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Ueyama HA, Licitra G, Gleason PT, Behbahani-Nejad O, Modi R, Rajagopal D, Byku I, Xie JX, Greenbaum AB, Paone G, Keeling WB, Grubb KJ, Hanzel GS, Devireddy CM, Block PC, Babaliaros VC. Impact of Tricuspid Regurgitation on Outcomes After Transcatheter Mitral Valve Replacement. Am J Cardiol 2024; 220:S0002-9149(24)00238-8. [PMID: 38604492 DOI: 10.1016/j.amjcard.2024.03.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 02/27/2024] [Accepted: 03/30/2024] [Indexed: 04/13/2024]
Abstract
Development of functional tricuspid regurgitation (TR) because of chronic mitral disease and subsequent heart failure is common. However, the effect of TR on clinical outcomes after transcatheter mitral valve replacement (TMVR) remains unclear. We aimed to evaluate the impact of baseline TR on outcomes after TMVR. This was a single-center, retrospective analysis of patients who received valve-in-valve or valve-in-ring TMVR between 2012 and 2022. Patients were categorized into none/mild TR and moderate/severe TR based on baseline echocardiography. The primary outcome was 3 years all-cause death and the secondary outcomes were in-hospital events. Of the 135 patients who underwent TMVR, 64 (47%) exhibited none/mild TR at baseline, whereas 71 (53%) demonstrated moderate/severe TR. There were no significant differences in in-hospital events between the groups. At 3 years, the moderate/severe TR group exhibited a significantly increased risk of all-cause death (adjusted hazard ratio 3.37, 95% confidence interval 1.35 to 8.41, p = 0.009). When patients with baseline moderate/severe TR were stratified by echocardiography at 30 days into improved (36%) and nonimproved (64%) TR groups, although limited by small sample size, there was no significant difference in 3-year all-cause mortality (p = 0.48). In conclusion, this study investigating the impact of baseline TR on clinical outcomes revealed that moderate/severe TR is prevalent in those who underwent TMVR and is an independent predictor of 3-year all-cause mortality. Earlier mitral valve intervention before the development of significant TR may play a pivotal role in improving outcomes after TMVR.
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Affiliation(s)
- Hiroki A Ueyama
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Giancarlo Licitra
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Patrick T Gleason
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Omid Behbahani-Nejad
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Roshan Modi
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Dhiren Rajagopal
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Isida Byku
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Joe X Xie
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Adam B Greenbaum
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Gaetano Paone
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - W Brent Keeling
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Kendra J Grubb
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - George S Hanzel
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Chandan M Devireddy
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Peter C Block
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia
| | - Vasilis C Babaliaros
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia.
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Crepy D'Orleans C, Duwayri YM, Zellner AB, Binongo J, Farrington WJ, Keeling WB, Jordan WD, Leshnower BG. Acute Type B Intramural Hematoma: Novel Insights in the Endovascular Era. Ann Vasc Surg 2024; 101:195-203. [PMID: 38301850 DOI: 10.1016/j.avsg.2023.11.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 10/13/2023] [Accepted: 11/04/2023] [Indexed: 02/03/2024]
Abstract
BACKGROUND The pathophysiology and behavior of acute type B intramural hematoma (TBIMH) is poorly understood. The purpose of this study is to characterize the pathophysiology, fate, and outcomes of TBIMH in the endovascular era. METHODS A retrospective analysis of a US Aortic Database identified 70 patients with TBIMH from 2008 to 2022. Patients were divided into groups and analyzed based upon subsequent management: early thoracic endovascular aortic repair (TEVAR; Group 1) or hospital discharge on optimal medical therapy (OMT) (Group 2). RESULTS Of 70 total patients, 43% (30/70) underwent TEVAR (Group 1) and 57% (40/70) were discharged on OMT (Group 2). There were no significant differences in age, demographics, or comorbidities between groups. Indications for TEVAR in Group 1 were as follows: 1) Penetrating atheroscletoic ulcer (PAU) or ulcer-like projection (n = 26); 2) Descending thoracic aortic aneurysm (n = 3); or 3) Progression to type B aortic dissection (TBAD) (n = 2). Operative mortality was zero. No patient suffered a stroke or spinal cord ischemia. During the follow-up period, 50% (20/40) of Group 2 patients required delayed surgical intervention, including TEVAR in 14 patients and open repair in 6 patients. Indications for surgical intervention were as follows: 1) Development of a PAU / ulcer-like projection (n = 13); 2) Progression to TBAD (n = 3), or 3) Concomitant aneurysmal disease (n = 4). Twenty patients did not require surgical intervention. Of the initial cohort, 71% of patients required surgery, 9% progressed to TBAD, and 19% had regression or stability of TBIMH with OMT alone. CONCLUSIONS The most common etiology of TBIMH is an intimal defect. Progression to TBAD and intramural hematoma regression without an intimal defect occurs in a small percentage of patients. An aggressive strategy with endovascular therapy and close surveillance for TBIMH results in excellent short-term and long-term outcomes.
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Affiliation(s)
| | - Yazan M Duwayri
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Alysa B Zellner
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Jose Binongo
- Emory University Rollins School of Public Health, Atlanta, GA
| | - Woodrow J Farrington
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - W Brent Keeling
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - William D Jordan
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, GA
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA.
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Ueyama H, Leshnower BG, Inci E, Keeling WB, Tully A, Guyton RA, Xie JX, Gleason PT, Byku I, Devireddy C, Hanzel GS, Block PC, Lederman RJ, Greenbaum AB, Babaliaros VC. Hybrid Closure of Postinfarction Apical Ventricular Septal Defect Using Septal Occluder Device and Right Ventricular Free Wall: The Apical BASSINET Concept. Circ Cardiovasc Interv 2023; 16:e013243. [PMID: 37732604 PMCID: PMC10592084 DOI: 10.1161/circinterventions.123.013243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 07/28/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Postinfarction ventricular septal defect (VSD) is a catastrophic complication of myocardial infarction. Surgical repair still has poor outcomes. This report describes clinical outcomes after a novel hybrid transcatheter/surgical repair in patients with apical VSD. METHODS Seven patients with postmyocardial infarction apical VSD underwent hybrid transcatheter repair via subxiphoid surgical access. A transcatheter occluder (Amplatzer Septal Occluder) with a trailing premounted suture was deployed through the right ventricular wall and through the ventricular septum into the left ventricular apex. The trailing suture was used to connect an anchor external to the right ventricular wall. Tension on the suture then collapses the right ventricular free wall against the septum and left ventricular occluder, thereby obliterating the VSD. Outcomes were compared with 9 patients who underwent surgical repair using either patch or primary suture closure. RESULTS All patients had significant left-to-right shunt (Qp:Qs 2.5:1; interquartile range [IQR, 2.1-2.6] hybrid repair versus 2.0:1 [IQR, 2.0-2.5] surgical repair), and elevated right ventricular systolic pressure (62 [IQR, 46-71] versus 49 [IQR, 43-54] mm Hg, respectively). All had severely depressed stroke volume index (22 versus 21 mL/m2) with ≈45% in each group requiring mechanical support preprocedurally. The procedure was done 15 (IQR, 10-50) versus 24 (IQR, 10-134) days postmyocardial infarction, respectively. Both groups of patients underwent repair with technical success and without intraprocedural death. One patient in the hybrid group and 4 in the surgical group developed multiorgan failure. The hybrid group had a higher survival at discharge (86% versus 56%) and at 30 days (71% versus 56%), but similar at 1 year (57% versus 56%). During follow-up, 1 patient in each group required reintervention for residual VSD (hybrid: 9 months versus surgical: 5 days). CONCLUSIONS Early intervention with a hybrid transcatheter/surgical repair may be a viable alternative to traditional surgery for postinfarction apical VSD.
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Affiliation(s)
- Hiroki Ueyama
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Bradley G. Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Errol Inci
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - W. Brent Keeling
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andy Tully
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Robert A. Guyton
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Joe X. Xie
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Patrick T. Gleason
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Isida Byku
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Chandan Devireddy
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - George S. Hanzel
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Peter C. Block
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Robert J. Lederman
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Adam B. Greenbaum
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
| | - Vasilis C. Babaliaros
- Division of Cardiology, Emory Structural Heart and Valve Center, Emory University Hospital Midtown, Atlanta, Georgia, USA
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Perkowski P, Moriarty JM, Keeling WB, Sterling KM, Dohad SY, Weinberg I. Computer-aided Mechanical Aspiration Thrombectomy with the Indigo Lightning 12 Aspiration System for the Treatment of Acute Pulmonary Embolism: Interim Analysis of the STRIKE-PE Study. J Vasc Surg 2023. [DOI: 10.1016/j.jvs.2023.01.145] [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: 03/18/2023]
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Westover D, Wright W, Aziz I, Goyal A, Keeling WB, Grubb KJ, Paone G, Shoffstall J, Giebler A, Groff R, Lacey D, Benameur K, Yaw S, Nahab FB. Abstract WP80: The Heart-brain Connection: Implementing Strategies To Reduce The Rate Of Perioperative Stroke For Patients Undergoing Coronary Artery Bypass Graft Surgery. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp80] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Stroke is a known complication of cardiac surgery. The objective of this study was to implement a systemwide strategy to reduce perioperative stroke after isolated coronary artery bypass graft (CABG) surgery utilizing best practices from cardiothoracic surgery and neurology expertise.
Methods:
A prospective, quality improvement study of all isolated CABG patients at three hospitals within a multicenter academic healthcare system, in a large metropolitan area, was completed from January 1, 2021 to June 30, 2022. Utilizing Lean methodology, a multidisciplinary team of cardiothoracic surgeons, neurologists, anesthesiologists, certified stroke nurses, and process improvement specialists conducted a gap analysis to identify interventions to decrease the observed to expected (O/E) ratio of risk-adjusted perioperative strokes. The team developed a pre-operative evaluation process for patients with a history of stroke, formalized the utilization of intra-operative epiaortic ultrasound, and deployed education on BE-FAST symptoms and the purpose of stroke alerts to providers, nurses, and ancillary staff caring for the patient population.
Results:
During the study period, 1175 patients underwent isolated CABG. Risk adjusted perioperative stroke rates in the first 6 months of 2021 compared to 2022 declined from an O/E ratio of 1.32 to 0.78. Among patients with new post-operative stroke symptoms, the time frame from last known well to symptom recognition decreased from 704 to 486 minutes. Following the implementation of the protocol, one site saw the utilization of inpatient stroke alerts after CABG increase from 81.3% to 100% for patients with new BE-FAST symptoms.
Conclusion:
Multidisciplinary implementation of best practices was associated with lower risk adjusted perioperative stroke rates, reductions in time to new symptom recognition, and increased utilization of inpatient stroke alert processes. Further study is needed to monitor the effects of the pre-operative evaluation process and the standardization of epiaortic ultrasound. Future goals are to standardize the methods and assess the benefit to other types of cardiac surgery.
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Cardona S, Tsegka K, Pasquel FJ, Jacobs S, Halkos M, Keeling WB, Davis GM, Fayfman M, Albury B, Urrutia MA, Galindo RJ, Migdal AL, Macheers S, Guyton RA, Vellanki P, Peng L, Umpierrez GE. Sitagliptin for the prevention and treatment of perioperative hyperglycaemia in patients with type 2 diabetes undergoing cardiac surgery: A randomized controlled trial. Diabetes Obes Metab 2021; 23:480-488. [PMID: 33140566 PMCID: PMC8573668 DOI: 10.1111/dom.14241] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 10/02/2020] [Accepted: 10/25/2020] [Indexed: 12/14/2022]
Abstract
AIM To assess whether treatment with sitagliptin, starting before surgery and continued during the hospital stay, can prevent and reduce the severity of perioperative hyperglycaemia in patients with type 2 diabetes undergoing coronary artery bypass graft (CABG) surgery. MATERIALS AND METHODS We conducted a double-blinded, placebo-controlled trial in adults with type 2 diabetes randomly assigned to receive sitagliptin or matching placebo starting 1 day prior to surgery and continued during the hospital stay. The primary outcome was difference in the proportion of patients with postoperative hyperglycaemia (blood glucose [BG] > 10 mmol/L [>180 mg/dL]) in the intensive care unit (ICU). Secondary endpoints included differences in mean daily BG in the ICU and after transition to regular wards, hypoglycaemia, hospital complications, length of stay and need of insulin therapy. RESULTS We included 182 participants randomized to receive sitagliptin or placebo (91 per group, age 64 ± 9 years, HbA1c 7.6% ± 1.5% and diabetes duration 10 ± 9 years). There were no differences in the number of patients with postoperative BG greater than 10 mmol/L, mean daily BG in the ICU or after transition to regular wards, hypoglycaemia, hospital complications or length of stay. There were no differences in insulin requirements in the ICU; however, sitagliptin therapy was associated with lower mean daily insulin requirements (21.1 ± 18.4 vs. 32.5 ± 26.3 units, P = .007) after transition to a regular ward compared with placebo. CONCLUSION The administration of sitagliptin prior to surgery and during the hospital stay did not prevent perioperative hyperglycaemia or complications after CABG. Sitagliptin therapy was associated with lower mean daily insulin requirements after transition to regular wards.
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Affiliation(s)
| | | | | | - Sol Jacobs
- Department of Medicine, Emory University, Atlanta, Georgia
| | - Michael Halkos
- Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, Georgia
| | - W. Brent Keeling
- Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, Georgia
| | | | - Maya Fayfman
- Department of Medicine, Emory University, Atlanta, Georgia
| | - Bonnie Albury
- Department of Medicine, Emory University, Atlanta, Georgia
| | | | | | | | - Steven Macheers
- Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, Georgia
| | - Robert A. Guyton
- Joseph B. Whitehead Department of Surgery, Emory University, Atlanta, Georgia
| | | | - Limin Peng
- Rollins School of Public Health, Emory University, Atlanta, Georgia
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7
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Maidman SD, Lisko JC, Kamioka N, Chen EP, Mavromatis K, Halkos M, Stewart JP, Lattouf OM, Keeling WB, Gleason P, Sommerfeld AJ, Maini A, Ibrahim AW, Grubb KJ, Leshnower BG, Guyton R, Greenbaum AB, Block PC, Babaliaros VC, Devireddy C. Outcomes Following Shock Aortic Valve Replacement: Transcatheter Versus Surgical Approaches. Cardiovasc Revasc Med 2020; 21:1313-1318. [PMID: 32305316 DOI: 10.1016/j.carrev.2020.03.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/12/2020] [Accepted: 03/12/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES To compare transcatheter aortic valve replacement (TAVR) with surgical aortic valve replacement (SAVR) for patients in shock. BACKGROUND There are minimal data on the clinical and echocardiographic outcomes for patients in shock that undergo TAVR and no data comparing these outcomes to similar patients undergoing SAVR. METHODS This is a single center, retrospective cohort study of patients having Society of Thoracic Surgeons (STS)-defined urgent or emergent AVR for aortic stenosis with clinical signs and symptoms of shock. Inclusion criteria were based on the Society of Cardiovascular Angiography & Interventions (SCAI) shock consensus statement and included: the need for inotropic or vasopressor agents, mechanical ventilation, continuous renal replacement therapy or newly initiated hemodialysis, and/or utilization of mechanical hemodynamic support. Clinical and echocardiographic outcomes for TAVR and SAVR were compared. RESULTS Thirty-seven patients met the inclusion criteria for this study (17 TAVR, 20 SAVR). TAVR patients had a higher STS Predicted Risk of Mortality (PROM) score of 22.3% compared to 11.8% for SAVR patients (p = 0.001). No significant differences were found in baseline echocardiographic results. TAVR procedures required less procedure room time (185.9 min TAVR, 348.5 min SAVR, p < 0.001) and fewer intraoperative packed red blood cell (pRBC) transfusions (0.2 units TAVR, 3.4 units SAVR, p < 0.001). TAVR patients also had lower rates of prolonged postoperative ventilation compared to SAVR patients (38.5% TAVR, 75.0% SAVR, p = 0.047). TAVR and SAVR had similar rates of mortality at discharge (2 TAVR, 1 SAVR, p = 0.584), 30-days (2 TAVR, 1 SAVR, p = 0.584), and 1-year (8 TAVR, 5 SAVR, p = 0.149). CONCLUSIONS Despite a higher risk TAVR group, patients in shock undergoing either TAVR or SAVR have similar 30-day mortality. At one year, SAVR patients have a numerically better, though not statistically significant, survival. These findings support the use of TAVR for patients in shock with aortic stenosis.
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Affiliation(s)
- Samuel D Maidman
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - John C Lisko
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Norihiko Kamioka
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Kreton Mavromatis
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Michael Halkos
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, United States of America
| | - James P Stewart
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Omar M Lattouf
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, United States of America
| | - W Brent Keeling
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Patrick Gleason
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Alex J Sommerfeld
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Aneesha Maini
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Akram W Ibrahim
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Kendra J Grubb
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Bradley G Leshnower
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Robert Guyton
- Division of Cardiothoracic Surgery, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Adam B Greenbaum
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Peter C Block
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
| | - Vasilis C Babaliaros
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America.
| | - Chandan Devireddy
- Division of Cardiology, Emory University School of Medicine, Atlanta, GA, United States of America
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Larson J, Merchant FM, Patel A, Ndubisi NM, Patel AM, DeLurgio DB, Lloyd MS, El‐Chami MF, Leon AR, Hoskins MH, Keeling WB, Halkos ME, Lattouf OM, Westerman S. Outcomes of convergent atrial fibrillation ablation with continuous rhythm monitoring. J Cardiovasc Electrophysiol 2020; 31:1270-1276. [DOI: 10.1111/jce.14454] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [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: 12/02/2019] [Revised: 02/12/2020] [Accepted: 02/21/2020] [Indexed: 01/20/2023]
Affiliation(s)
- John Larson
- Emory University School of Medicine Atlanta Georgia
| | - Faisal M. Merchant
- Emory University School of Medicine Atlanta Georgia
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
| | - Akshar Patel
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
| | - Nnaemeka M. Ndubisi
- Emory University School of Medicine Atlanta Georgia
- Division of Cardiothoracic Surgery, Department of SurgeryEmory University School of Medicine Atlanta Georgia
| | - Anshul M. Patel
- Emory University School of Medicine Atlanta Georgia
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
| | - David B. DeLurgio
- Emory University School of Medicine Atlanta Georgia
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
| | - Michael S. Lloyd
- Emory University School of Medicine Atlanta Georgia
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
| | - Mikhael F. El‐Chami
- Emory University School of Medicine Atlanta Georgia
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
| | - Angel R. Leon
- Emory University School of Medicine Atlanta Georgia
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
| | - Michael H. Hoskins
- Department of CardiologyNew Mexico Heart Institute Albuquerque New Mexico
| | - W. Brent Keeling
- Emory University School of Medicine Atlanta Georgia
- Division of Cardiothoracic Surgery, Department of SurgeryEmory University School of Medicine Atlanta Georgia
| | - Michael E. Halkos
- Emory University School of Medicine Atlanta Georgia
- Division of Cardiothoracic Surgery, Department of SurgeryEmory University School of Medicine Atlanta Georgia
| | - Omar M. Lattouf
- Emory University School of Medicine Atlanta Georgia
- Division of Cardiothoracic Surgery, Department of SurgeryEmory University School of Medicine Atlanta Georgia
| | - Stacy Westerman
- Emory University School of Medicine Atlanta Georgia
- Cardiology Division, Section of Cardiac ElectrophysiologyEmory University School of Medicine Atlanta Georgia
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Winters AA, McDaniel MJ, Binongo JN, Moon RC, Jaber WA, Rajani RR, Liberman HA, Lattouf OM, Halkos ME, Stouffer CW, Keeling WB. A comparison of surgical pulmonary embolectomy and catheter-directed lysis for life-threatening pulmonary emboli. Interact Cardiovasc Thorac Surg 2020; 30:388-393. [PMID: 31834382 DOI: 10.1093/icvts/ivz288] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Revised: 10/29/2019] [Accepted: 11/08/2019] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Patients with life-threatening pulmonary emboli (PE) have traditionally been treated with anticoagulation alone, yet emerging data suggest that more aggressive therapy may improve short-term outcomes. The purpose of this study was to compare postoperative outcomes between catheter-directed thrombolysis (CDL) and surgical pulmonary embolectomy (SPE) in the treatment of life-threatening PE. METHODS A retrospective single-centre observational study was conducted for patients who underwent SPE or CDL at a single US academic centre. Preprocedural and postprocedural echocardiographic data were collected. Unadjusted regression models were constructed to assess the significance of the between-group postoperative differences. RESULTS A total of 126 patients suffered a life-threatening PE during the study period [60 SPE (47.6%), 66 CDL 52.4%]. Ten (24.4%) SPE patients and 10 (15.2%) CDL patients had massive PEs marked by preprocedural hypotension. Six (10.0%) SPE patients and 4 (6.0%) CDL patients suffered a preprocedure cardiac arrest (P = 0.41). In-hospital mortality rate was 3.3% (2) for SPE, and 3.0% (2) for CDL (P = 0.99). SPE patients were more likely to require prolonged ventilation (15.0% vs 1.5%, P = 0.01). No significant differences were found in other major complications. At baseline echocardiography, 76.9% of SPE patients and 56.9% of CDL patients had moderate or severe right ventricular (RV) dysfunction. Both treatment groups showed marked and durable improvement in echocardiographic markers of RV function from baseline at midterm follow-up. CONCLUSIONS Both SPE and CDL can be applied to well-selected high-risk patients with low rates of morbidity and mortality. Further research is necessary to delineate which patients would benefit most from either SPE or CDL following a life-threatening PE.
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Affiliation(s)
- Amalia A Winters
- Clinical Research Unit, Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael J McDaniel
- Department of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Jose N Binongo
- Department of Biostatistics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA
| | - Rena C Moon
- Department of Biostatistics, Rollins School of Public Health, Emory University School of Medicine, Atlanta, GA, USA
| | - Wissam A Jaber
- Department of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Ravi R Rajani
- Division of Vascular Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Henry A Liberman
- Department of Cardiology, Emory University School of Medicine, Atlanta, GA, USA
| | - Omar M Lattouf
- Clinical Research Unit, Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael E Halkos
- Clinical Research Unit, Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Chadwick W Stouffer
- Clinical Research Unit, Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - W Brent Keeling
- Clinical Research Unit, Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
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Leshnower BG, Keeling WB, Duwayri YM, Jordan WD, Chen EP. The “thoracic endovascular aortic repair-first” strategy for acute type A dissection with mesenteric malperfusion: Initial results compared with conventional algorithms. J Thorac Cardiovasc Surg 2019; 158:1516-1524. [DOI: 10.1016/j.jtcvs.2019.01.116] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2018] [Revised: 12/17/2018] [Accepted: 01/03/2019] [Indexed: 11/17/2022]
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11
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Keeling WB, Hunting J, Leshnower BG, Stouffer C, Binongo J, Chen EP. Salvage Coronary Artery Bypass Predicts Increased Mortality During Aortic Root Operation. Ann Thorac Surg 2018; 106:1727-1734. [PMID: 30171853 DOI: 10.1016/j.athoracsur.2018.06.079] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [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: 02/19/2018] [Revised: 06/18/2018] [Accepted: 06/25/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Aortic root replacement (ROOT) has been an established therapy, yet the impact of adding coronary artery bypass grafting (CABG) to ROOT (CABG-R) is unknown. The purpose of this research was to investigate the impact of CABG on the outcomes of ROOT. METHODS A retrospective review from 2004 to 2016 of patients undergoing nonemergent ROOT surgical procedure was performed. Cohorts were established based on the presence or absence of added CABG. A propensity-score weighted comparison of outcomes was then conducted. RESULTS A total of 867 patients met inclusion criteria and were analyzed (711 ROOT [72.0%], 156 CABG-R [18.0%]). CABG-R patients were older and had higher proportions of previous valve operation, hypertension, endocarditis, immunosuppressive therapy, renal insufficiency, and redo operation (all p < 0.01). Indications for CABG included anatomy (n = 48, 30.8%), coronary artery disease (80, 51.3%), and ventricular failure (28, 17.9%). The permanent stroke rate was not significantly increased with the addition of CABG-R (p = 0.06). Thirty-day mortality was 5.5% for the entire cohort but was substantially higher in patients who underwent concomitant CABG (3.4% ROOT, 15.4% CABG-R). Mortality rates were highest among patients with acute ventricular failure and CABG (28.8%) compared with patients who underwent CABG for coronary artery disease (6.3%) or patients for anatomy (22.9%; p = 0.003). CONCLUSIONS CABG-R results in increased postoperative morbidity or mortality compared with isolated ROOT. Outcomes, however, are influenced by the specific clinical indication. CABG for coronary artery disease was associated with similar outcomes compared with isolated ROOT. Patients undergoing unplanned CABG for acute ventricular failure had the worst outcomes, thus underscoring the importance of technical success during coronary reimplantation.
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Affiliation(s)
- W Brent Keeling
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia.
| | - John Hunting
- Department of Anesthesiology, Duke University, Durham, North Carolina
| | | | - Chad Stouffer
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Jose Binongo
- Rollins School of Public Health, Emory University, Atlanta, Georgia
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
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Englum BR, He X, Gulack BC, Ganapathi AM, Mathew JP, Brennan JM, Reece TB, Keeling WB, Leshnower BG, Chen EP, Jacobs JP, Thourani VH, Hughes GC. Hypothermia and cerebral protection strategies in aortic arch surgery: a comparative effectiveness analysis from the STS Adult Cardiac Surgery Database. Eur J Cardiothorac Surg 2017; 52:492-498. [DOI: 10.1093/ejcts/ezx133] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Accepted: 03/30/2017] [Indexed: 01/16/2023] Open
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13
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Keeling WB, Leshnower BG, Binongo J, Lasanajak Y, McPherson L, Chen EP. Severity of Preoperative Aortic Regurgitation Does Not Impact Valve Durability of Aortic Valve Repair Following the David V Valve Sparing Aortic Root Replacement. Ann Thorac Surg 2017; 103:756-763. [DOI: 10.1016/j.athoracsur.2016.07.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 06/04/2016] [Accepted: 07/05/2016] [Indexed: 10/21/2022]
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14
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Keeling WB, Sundt T, Leacche M, Okita Y, Binongo J, Lasajanak Y, Aklog L, Lattouf OM. Outcomes After Surgical Pulmonary Embolectomy for Acute Pulmonary Embolus: A Multi-Institutional Study. Ann Thorac Surg 2016; 102:1498-1502. [PMID: 27373187 DOI: 10.1016/j.athoracsur.2016.05.004] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2016] [Revised: 04/02/2016] [Accepted: 05/02/2016] [Indexed: 11/19/2022]
Abstract
BACKGROUND Surgical pulmonary embolectomy (SPE) has been sparingly used for the successful treatment of massive and submassive pulmonary emboli. To date, all data regarding SPE have been limited to single-center experiences. The purpose of this study was to document short-term outcomes after SPE for acute pulmonary emboli (PE) at four high-volume institutions. METHODS A retrospective review of multiple local Society of Thoracic Surgeons databases of adults undergoing SPE from 1998 to 2014 for acute PE was performed (n = 214). Demographic, operative, and outcomes data were collected and analyzed. Patients were summarily categorized as having either massive or submassive PEs based on the presence or absence of preoperative vasopressors. RESULTS A total of 214 patients with acute PE were treated by SPE. The mean age was 56.0 ± 14.5 years, and 92 (43.6%) patients were female. Of those, 176 (82.2%) PEs were submassive and 38 (17.8%) were massive. Fifteen (7.0%) patients underwent concomitant cardiac procedures, with 10 (4.7%) having simultaneous valvular interventions and 5 (2.4%) undergoing concomitant bypass grafting. Cardiopulmonary bypass (CPB) was used for all cases. Cardioplegic arrest was used for 80 (37.4%) patients. The median CPB and aortic cross clamp times were 71.5 (interquartile range [IQR], 47.0-109.5) and 46.0 (IQR, 26.0-74.5), respectively. Notably, only 25 (11.7%) patients died in the hospital. Mortality was highest among the 28 patients who experienced preoperative cardiac arrest (9, 32.1%) CONCLUSIONS: These data represent the first multicenter experience with SPE for acute pulmonary emboli. Surgical pulmonary embolectomy for acute massive and submassive PE is safe and can be performed with acceptable in-hospital outcomes; the procedure should be included in the multimodality treatment of life-threatening pulmonary emboli.
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Affiliation(s)
- W Brent Keeling
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia.
| | - Thor Sundt
- Division of Cardiothoracic Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Marzia Leacche
- Division of Cardiothoracic Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Yutaka Okita
- Division of Cardiothoracic Surgery, Kobe University, Kobe, Japan
| | - Jose Binongo
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | - Yi Lasajanak
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
| | | | - Omar M Lattouf
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Georgia
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15
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Keeling WB, Chen EP. Maxing out the axillary artery for arterial cannulation in acute type A dissection. J Thorac Cardiovasc Surg 2016; 152:808-9. [PMID: 27321432 DOI: 10.1016/j.jtcvs.2016.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Accepted: 05/26/2016] [Indexed: 11/17/2022]
Affiliation(s)
- W Brent Keeling
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Ga
| | - Edward P Chen
- Division of Cardiothoracic Surgery, Emory University, Atlanta, Ga.
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16
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Maldonado C, Rodriguez‐Alvarez W, Khundmiri S, Pantalos G, Bauer P, Keeling WB, Gray L, Perez‐Abadia G. Infusion of cardioplegia with monounsaturated lipids attenuates myocardial injury: involvement of lipid rafts in the protective effect (667.8). FASEB J 2014. [DOI: 10.1096/fasebj.28.1_supplement.667.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Claudio Maldonado
- EndoProtech, Inc.LouisvilleKYUnited States
- Department of Physiology and Biophysics University of LouisvilleLouisvilleKYUnited States
| | | | - Syed Khundmiri
- Kidney Disease Program University of LouisvilleLouisvilleKYUnited States
| | - George Pantalos
- Department of Surgery University of LouisvilleLouisvilleKYUnited States
| | | | | | - Laman Gray
- Department of Surgery University of LouisvilleLouisvilleKYUnited States
| | - Gustavo Perez‐Abadia
- EndoProtech, Inc.LouisvilleKYUnited States
- Department of Physiology and Biophysics University of LouisvilleLouisvilleKYUnited States
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17
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Keeling WB, Williams ML, Slaughter MS, Zhao Y, Puskas JD. Off-Pump and On-Pump Coronary Revascularization in Patients With Low Ejection Fraction: A Report From The Society of Thoracic Surgeons National Database. Ann Thorac Surg 2013; 96:83-8: discussion 88-9. [DOI: 10.1016/j.athoracsur.2013.03.098] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2013] [Revised: 03/22/2013] [Accepted: 03/27/2013] [Indexed: 10/26/2022]
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18
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Fensterer TF, Keeling WB, Patibandla PK, Pushpakumar S, Perez-Abadia G, Bauer P, Soni CV, Anderson GL, Maldonado C. Stabilizing endothelium of donor hearts with fusogenic liposomes reduces myocardial injury and dysfunction. J Surg Res 2012; 182:331-8. [PMID: 23140789 DOI: 10.1016/j.jss.2012.10.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2012] [Revised: 09/27/2012] [Accepted: 10/12/2012] [Indexed: 11/30/2022]
Abstract
BACKGROUND Myocardial injury after heart transplantation is a consequence of pathophysiologic events initiated by local ischemia/reperfusion injury that is further aggravated by the inflammatory response due to blood exposure to the pump's artificial surfaces during cardiopulmonary bypass. The purpose of the present study was to determine the effectiveness of fusogenic lipid vesicles (FLVs) in enhancing the cardioprotective effect of St. Thomas organ preservation solution (ST). We hypothesized that donor hearts preserved with ST+FLVs will stabilize the endothelium during reperfusion, which, in turn, will reduce both endothelial barrier dysfunction and myocardial damage. METHODS To examine the effect of ST+FLVs therapy in vitro, C3b deposition and adhesion molecule expression studies were performed on human umbilical vein endothelial cells challenged with plastic contact-activated plasma. To assess the therapy in vivo, a cervical heterotopic working heart transplantation model in rats was used. Donor hearts were preserved for 1 h at 27°C (15 min) and 4°C (45 min) and, after transplantation, were followed up for 2 h. Left ventricular function and the blood cardiac troponin I levels were quantified. RESULTS Human umbilical vein endothelial cells treated with ST+FLVs had reduced C3b deposition and expression of adhesion molecules compared with ST alone (P < 0.05). Donor hearts receiving ST+FLVs therapy had reduced left ventricular dysfunction and cardiac troponin I compared with ST alone. CONCLUSIONS We concluded that FLVs enhanced the cardioprotective effect of ST and reduced postischemic left ventricular dysfunction and myocardial damage. The mechanism of protection appears to be associated with the stabilization of endothelial cell membranes owing to incorporation of FLV-derived lipids.
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Affiliation(s)
- Tathyana F Fensterer
- Department of Physiology and Biophysics, University of Louisville, Louisville, KY 40292, USA
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19
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Thourani VH, Keeling WB, Kilgo PD, Puskas JD, Lattouf OM, Chen EP, Guyton RA. The impact of body mass index on morbidity and short- and long-term mortality in cardiac valvular surgery. J Thorac Cardiovasc Surg 2011; 142:1052-61. [DOI: 10.1016/j.jtcvs.2011.02.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2010] [Revised: 01/13/2011] [Accepted: 02/09/2011] [Indexed: 01/29/2023]
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20
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Thourani VH, Keeling WB, Sarin EL, Guyton RA, Kilgo PD, Dara AB, Puskas JD, Chen EP, Cooper WA, Vega JD, Morris CD, Halkos ME, Lattouf OM. Impact of Preoperative Renal Dysfunction on Long-Term Survival for Patients Undergoing Aortic Valve Replacement. Ann Thorac Surg 2011; 91:1798-806; discussion 1806-7. [DOI: 10.1016/j.athoracsur.2011.02.015] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Revised: 02/04/2011] [Accepted: 02/08/2011] [Indexed: 12/01/2022]
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21
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Hernandez JM, Humphries LA, Keeling WB, Golkar F, Dimou F, Garrett J, Sommers KE. Robotic lobectomy: flattening the learning curve. J Robot Surg 2011; 6:41-5. [PMID: 27637978 DOI: 10.1007/s11701-011-0275-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2010] [Accepted: 05/09/2011] [Indexed: 10/18/2022]
Abstract
Early experience with robotic technology in pulmonary resection has emphasized a steep learning curve. We initiated a robotic thoracic surgical program with the goal of minimizing complications, operative times, and hospital stays. We implemented robotic lobe resections at our institution with the intent of performing an operationally analogous procedure to that of the open technique. Specifically, we used single docking of the robotic cart, innovative retraction, single interspace port placement, and dockings specific to the resected lobe. We reviewed outcomes for patients undergoing robotic lobectomy at our institution. Data is presented as mean ± standard deviation. 20 patients (69 ± 12 years) underwent robotic lobe resections. American Joint Committee on Cancer staging for 14 patients undergoing resections for non-small cell lung cancers were Stage I (10), Stage II (2), and Stage III (2). Operative times for 20 patients undergoing robotic lobectomies were 203 ± 53 min. Median postoperative hospital stay was 3 days. Conversions to open procedures were required in two patients secondary to failure to progress (1) and bleeding (1). Complications occurred in four (20%) patients and included atelectasis (2), myocardial infarction (1), and atrial fibrillation (1). No fatalities occurred. The perception that robotic pulmonary resection involves a steep learning curve may not be universally accurate; our operative times and hospital stays are consistent with those reported by established programs. For surgeons experienced in open and thoracoscopic lobectomy, appropriate patient selection coupled with the specific robotic techniques described may flatten the learning curve.
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Affiliation(s)
- Jonathan M Hernandez
- Division of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, FOB-2, Tampa, FL, 33612, USA. .,Department of Surgery, University of South Florida, 1 Tampa General Circle, Tampa, FL, 33606, USA.
| | - Leigh Ann Humphries
- Division of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, FOB-2, Tampa, FL, 33612, USA
| | - W Brent Keeling
- Division of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, FOB-2, Tampa, FL, 33612, USA.,Department of Surgery, University of South Florida, 1 Tampa General Circle, Tampa, FL, 33606, USA
| | - Farhaad Golkar
- Division of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, FOB-2, Tampa, FL, 33612, USA.,Department of Surgery, University of South Florida, 1 Tampa General Circle, Tampa, FL, 33606, USA
| | - Francesca Dimou
- Division of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, FOB-2, Tampa, FL, 33612, USA.,Department of Surgery, University of South Florida, 1 Tampa General Circle, Tampa, FL, 33606, USA
| | - Joseph Garrett
- Division of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, FOB-2, Tampa, FL, 33612, USA
| | - K Eric Sommers
- Division of Thoracic Oncology, H. Lee Moffitt Cancer Center and Research Institute, 12902 Magnolia Drive, FOB-2, Tampa, FL, 33612, USA
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Thourani VH, Keeling WB, Guyton RA, Dara A, Hurst SD, Lattouf OM. Outcomes of Off-Pump Aortic Valve Bypass Surgery for the Relief of Aortic Stenosis in Adults. Ann Thorac Surg 2011; 91:131-6. [DOI: 10.1016/j.athoracsur.2010.10.074] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2010] [Revised: 10/24/2010] [Accepted: 10/26/2010] [Indexed: 11/26/2022]
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Keeling WB, Halkos ME, Puskas JD. Management of patients with a calcified aorta or low ejection fraction undergoing multivessel coronary revascularization. Semin Thorac Cardiovasc Surg 2010; 22:250-2. [PMID: 21167460 DOI: 10.1053/j.semtcvs.2010.10.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/15/2010] [Indexed: 11/11/2022]
Abstract
Off-pump coronary artery bypass surgery (OPCAB) provides an alternative method of surgical revascularization by allowing coronary anastomoses to be constructed without the use of cardiopulmonary bypass and without manipulation of the aorta. The presence of a calcified aorta is one of the strongest indications for OPCAB because both distal and proximal anastomoses can be performed without cannulation or clamping of the aorta. In patients with left ventricular dysfunction, OPCAB techniques allow for revascularization without the need for global myocardial ischemia associated with cardioplegic arrest.
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Affiliation(s)
- W Brent Keeling
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Keeling WB, Miller DL, Lam GT, Kilgo P, Miller JI, Mansour KA, Force SD. Low mortality after treatment for esophageal perforation: a single-center experience. Ann Thorac Surg 2010; 90:1669-73; discussion 1673. [PMID: 20971287 DOI: 10.1016/j.athoracsur.2010.06.129] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [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: 01/27/2010] [Revised: 06/21/2010] [Accepted: 06/23/2010] [Indexed: 02/02/2023]
Abstract
BACKGROUND Historically, esophageal perforation has been associated with significant mortality. Improvements in diagnosis, critical care, and surgical and endoscopic techniques may lead to lower mortality rates in the modern era. We reviewed our experience with the management of esophageal perforation to determine whether outcomes have improved. METHODS We retrospectively reviewed all cases of esophageal perforation from 1997 through 2008 at our institution. Univariate and propensity-matching analysis were performed. RESULTS We reviewed the charts of 147 patients, and 97 met eligibility criteria. There were 45 women, (46.4%); mean age was 60.7 ± 15.6 years. Etiologies included iatrogenic in 50 (51.6%), spontaneous in 23 (23.7%), and idiopathic in 22 (22.7%). Treatment within 24 hours of presentation occurred in 55.2% of patients; 22.7% of patients were septic on presentation. Treatment included surgery in 72 patients (74.2%) and nonoperative management in 25 (25.8%). Forty-one patients (42.3%) underwent primary repair, 5 (6.9%) underwent esophageal resection, 4 (5.6%) underwent exclusion, and 22 (22.7%) underwent drainage or stent placement. Thirty-day mortality rate for the entire cohort was only 8.3% (8 patients). The mortality rate for the primary repair patients was 7.7%, and none of the resection patients died. There was similar in-hospital mortality rate between operative and nonoperative treatment groups (p = 0.96). Propensity-matching analysis showed equal morbidity (p = 0.74) and 30-day mortality (p = 0.35) between operative and nonoperative treatment groups. CONCLUSIONS Our study represents a large series of patients treated for esophageal perforation. The results demonstrate that the overall mortality from esophageal perforation can be less than 10%. Primary repair should be considered as first-line treatment when appropriate even in patients who present more than 24 hours after perforation. Nonoperative management, in appropriate patients, can also lead to good success rates and low mortality.
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Keeling WB, Hernandez JM, Lewis V, Czapla M, Zhu W, Garrett JR, Sommers KE. Increased age is an independent risk factor for radiographic aspiration and laryngeal penetration after thoracotomy for pulmonary resection. J Thorac Cardiovasc Surg 2010; 140:573-7. [DOI: 10.1016/j.jtcvs.2010.02.049] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Revised: 01/30/2010] [Accepted: 02/27/2010] [Indexed: 10/19/2022]
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Klepczyk L, Keeling WB, Stone PA, Shames ML. Superior mesenteric artery stent fracture producing stenosis and recurrent chronic mesenteric ischemia: case report. Vasc Endovascular Surg 2008; 42:79-81. [PMID: 18238874 DOI: 10.1177/1538574407308207] [Citation(s) in RCA: 21] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Endovascular modalities are being increasingly employed in the treatment of a variety of vascular diseases. With new technologies come novel complications, and one such complication unique to endovascular surgery is stent fracture. We present two cases of stent fracture following stenting of the superior mesenteric artery and discuss possible causes and treatments.
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Affiliation(s)
- Lisa Klepczyk
- Division of Vascular and Endovascular Surgery, University of South Florida College of Medicine, Tampa, Florida, USA
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Keeling WB, Hackmann AE, Colter ME, Stone PA, Johnson BL, Back MR, Bandyk DF, Shames ML. MF-tricyclic inhibits growth of experimental abdominal aortic aneurysms. J Surg Res 2007; 141:192-5. [PMID: 17574591 DOI: 10.1016/j.jss.2006.12.544] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2006] [Revised: 12/13/2006] [Accepted: 12/13/2006] [Indexed: 11/19/2022]
Abstract
BACKGROUND Experimental abdominal aortic aneurysm (AAA) development can be pharmacologically suppressed by inhibiting matrix metalloproteinase-9 (MMP-9). Cyclooxygenase-2 (COX-2) inhibitors are potent anti-inflammatory agents that have been demonstrated to inhibit experimental aneurysm development. We hypothesized that treatment with MF-tricyclic, a selective COX-2 inhibitor, incorporated into rodent chow would inhibit aneurysm development in a rat AAA model. METHODS Twelve male Sprague Dawley rats underwent induction of experimental AAA using intra-aortic porcine elastase infusion. Six rats received control feed, and six received MF-tricyclic rodent chow for a period of 14 days. Aortic diameters were measured pre- and postinfusion as well as at harvest. Aortic tissue samples were evaluated by real-time polymerase chain reaction (RT-PCR) for MMP-9, by immunohistochemistry for elastin. RESULTS Elastase infusion produced AAA in all untreated rats. At 14 days MF-tricyclic-treated rats had significantly reduced aortic diameter (1.9 +/- 0.1 mm versus 2.4 +/- 0.0 mm, P = 0.00001). Percent increase in aortic diameter was also significantly less in animals receiving MF-tricyclic (65.7 +/- 8.5% versus 132.3 +/- 7.3%, P = 0.0001). RT-PCR demonstrated a decrease in the mean expression of MMP-9 in the treated animals (0.414 ng of RNA versus 1.114 ng of RNA) (P = 0.07). Sections stained for elastin demonstrated preserved elastin integrity in MF-tricyclic treated aortas. CONCLUSIONS COX-2 inhibition helps to retard the growth of experimental AAAs possibly through inhibition of MMP-9. Experimentally treated animals demonstrated smaller aortic diameters and lower levels of tissue MMP-9 when compared to untreated animals. Selective COX-2 inhibition may offer an additional method to pharmacologically inhibit AAAs.
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Affiliation(s)
- W Brent Keeling
- University of South Florida Division of Vascular and Endovascular Surgery, Tampa, Florida 33606, USA
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Keeling WB, Maxey TS, Sayad D, Martini N, Blazick E, Sommers KE. A novel stentless mitral valve. Surg Innov 2007; 14:9-11. [PMID: 17442873 DOI: 10.1177/1553350606298719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Stentless mitral valves have found little clinical utility to date due to difficulty in insertion. A new design for a stentless mitral valve, a modification of an existing aortic stentless prosthesis, is described. The new design mimics the native mitral physiology, and its insertion is easier than with existing stentless mitral valves. Commercially available stentless aortic valves were inserted into 2 pigs. The valves were modified so that the commissural posts were restrained. The valves were partially recessed into the left ventricular cavity, secured to the annulus, and anchored to the native papillary muscles. Both pigs were weaned from bypass successfully, and both valves functioned normally with trace regurgitation noted on echocardiography. This design affords the benefit of the reapproximation of native physiology. Preservation of papillary-annular continuity should allow maximal left ventricular function. Lack of a stent should allow avoidance of long-term anticoagulation.
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Affiliation(s)
- W Brent Keeling
- University of South Florida, Division of Cardiothoracic Surgery, Tampa, Florida, USA
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Keeling WB, Lewis V, Blazick E, Maxey TS, Garrett JR, Sommers KE. Routine Evaluation for Aspiration After Thoracotomy for Pulmonary Resection. Ann Thorac Surg 2007; 83:193-6. [PMID: 17184659 DOI: 10.1016/j.athoracsur.2006.08.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2006] [Revised: 07/31/2006] [Accepted: 08/02/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the role of a routine protocol for evaluation of oropharyngeal aspiration after thoracotomy for pulmonary resection. METHODS Demographic, operative, and outcomes data were collected prospectively for consecutive patients undergoing thoracotomy for pulmonary resection starting in April 2005. Starting on postoperative day one, patients underwent evaluation by a licensed speech therapist before per os intake. Patients failing clinical examination were referred for radiographic evaluation. Diets were advanced on the basis of results from both clinical and radiographic evaluation. Data analysis included descriptive statistics, Student's t test, and chi2 test when appropriate. RESULTS One hundred forty patients were prospectively evaluated during this period. Thirty-two patients (22.9%) failed initial clinical swallowing evaluation and were referred for dynamic videofluoroscopic esophagram. Twenty-five patients (17.8%) had evidence of potential oropharyngeal aspiration on videofluoroscopic esophagram. Only 1 patient (0.7%) aspirated after a negative clinical evaluation. Univariate risk factor analysis revealed that patients demonstrating aspiration were older (67.7 +/- 1.6 years versus 64.4 +/- 1.1 years; p = 0.10) and had a higher incidence of head and neck malignancy (p < 0.001). Patients without radiographic aspiration had a shorter median hospital stay when compared with those who did (6 days versus 5 days). CONCLUSIONS Aspiration after thoracotomy for pulmonary resection may affect nearly 20% of patients and is likely underrepresented in the surgical literature. The institution of a protocol to evaluate risk of aspiration has characterized patients at high risk and led to an increased awareness of the potential for aspiration after thoracotomy.
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Affiliation(s)
- W Brent Keeling
- Division of Cardiothoracic Surgery, University of South Florida, Tampa, Florida, USA
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Keeling WB, Shames ML, Stone PA, Armstrong PA, Johnson BL, Back MR, Bandyk DF. Plaque excision with the Silverhawk catheter: Early results in patients with claudication or critical limb ischemia. J Vasc Surg 2007; 45:25-31. [PMID: 17210379 DOI: 10.1016/j.jvs.2006.08.080] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2006] [Accepted: 08/29/2006] [Indexed: 11/17/2022]
Abstract
OBJECTIVE This study was conducted to detail the early experience after infrainguinal atherectomy using the Silverhawk plaque excision catheter for the treatment of symptomatic peripheral vascular disease. METHODS A prospective database was established in August 2004 in which data for operations, outcomes, and follow-up were recorded for patients undergoing percutaneous plaque excision for peripheral arterial occlusive disease. Society for Vascular Surgery (SVS) ischemia scores and femoropopliteal TransAtlantic Inter-Society Consensus (TASC) criteria were assigned. A follow-up protocol included duplex ultrasound surveillance at 1, 3, and 6 months and then yearly thereafter. Standard statistical analyses were performed. RESULTS During a 17-month period, 66 limbs of 60 patients (37 men [61.7%]) underwent 70 plaque excisions (four repeat procedures). Indications included tissue loss based on SVS ischemia at grades 5 and 6 (25/70), rest pain at grade 4 (22/70), and claudication at grades 2 to 3 (23/70). The mean lesion length was 8.8 +/- 0.7 cm. The technical success rate was 87.1% (61/70). Adjunctive treatment was required in 17 procedures (24.3%), consisting of 14 balloon angioplasties and three stents. Femoropopliteal TASC criteria included 5 TASC A lesions, 14 TASC B lesions, 32 TASC C lesions, and 19 TASC D lesions. Although 17 plaque excisions included a tibial vessel, no patient underwent isolated tibial atherectomy. The mean increase in ankle-brachial index was 0.27 +/- 0.04 and in toe pressure, 20.3 +/- 6.9 mm Hg. Mean duplex ultrasound follow-up was 5.2 months (range, 1 to 17 months). One-year primary, primary assisted, and secondary patency was 61.7%, 64.1%, and 76.4%, respectively. Restenosis or occlusion developed in 12 patients (16.7%) and was detected at a mean of 2.8 +/- 0.7 months. Restenosis or occlusion was significantly more common (P < .05) in patients with TASC C and D lesions compared with patients with TASC A and B lesions. Six (8.3%) of 12 patients underwent reintervention on the basis of duplex ultrasound surveillance results. Four (33.3%) of 12 patients experienced reocclusion during the same hospitalization, and amputation and open revascularization were required in two patients each. CONCLUSIONS Percutaneous plaque excision is a viable treatment option for lower extremity revascularization. Outcomes are related to ischemia and lesion severity. Patency and limb salvage rates are equivalent to other endovascular modalities.
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Affiliation(s)
- W Brent Keeling
- Division of Vascular and Endovascular Surgery, University of South Florida,Tampa, FL, USA
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Keeling WB, Armstrong PA, Stone PA, Zweibel BR, Kudryk BT, Johnson BL, Back MR, Bandyk DF, Shames ML. Risk factors for recurrent hemorrhage after successful mesenteric arterial embolization. Am Surg 2006; 72:802-6; discussion 806-7. [PMID: 16986390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
The objective of this study was to describe the risk factors and to determine the outcomes after recurrent gastrointestinal hemorrhage after successful mesenteric arterial embolization A retrospective analysis was undertaken of a single-center experience with mesenteric arterial embolization performed for gastrointestinal hemorrhage over a 5-year period. Statistical analyses including Student's t test and Fisher's exact test were used to compare results. For the years 2001 through 2005, 36 patients (10 women; average age, 60.8 years) underwent 37 technically successful mesenteric embolizations for acute gastrointestinal hemorrhage. Two (5.4%) cases required surgical intervention for cessation of hemorrhage, and six (16.2%) patients died during their hospitalization after technically successful embolization. Nine (24.3%) patients experienced in-hospital rehemorrhage, and of these, five (55.6%) died. Risk factors for rehemorrhage included intra-abdominal malignancy (P < 0.05), transfusion requirement greater than 10 units before angiography (P < 0.05), and the source of hemorrhage other than solitary gastroduodenal artery hemorrhage (P < 0.05). The failure of initial embolization was associated with an increased incidence of death (55.6% vs 5.0%; P < 0.05) and operative intervention to cease hemorrhage (P < 0.05). The failure of technically successful mesenteric embolization is not uncommon and is associated with identifiable risk factors. Risk factor awareness should assist in patient selection for and timing of mesenteric embolization.
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Affiliation(s)
- W Brent Keeling
- University of South Florida Division of Vascular and Endovascular Surgery, Tampa, USA
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Stone PA, Armstrong PA, Bandyk DF, Keeling WB, Flaherty SK, Shames ML, Johnson BL, Back MR. Duplex ultrasound criteria for femorofemoral bypass revision. J Vasc Surg 2006; 44:496-502. [PMID: 16950423 DOI: 10.1016/j.jvs.2006.06.002] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2006] [Accepted: 06/03/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE This study was conducted to evaluate the impact of duplex ultrasound surveillance on the patency of femorofemoral bypasses performed for symptomatic peripheral arterial occlusive disease (PAOD). METHODS A retrospective review was conducted of 108 patients (78 men, 30 women) with a mean age of 62 +/- 10 years who underwent femorofemoral prosthetic (n = 100) or vein (n = 8) bypass grafting for symptomatic PAOD (claudication, 38%; rest pain, 41%; tissue loss, 11%; infection, 10%) during a 10-year period. Prior or concomitant inflow iliac artery stenting was performed in 26 patients (24%), and a redo femorofemoral bypass was performed in 19 patients (18%). Duplex ultrasound surveillance of the reconstruction was performed at 6-month intervals to assess patency, graft (midgraft peak systolic flow velocity) hemodynamics, and identify inflow or outflow stenotic lesions. Repair was recommended for a stenosis with a peak systolic velocity (PSV) >300 cm/s and a PSV ratio >3.5. Life-table analysis was used to estimate primary, assisted-primary, and secondary graft patency. RESULTS During a mean 40-month follow-up (range, 2 to 120 months), 31 bypasses (29%) were revised: 19 duplex-detected stenosis involving the inflow iliac artery (n = 15) or anastomotic stenosis (n = 4), or both, 11 for graft thrombosis, and 1 for graft infection. Abnormal inflow iliac (PSV >300 cm/s) hemodynamics or a mid-graft PSV <60 cm/s was measured in eight of 11 grafts before thrombosis. Mean time to revision was 30 +/- 17 months. The primary graft patency at 1, 3, and 5 years was 86%, 78%, and 62%, respectively. Correction of duplex-detected stenosis resulted in assisted-primary patency of 95% at 1 year and 88% at 3 and 5 years (P < .0001, log-rank). Secondary graft patency was 98% at 1 year and 93% at 3 and 5 years. CONCLUSIONS Vascular laboratory surveillance after femorofemoral bypass that included duplex ultrasound imaging of the inflow iliac artery and graft accurately identified failing grafts. A duplex-detected identified stenosis with a PSV >300 cm/s correlated with failure, and repair of identified lesions was associated with excellent 5-year patency.
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Affiliation(s)
- Patrick A Stone
- Division of Vascular & Endovascular Surgery, University of South Florida College of Medicine, Tampa, 33606, USA
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Blazick E, Keeling WB, Armstrong P, Letson D, Back M. Pseudoaneurysm of the superficial femoral artery associated with osteochondroma--a case report. Vasc Endovascular Surg 2006; 39:355-8. [PMID: 16079946 DOI: 10.1177/153857440503900409] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [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: 11/15/2022]
Abstract
Osteochondromas, the most common benign bone tumor, often go undetected and seldom cause significant clinical sequelae. Rarely they present as an arterial pseudoaneurysm, usually of the popliteal or superficial femoral artery. The authors present the case of a 14-year-old male with a distal superficial femoral artery pseudoaneurysm accompanied by distal embolization from a femoral exostosis.
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Affiliation(s)
- Elizabeth Blazick
- University of South Florida, Division of Vascular and Endovascular Surgery, Tampa, FL 33606, USA
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Keeling WB, Stone PA, Armstrong PA, Kearney H, Klepczyk L, Blazick E, Back MR, Johnson BL, Bandyk DF, Shames ML. Increasing Endovascular Intervention for Claudication: Impact on Vascular Surgery Resident Training. J Endovasc Ther 2006; 13:507-13. [PMID: 16928167 DOI: 10.1583/06-1843.1] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
PURPOSE To audit the caseloads of vascular surgery residents in the management of disabling claudication and assess the influence of endovascular procedures on overall operative experience. METHODS A retrospective review was conducted of vascular surgery resident experience in the open and endovascular management of lower limb claudication during two 3-year periods (January 2000 to December 2002 and January 2003 to December 2005). The time periods differed with regard to number of surgical faculty with advanced endovascular skills (3 in the first period and 4 in the second) and the availability of portable operating room angiography equipment. RESULTS During the 6-year period, the operative logs of vascular surgery residents indicated participation in 283 procedures [170 (60%) open surgical interventions, including 146 suprainguinal procedures] performed for claudication. The number of procedures increased by 62% (p<0.05) from the first period (n=108) to the second (n=175). Endovascular intervention to treat aortoiliac occlusive disease increased 4-fold (14 versus 56 interventions, p=0.01) compared to a decrease in open (bypass grafting, endarterectomy) surgical repair (45 to 31 procedures, p=0.22). The greatest change in resident experience was in endovascular intervention of infrainguinal occlusive disease: the case volume increased from 4 to 39 procedures (p=0.07) during the 2 time intervals. By contrast, the number of open surgical bypass procedures was similar (45 versus 49) in each 3-year period. CONCLUSION An audit of resident experience demonstrated intervention for claudication has increased during the past 6 years. The increased operative experience reflects more endovascular treatment (atherectomy, angioplasty, stent-graft placement) of femoropopliteal and aortoiliac occlusive disease, but no decrease in open surgical operative experience for claudication. This increase in endovascular intervention may be related to a decrease in the threshold for intervention.
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Affiliation(s)
- W Brent Keeling
- Division of Vascular and Endovascular Surgery, University of South Florida College of Medicine, Tampa, Florida, USA
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Abstract
The objective of this study is to demonstrate the effectiveness and feasibility in treating empyema after pulmonary resection with a modified Clagett procedure performed at the bedside (BMCP). A retrospective review of a single surgeon's experience at a single institution was undertaken. All operative, postoperative, and outcome data were analyzed. Follow-up data were obtained from subsequent clinic charts. Five patients, including four males, were identified who underwent BMCP after pulmonary resection. The original operative procedures included two lobectomies, one pneumonectomy, one bilobectomy, and one bilateral metastastectomy. Patients were diagnosed with an empyema (positive thoracostomy tube culture, fever, and radiographic abnormality) at a mean time of 31 days from their initial procedure. Culture results disclosed Gram-positive empyemas in all patients. Three patients underwent BMCP as an outpatient, whereas the other two had BMCP during their hospitalizations. All patients are free from complications or recurrence at a mean follow up of 11.2 months. No patient required a further procedure after BMCP. The bedside modified Clagett procedure is both safe and effective. It is a valuable option in the management of postoperative empyema because it avoids additional operative procedures. This procedure is cost-effective when compared with operative management of perioperative empyema.
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Affiliation(s)
- W. Brent Keeling
- From the University of South Florida, Division of Cardiothoracic Surgery, Tampa, Florida
| | - Joseph R. Garrett
- From the University of South Florida, Division of Cardiothoracic Surgery, Tampa, Florida
| | - Nasreen Vohra
- From the University of South Florida, Division of Cardiothoracic Surgery, Tampa, Florida
| | - Thomas S. Maxey
- From the University of South Florida, Division of Cardiothoracic Surgery, Tampa, Florida
| | - Elizabeth Blazick
- From the University of South Florida, Division of Cardiothoracic Surgery, Tampa, Florida
| | - K. Eric Sommers
- From the University of South Florida, Division of Cardiothoracic Surgery, Tampa, Florida
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Keeling WB, Garrett JR, Vohra N, Maxey TS, Blazick E, Sommers KE. Bedside modified Clagett procedure for empyema after pulmonary resection. Am Surg 2006; 72:627-30. [PMID: 16875085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
The objective of this study is to demonstrate the effectiveness and feasibility in treating empyema after pulmonary resection with a modified Clagett procedure performed at the bedside (BMCP). A retrospective review of a single surgeon's experience at a single institution was undertaken. All operative, postoperative, and outcome data were analyzed. Follow-up data were obtained from subsequent clinic charts. Five patients, including four males, were identified who underwent BMCP after pulmonary resection. The original operative procedures included two lobectomies, one pneumonectomy, one bilobectomy, and one bilateral metastastectomy. Patients were diagnosed with an empyema (positive thoracostomy tube culture, fever, and radiographic abnormality) at a mean time of 31 days from their initial procedure. Culture results disclosed Gram-positive empyemas in all patients. Three patients underwent BMCP as an outpatient, whereas the other two had BMCP during their hospitalizations. All patients are free from complications or recurrence at a mean follow up of 11.2 months. No patient required a further procedure after BMCP. The bedside modified Clagett procedure is both safe and effective. It is a valuable option in the management of postoperative empyema because it avoids additional operative procedures. This procedure is cost-effective when compared with operative management of perioperative empyema.
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Affiliation(s)
- W Brent Keeling
- University of South Florida, Division of Cardiothoracic Surgery, Tampa, Florida, USA
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Maxey TS, Keeling WB, Sommers KE. Surgical alternatives for the palliation of heart failure: a prospectus. J Card Fail 2006; 11:670-6. [PMID: 16360961 DOI: 10.1016/j.cardfail.2005.07.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2005] [Revised: 07/11/2005] [Accepted: 07/14/2005] [Indexed: 11/29/2022]
Abstract
BACKGROUND Congestive heart failure (CHF) is the leading cause of hospital admissions in the United States. METHODS AND RESULTS CHF has a variety of palliative options for treatment and 1 curative one: cardiac transplantation. Palliative medical therapies are often limited in effectiveness by progression of the disease or patient intolerance. Because of limited donor availability, alternative surgical strategies are now being relied on for palliation of patients in end-stage CHF. CONCLUSION In this manuscript, we review the principles, outcomes, and practices of some of these surgical strategies often used in the palliation of end-stage CHF.
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Affiliation(s)
- Thomas S Maxey
- Department of Surgery, University of South Florida, Tampa, Florida 33612, USA
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Keeling WB, Armstrong PA, Stone PA, Bandyk DF, Shames ML. An overview of matrix metalloproteinases in the pathogenesis and treatment of abdominal aortic aneurysms. Vasc Endovascular Surg 2006; 39:457-64. [PMID: 16382266 DOI: 10.1177/153857440503900601] [Citation(s) in RCA: 87] [Impact Index Per Article: 4.8] [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: 11/16/2022]
Abstract
Recent basic and clinical research has established a link between the pathogenesis of abdominal aortic aneurysms (AAA) and matrix metalloproteinases (MMP). The discovery of the influence of MMPs on in vitro and in vivo aneurysm development has yielded promising information that may eventually decode the pathogenetic factors affecting the initiation and growth rate of AAAs. In this review, an analysis of MMPs involved in AAA disease is presented, including the data from recent research studies and planned clinical drug trails designed to retard the AAA growth by inhibiting MMP activity.
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Affiliation(s)
- W Brent Keeling
- Division of Vascular and Endovascular Surgery, University of South Florida College of Medicine, Tampa, FL 33606, USA
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Stone PA, Back MR, Armstrong PA, Flaherty SK, Keeling WB, Johnson BL, Shames ML, Bandyk DF. Midfoot Amputations Expand Limb Salvage Rates for Diabetic Foot Infections. Ann Vasc Surg 2005; 19:805-11. [PMID: 16205848 DOI: 10.1007/s10016-005-7973-3] [Citation(s) in RCA: 81] [Impact Index Per Article: 4.3] [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: 11/25/2022]
Abstract
The persistent high incidence of limb loss resulting from advanced forefoot tissue loss and infection in diabetic patients prompted an evaluation of transmetatarsal (TMA) and transtarsal/midfoot amputations in achieving foot salvage at our tertiary vascular practice. Over the last 8 years, 74 diabetic patients required 77 TMAs for tissue loss and/or infection. Twelve (16%) of the patients had a contralateral below-knee amputation (BKA) and 26% (n = 20) had dialysis-dependent renal failure. Thirty-five (45%) limbs had concomitant revascularization (bypass grafting or percutaneous transluminal angioplasty), 32 (42%) had arterial occlusive disease by noninvasive testing and/or arteriography but were not or could not be revascularized, and seven (13%) had normal hemodynamics. Patient factors, arterial testing, operative complications, operative mortality (<60 days), wound healing (at 90 days), limb salvage, functional status, and survival were evaluated during a mean follow-up of 20 months (range 3-48). Operative mortality was 5% (n = 4) after TMA and/or midfoot amputation. Although 32 TMAs initially healed (44%), six BKAs were required 5-38 months later. Of the 41 nonhealing TMAs (56%), progressive infection/tissue loss necessitated major amputation of nine limbs. Chopart (n = 22) or Lisfranc (n = 10) midfoot amputations were done in the remaining 32 nonhealing TMAs. Despite additional wound revisions in 14 patients (44%), major amputation was needed in six limbs. However, functional ambulation was achieved in 23 of 25 (92%) limbs with healed midfoot amputations, and foot salvage was possible in 61% (25/41) of nonhealing TMAs. Overall limb salvage for TMA/midfoot procedures was estimated from Kaplain-Meier life tables to be 73%, 68%, and 62% at 1, 3, and 5 years, respectively, with only 50% of dialysis patients avoiding major amputation. Ankle pressure >100 mm Hg and a biphasic pedal waveform had a positive predictive value (PPV) of 79%, and toe pressure >50 mm Hg had a PPV of 91% for determining healing of TMA/midfoot amputations. One- and 3-year survival rates were only 72% and 69% for the entire cohort from life table estimates. Aggressive attempts at foot salvage are justified in diabetic patients with advanced forefoot tissue loss/infection after assuring adequate arterial perfusion. Transtarsal amputations salvaged over half of nonhealing TMAs with excellent functional results.
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Affiliation(s)
- Patrick A Stone
- Division of Vascular and Endovascular Surgery, University of South Florida, Tampa, FL 33606, USA
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Keeling WB, Haines K, Stone PA, Armstrong PA, Murr MM, Shames ML. Current Indications for Preoperative Inferior Vena Cava Filter Insertion in Patients Undergoing Surgery for Morbid Obesity. Obes Surg 2005; 15:1009-12. [PMID: 16105398 DOI: 10.1381/0960892054621279] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [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: 11/08/2022]
Abstract
BACKGROUND Pulmonary embolus is a potentially lethal complication in patients undergoing surgery for morbid obesity. In a select group of patients at high risk for venous thromboembolic events (VTE), we have chosen to prophylactically insert inferior vena cava filters via a jugular percutaneous approach. We propose guidelines for preoperative insertion of inferior vena cava filters in patients with clinically significant obesity. METHODS All patients who underwent preoperative insertion of inferior vena cava (IVC) filters as prophylaxis for pulmonary emboli were reviewed. Data regarding body mass index (BMI), prior history of venous thromboembolism, current anticoagulant usage, as well as other patient data were compiled and analyzed. Additionally, all operative notes were reviewed, and operative data were analyzed and compared. RESULTS 14 patients underwent preoperative IVC filter placement before gastric bypass. Mean patient age was 49.1 +/- 1.52 years and mean BMI was 56.5 +/- 4.45 kg/m2. No complications occurred due to preoperative filter placement, and no pulmonary emboli occurred in this group. Indications for preoperative IVC filter insertion included prior pulmonary embolus (6), prior deep venous thrombosis (7), and lower extremity venous stasis (1). CONCLUSIONS Vena caval filter placement in the preoperative period can be undertaken safely in bariatric patients. We recommend that routine preoperative vena caval filter placement should be undertaken in all bariatric patients with prior pulmonary embolus, prior deep venous thrombosis, evidence of venous stasis, or known hypercoagulable state. Possible roles for IVC filter placement in this patient population are expanding as more data is acquired.
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Affiliation(s)
- W Brent Keeling
- University of South Florida, Department of Surgery and Division of Vascular Surgery, Tampa, FL, USA
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Stone PA, Armstrong PA, Bandyk DF, Keeling WB, Flaherty SK, Shames ML, Johnson BL, Back MR. The value of duplex surveillance after open and endovascular popliteal aneurysm repair. J Vasc Surg 2005; 41:936-41. [PMID: 15944589 DOI: 10.1016/j.jvs.2005.03.021] [Citation(s) in RCA: 61] [Impact Index Per Article: 3.2] [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: 11/26/2022]
Abstract
OBJECTIVE The objective of this study was to determine the clinical value of vascular laboratory surveillance after open or endovascular repair of popliteal aneurysm by analysis of the frequency and nature of secondary interventions performed. METHODS Over an 8-year period, 55 popliteal artery aneurysms were repaired in 46 men (mean age, 72 years) by aneurysm ligation and bypass grafting (vein, 37; prosthetic, 7), endoaneurysmorrhaphy and interposition grafting (prosthetic, 3; vein, 1), or endograft exclusion (n = 7). Indications for intervention included aneurysm thrombosis with critical limb ischemia (n = 8), symptomatic (n = 10) or asymptomatic (n = 37), >1.75 cm popliteal aneurysm with mural thrombus. Catheter-directed thrombolysis was used in three limbs to restore aneurysm and tibial artery patency before open repair. Duplex ultrasound surveillance was performed after repair to identify residual and acquired lesions. Life-table analysis was used to estimate repair site intervention-free (primary) and assisted-primary patency. RESULTS During a mean 20-month follow-up interval, 20 secondary procedures were performed in 18 (31%) limbs to repair duplex-detected graft stenosis (n = 10), repair site thrombosis (n = 5), vein graft aneurysm (n = 3), graft entrapment (n = 1), or type 1 endoleak (n = 1). Primary patency was 76% and 68% at 1 and 3 years, and was uninfluenced by tibial artery runoff status or type of bypass conduit. Open (n = 12) or endovascular (n = 8) secondary procedures were performed on 15 (12 vein, 3 prosthetic) bypass grafts, 2 endografts, and 1 interposition graft. Mean time to repair graft stenosis (11 months) was shorter than to repair of vein graft aneurysm (37 months). Assisted-primary patency was 93% and 88% at 1 and 3 years; redo bypass grafting was required and successful in five limbs. Limb salvage was 100%. CONCLUSIONS One third of popliteal artery aneurysms repaired by open or endovascular procedures required a secondary intervention within 2 years of repair. Repair-site surveillance using duplex ultrasound was able to identify lesions that threaten patency, which resulted in excellent assisted patency and limb preservation rates when corrected.
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Affiliation(s)
- Patrick A Stone
- Division of Vascular and Endovascular Surgery, University of South Florida College of Medicine, Tampa, USA
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