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Melissa M. Levack
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania
| | - Mathieu Vergnat
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania
| | - Robert C. Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joseph H. Gorman
- Gorman Cardiovascular Research Group, University of Pennsylvania, Glenolden, Pennsylvania
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Benjamin M. Jackson
- Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
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Vergnat M, Levack MM, Jassar AS, Jackson BM, Acker MA, Woo YJ, Gorman RC, Gorman JH. The influence of saddle-shaped annuloplasty on leaflet curvature in patients with ischaemic mitral regurgitation. Eur J Cardiothorac Surg 2012; 42:493-9. [PMID: 22351705 DOI: 10.1093/ejcts/ezs040] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [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: 11/12/2022] Open
Abstract
OBJECTIVES Reports indicate that repair procedures for ischaemic mitral regurgitation (IMR) are less durable than previously thought. Repair failure has been shown to be stress related. Leaflet curvature is the major determinant of valve stress. Theoretical and animal experiments have shown that saddle-shaped annuloplasty optimizes leaflet curvature when compared with standard flat ring annuloplasty. Despite this, the influence of the ring shape on leaflet curvature has not been described in patients with IMR. This study uses real-time three-dimensional echocardiography (rt-3DE) to assess the influence of the ring shape on leaflet curvature. METHODS Rt-3DE was performed in 21 patients with IMR after placement of either a flat (n = 10, CE-Physio, Edwards) or saddle-shaped (n = 11, Profile 3D, Medtronic) annuloplasty ring. A combination of commercially available and customized software was used to measure multiple leaflet curvature parameters across all regions of the mitral valve. RESULTS Independently of the shape of the annuloplasty ring, all patients were subject to the same degree of annular undersizing. Patients who received saddle-shaped annuloplasty rings had greater leaflet curvature in all six mitral valve leaflet regions (A1 = 0.36 ± 0.10, A2 = 0.53 ± 0.13, A3 = 0.47 ± 0.13, P1 = 0.35 ± 0.23, P2 = 0.53 ± 0.34, P3 = 0.42 ± 0.20 cm(-2)) compared with patients who received flat annuloplasty rings (A1 = 0.16 ± 0.11, A2 = 0.18 ± 0.09, A3 = 0.16 ± 0.11, P1 = 0.20 ± 0.17, P2 = 0.21 ± 0.11, P3 = 0.18 ± 0.13 cm(-2)). These differences were statistically significant in all regions except the P1 region. CONCLUSIONS Saddle-shaped annuloplasty rings increase leaflet curvature compared with flat rings in patients with IMR. As a result, saddle-shaped annuloplasty may decrease leaflet stress and potentially increases the durability of the repair in patients with IMR.
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Affiliation(s)
- Mathieu Vergnat
- Glenolden Research Laboratory, Gorman Cardiovascular Research Group, University of Pennsylvania, Philadelphia, PA, USA
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Witschey WR, Contijoch FJ, Pilla JJ, Dougherty L, Song HK, Levack MM, McGarvey JR, Kondo N, Zsido GA, Gorman JH, Gorman RC. Real time measurement of cardiac pressure-volume relationships. J Cardiovasc Magn Reson 2012. [PMCID: PMC3305248 DOI: 10.1186/1532-429x-14-s1-p227] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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Levack MM, Pettitt BJ, Winston AD. Carotid artery thrombosis and delayed stroke associated with the use of a shoulder belt in a teenager. J Pediatr Surg 2009; 44:E29-33. [PMID: 19635289 DOI: 10.1016/j.jpedsurg.2009.05.026] [Citation(s) in RCA: 7] [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: 02/20/2009] [Revised: 05/18/2009] [Accepted: 05/18/2009] [Indexed: 11/28/2022]
Abstract
Blunt carotid artery injury caused by shoulder belts is rare and requires a high index of suspicion to diagnose before the onset of neurologic sequelae. Neurologic abnormalities may be erroneously attributed to concomitant head trauma, and the onset of neurologic abnormalities may be delayed for hours or days. The case of a young, teenaged driver with a "seatbelt sign" and presentation of signs and symptoms of carotid artery thrombosis 13 days after injury is described. Occult vascular injury should be suspected if neurologic deterioration occurs after a lucid interval and/or computed tomography of the head is inconsistent with neurologic findings. Screening criteria and possible screening modalities are discussed.
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Affiliation(s)
- Melissa M Levack
- Division of Pediatric Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA 30303, USA
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Abstract
OBJECTIVES To study the effect of celecoxib (Celebrex; Pfizer, Cambridge, Mass) on (1) primary ischemic time and (2) revascularization of fasciocutaneous free flaps in a rat model. METHODS In the ischemia study, 50 male Sprague-Dawley rats were divided into 2 groups of 25 rats each, a control group and a celecoxib group. Five rats in each treatment group were exposed to ischemic times of 4, 6, 8, 10, and 12 hours. Survival of the flap was assessed 7 days after reversal of the ischemia. Probit curves and the critical ischemic time were calculated. In the revascularization study, 30 male Sprague-Dawley rats were divided into 2 groups of 15 rats each. One group was fed celecoxib, while the other was fed a normal diet. All rats had a 3 x 6-cm fasciocutaneous flap based on the inferior epigastric artery elevated and exposed to 2 hours of primary ischemia. The flap was then sutured back into the wound bed. Each of these groups was then divided into 3 groups of 5 rats whose pedicles were divided on postoperative day 5, 6, or 7. Percentage survival of the flap was measured 7 days later. In both parts of the study, the experimental group was fed celecoxib, 1500 ppm, throughout the interoperative period. In each animal, a 3 x 6-cm ventral fasciocutaneous groin flap based on the left superficial epigastric artery was elevated. RESULTS In the ischemia study, respective flap survival rates from the control and celecoxib groups at the various ischemic times were as follows: 4 hours, 100% and 100%; 6 hours, 80% and 100%; 8 hours, 80% and 80%; 10 hours, 60% and 60%; and 12 hours, 20% and 10%. The median lethal ischemic times were 9.7 and 9.6 hours, respectively. There was no statistical difference in flap survival between the celecoxib and control groups. In the revascularization study, ligation of the flap pedicle on day 5, 6, or 7 did not result in any difference in the percentage of flap survival among the 3 groups. CONCLUSION Celecoxib appears to have no deleterious effect on free tissue transfer survival or healing, as evidenced by revascularization in a fasciocutaneous free flap model.
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Affiliation(s)
- Mark K Wax
- Department of Otolaryngology--Head and Neck Surgery, Oregon Health and Science University, Portland, OR 97201, USA.
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