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Meidan TG, Lanfear AT, Squiers JJ, Hamandi M, Lytle BW, DiMaio JM, Smith RL. Robotic Mitral Valve Surgery After Prior Sternotomy. JTCVS Tech 2022; 13:46-51. [PMID: 35711230 PMCID: PMC9196136 DOI: 10.1016/j.xjtc.2022.01.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Accepted: 01/12/2022] [Indexed: 11/17/2022] Open
Abstract
Objective Despite the recent increase in the use of minimally invasive approaches to mitral valve surgery in patients with a prior sternotomy, the outcomes of the robotic approach to mitral valve surgery in this patient population have not been examined. Methods We retrospectively reviewed 342 consecutive patients who underwent mitral valve surgery after a prior sternotomy between 2013 and 2020, in which the robotic approach was used in 21 patients (6.1%). We reviewed the clinical details of these 21 patients. Results The median age was 71 years [interquartile range 64.00, 74.00 years], and mean Society of Thoracic Surgeons Predicted Risk of Mortality was 4.2% ± 3.8%. The indication for mitral valve surgery was degenerative mitral valve disease in 33.3% (7/21), functional disease in 28.6% (6/21), mixed disease in 4.8% (1/21), rheumatic disease in 9.5% (2/21), and failed repair for degenerative disease in 23.8% (5/21). No cases required conversion from robotic assistance to alternative approaches, there were no intraoperative deaths, and intraoperative transesophageal echocardiogram confirmed complete elimination of mitral regurgitation in 90.5% (19/21) of cases. Thirty-day mortality was 0.0% (0/21), and 1-year mortality was 4.8% (1/21). There were no strokes or wound infections at 30 days, and 14.3% (3/21) of patients received intraoperative blood product transfusions. Conclusions The results of this retrospective review suggest that the robotic approach to mitral valve surgery in patients with a prior sternotomy is safe in experienced hands. Although some centers have considered prior sternotomy a relative contraindication to robotic mitral valve surgery, this approach is feasible and can be considered an option for experienced surgeons.
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Affiliation(s)
- Talia G. Meidan
- Baylor Scott & White Research Institute, Baylor Scott & White The Heart Hospital – Plano, Plano, Tex
- Address for reprints: Talia G. Meidan, BS, Baylor Scott & White The Heart Hospital – Plano, 1100 Allied Dr, Plano, TX 75093.
| | - Allison T. Lanfear
- Baylor Scott & White Research Institute, Baylor Scott & White The Heart Hospital – Plano, Plano, Tex
| | - John J. Squiers
- Baylor Scott & White Research Institute, Baylor Scott & White The Heart Hospital – Plano, Plano, Tex
| | - Mohanad Hamandi
- Baylor Scott & White Research Institute, Baylor Scott & White The Heart Hospital – Plano, Plano, Tex
| | - Bruce W. Lytle
- Department of Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital – Plano, Plano, Tex
| | - J. Michael DiMaio
- Department of Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital – Plano, Plano, Tex
| | - Robert L. Smith
- Department of Cardiothoracic Surgery, Baylor Scott & White The Heart Hospital – Plano, Plano, Tex
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Navia JL, Elgharably H, Hakim AH, Witten JC, Haupt MJ, Germano E, Houghtaling PL, Bakaeen FG, Pettersson GB, Lytle BW, Roselli EE, Gillinov AM, Svensson LG. Long-term Outcomes of Surgery for Invasive Valvular Endocarditis Involving the Aortomitral Fibrosa. Ann Thorac Surg 2019; 108:1314-1323. [DOI: 10.1016/j.athoracsur.2019.04.119] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 10/26/2022]
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Wojnarski CM, Roselli EE, Idrees JJ, Zhu Y, Carnes TA, Lowry AM, Collier PH, Griffin B, Ehrlinger J, Blackstone EH, Svensson LG, Lytle BW. Machine-learning phenotypic classification of bicuspid aortopathy. J Thorac Cardiovasc Surg 2018; 155:461-469.e4. [DOI: 10.1016/j.jtcvs.2017.08.123] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 07/27/2017] [Accepted: 08/28/2017] [Indexed: 01/08/2023]
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Affiliation(s)
- Bruce W Lytle
- Department of Cardiac and Thoracic Surgery, the Baylor-Plano Heart Hospital, Plano, Texas, USA
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Raza S, Hussain ST, Rajeswaran J, Ansari A, Trezzi M, Arafat A, Witten J, Ravichandren K, Riaz H, Javadikasgari H, Panwar S, Demirjian S, Shrestha NK, Fraser TG, Navia JL, Lytle BW, Blackstone EH, Pettersson GB. Value of surgery for infective endocarditis in dialysis patients. J Thorac Cardiovasc Surg 2017. [DOI: 10.1016/j.jtcvs.2017.02.063] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Svensson LG, Pillai ST, Rajeswaran J, Desai MY, Griffin B, Grimm R, Hammer DF, Thamilarasan M, Roselli EE, Pettersson GB, Gillinov AM, Navia JL, Smedira NG, Sabik JF, Lytle BW, Blackstone EH. Long-term survival, valve durability, and reoperation for 4 aortic root procedures combined with ascending aorta replacement. J Thorac Cardiovasc Surg 2015; 151:764-774.e4. [PMID: 26778214 DOI: 10.1016/j.jtcvs.2015.10.113] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Revised: 10/23/2015] [Accepted: 10/27/2015] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To evaluate long-term results of aortic root procedures combined with ascending aorta replacement for aneurysms, using 4 surgical strategies. METHODS From January 1995 to January 2011, 957 patients underwent 1 of 4 aortic root procedures: valve preservation (remodeling or modified reimplantation, n = 261); composite biologic graft (n = 297); composite mechanical graft (n = 156); or allograft root (n = 243). RESULTS Seven deaths occurred (0.73%), none after valve-preserving procedures, and 13 strokes (1.4%). Composite grafts exhibited higher gradients than allografts or valve preservation, but the latter 2 exhibited more aortic regurgitation (2.7% biologic and 0% mechanical composite grafts vs 24% valve-preserving and 19% allografts at 10 years). Within 2 to 5 years, valve preservation exhibited the least left ventricular hypertrophy, allograft replacement the greatest; however, valve preservation had the highest early risk of reoperation, allograft replacement the lowest. Patients receiving allografts had the highest risk of late reoperation (P < .05), and those receiving composite mechanical grafts and valve preservation had the lowest. Composite bioprosthesis patients had the highest risk of late death (57% at 15 years vs 14%-26% for the remaining procedures, P < .0001), because they were substantially older and had more comorbidities (P < .0001). CONCLUSIONS These 4 aortic root procedures, combined with ascending aorta replacement, provide excellent survival and good durability. Valve-preserving and allograft procedures have the lowest gradients and best ventricular remodeling, but they have more late regurgitation, and likely, less risk of valve-related complications, such as bleeding, hemorrhage, and endocarditis. Despite the early risk of reoperation, we recommend valve-preserving procedures for young patients when possible. Composite bioprostheses are preferable for the elderly.
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Affiliation(s)
- Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Saila T Pillai
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Milind Y Desai
- Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian Griffin
- Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Richard Grimm
- Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Donald F Hammer
- Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Maran Thamilarasan
- Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jose L Navia
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas G Smedira
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bruce W Lytle
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Aorta Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
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Desai MY, Smedira NG, Bhonsale A, Thamilarasan M, Lytle BW, Lever HM. Symptom assessment and exercise impairment in surgical decision making in hypertrophic obstructive cardiomyopathy: Relationship to outcomes. J Thorac Cardiovasc Surg 2015; 150:928-35.e1. [DOI: 10.1016/j.jtcvs.2015.07.063] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 07/01/2015] [Accepted: 07/16/2015] [Indexed: 10/23/2022]
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Maron BJ, Dearani JA, Ommen SR, Maron MS, Schaff HV, Nishimura RA, Ralph-Edwards A, Rakowski H, Sherrid MV, Swistel DG, Balaram S, Rastegar H, Rowin EJ, Smedira NG, Lytle BW, Desai MY, Lever HM. Low Operative Mortality Achieved With Surgical Septal Myectomy. J Am Coll Cardiol 2015; 66:1307-1308. [DOI: 10.1016/j.jacc.2015.06.1333] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2015] [Revised: 06/29/2015] [Accepted: 06/30/2015] [Indexed: 11/17/2022]
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9
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Szeto WY, Svensson LG, Rajeswaran J, Ehrlinger J, Suri RM, Smith CR, Mack M, Miller DC, McCarthy PM, Bavaria JE, Cohn LH, Corso PJ, Guyton RA, Thourani VH, Lytle BW, Williams MR, Webb JG, Kapadia S, Tuzcu EM, Cohen DJ, Schaff HV, Leon MB, Blackstone EH. Appropriate patient selection or health care rationing? Lessons from surgical aortic valve replacement in the Placement of Aortic Transcatheter Valves I trial. J Thorac Cardiovasc Surg 2015; 150:557-68.e11. [DOI: 10.1016/j.jtcvs.2015.05.073] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 04/22/2015] [Accepted: 05/06/2015] [Indexed: 10/23/2022]
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10
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Svensson LG, Blackstone EH, Apperson-Hansen C, Ruggieri PM, Ainkaran P, Naugle RI, Lima B, Roselli EE, Cooper M, Somogyi D, Tuzcu EM, Kapadia S, Clair DG, Sabik JF, Lytle BW. Implications from neurologic assessment of brain protection for total arch replacement from a randomized trial. J Thorac Cardiovasc Surg 2015; 150:1140-7.e11. [PMID: 26409997 DOI: 10.1016/j.jtcvs.2015.07.054] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 07/16/2015] [Accepted: 07/20/2015] [Indexed: 11/15/2022]
Abstract
OBJECTIVE The study objective was to perform a randomized trial of brain protection during total aortic arch replacement and identify the best way to assess brain injury. METHODS From June 2003 to January 2010, 121 evaluable patients were randomized to retrograde (n = 60) or antegrade (n = 61) brain perfusion during hypothermic circulatory arrest. We assessed the sensitivity of clinical neurologic evaluation, brain imaging, and neurocognitive testing performed preoperatively and 4 to 6 months postoperatively to detect brain injury. RESULTS A total of 29 patients (24%) experienced neurologic events. Clinical stroke was evident in 1 patient (0.8%), and visual changes were evident in 2 patients; all had brain imaging changes. A total of 14 of 95 patients (15%) undergoing both preoperative and postoperative brain imaging had evidence of new white or gray matter changes; 10 of the 14 patients had neurocognitive testing, but only 2 patients experienced decline. A total of 17 of 96 patients (18%) undergoing both preoperative and postoperative neurocognitive testing manifested declines of 2 or more reliable change indexes; of these 17, 11 had neither imaging changes nor clinical events. Thirty-day mortality was 0.8% (1/121), with no neurologic deaths and a similar prevalence of neurologic events after retrograde and antegrade brain perfusion (22/60, 37% and 15/61, 25%, respectively; P = .2). CONCLUSIONS Although this randomized clinical trial revealed similar neurologic outcomes after retrograde or antegrade brain perfusion for total aortic arch replacement, clinical examination for postprocedural neurologic events is insensitive, brain imaging detects more events, and neurocognitive testing detects even more. Future neurologic assessments for cardiovascular procedures should include not only clinical examination but also brain imaging studies, neurocognitive testing, and long-term assessment.
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Affiliation(s)
- Lars G Svensson
- Aortic Center, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
| | - Eugene H Blackstone
- Aortic Center, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, Ohio
| | | | - Paul M Ruggieri
- Department of Neuroradiology, Cleveland Clinic, Cleveland, Ohio
| | | | - Richard I Naugle
- Department of Psychiatry and Psychology, Cleveland Clinic, Cleveland, Ohio
| | - Brian Lima
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Aortic Center, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Maxwell Cooper
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - David Somogyi
- Department of Perfusion Services, Cleveland Clinic, Cleveland, Ohio
| | - E Murat Tuzcu
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Samir Kapadia
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Daniel G Clair
- Aortic Center, Cleveland Clinic, Cleveland, Ohio; Department of Vascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Aortic Center, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Bruce W Lytle
- Aortic Center, Cleveland Clinic, Cleveland, Ohio; Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
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Wojnarski CM, Svensson LG, Roselli EE, Idrees JJ, Lowry AM, Ehrlinger J, Pettersson GB, Gillinov AM, Johnston DR, Soltesz EG, Navia JL, Hammer DF, Griffin B, Thamilarasan M, Kalahasti V, Sabik JF, Blackstone EH, Lytle BW. Aortic Dissection in Patients With Bicuspid Aortic Valve-Associated Aneurysms. Ann Thorac Surg 2015. [PMID: 26209494 DOI: 10.1016/j.athoracsur.2015.04.126] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Data regarding the risk of aortic dissection in patients with bicuspid aortic valve and large ascending aortic diameter are limited, and appropriate timing of prophylactic ascending aortic replacement lacks consensus. Thus our objectives were to determine the risk of aortic dissection based on initial cross-sectional imaging data and clinical variables and to isolate predictors of aortic intervention in those initially prescribed serial surveillance imaging. METHODS From January 1995 to January 2014, 1,181 patients with bicuspid aortic valve underwent cross-sectional computed tomography (CT) or magnetic resonance imaging (MRI) to ascertain sinus or tubular ascending aortic diameter greater than or equal to 4.7 cm. Random Forest classification was used to identify risk factors for aortic dissection, and among patients undergoing surveillance, time-related analysis was used to identify risk factors for aortic intervention. RESULTS Prevalence of type A dissection that was detected by imaging or was found at operation or on follow-up was 5.3% (n = 63). Probability of type A dissection increased gradually at a sinus diameter of 5.0 cm--from 4.1% to 13% at 7.2 cm--and then increased steeply at an ascending aortic diameter of 5.3 cm--from 3.8% to 35% at 8.4 cm--corresponding to a cross-sectional area to height ratio of 10 cm(2)/m for sinuses of Valsalva and 13 cm(2)/m for the tubular ascending aorta. Cross-sectional area to height ratio was the best predictor of type A dissection (area under the curve [AUC] = 0.73). CONCLUSIONS Early prophylactic ascending aortic replacement in patients with bicuspid aortic valve should be considered at high-volume aortic centers to reduce the high risk of preventable type A dissection in those with aortas larger than approximately 5.0 cm or with a cross-sectional area to height ratio greater than approximately 10 cm(2)/m.
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Affiliation(s)
- Charles M Wojnarski
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Jay J Idrees
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Ashley M Lowry
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - John Ehrlinger
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Jose L Navia
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Donald F Hammer
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Brian Griffin
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Maran Thamilarasan
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Vidyasagar Kalahasti
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bruce W Lytle
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
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Patel P, Dhillon A, Popovic ZB, Smedira NG, Rizzo J, Thamilarasan M, Agler D, Lytle BW, Lever HM, Desai MY. Left Ventricular Outflow Tract Obstruction in Hypertrophic Cardiomyopathy Patients Without Severe Septal Hypertrophy. Circ Cardiovasc Imaging 2015; 8:e003132. [DOI: 10.1161/circimaging.115.003132] [Citation(s) in RCA: 110] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
In patients with hypertrophic cardiomyopathy and left ventricular outflow tract (LVOT) obstruction, but without basal septal hypertrophy, we sought to identify mitral valve (MV) and papillary muscle (PM) abnormalities that predisposed to LVOT obstruction, using echo and cardiac magnetic resonance.
Methods and Results—
We studied 121 patients with hypertrophic cardiomyopathy hypertrophic cardiomyopathy (age, 49±17 years; 60% men; 57% on β-blockers) with a basal septal thickness of ≤1.8 cm who underwent echocardiography (rest+stress) and cine cardiac magnetic resonance. Echo measurements included maximal LVOT gradient (rest/provocable), MV leaflet length (parasternal long, 4 and 3-chamber views), and abnormal chordal attachment to mid/base of anterior MV. Cine cardiac magnetic resonance measurements included basal septal thickness, number/area of PM heads, and bifid PM mobility (in systole and diastole). Mean basal septal thickness, LVOT gradient, and LV ejection fraction were 1.5±0.3 cm, 72±54 mm Hg, and 61±6%, respectively. The number of anterolateral and posteromedial PM heads was 2.7±0.7 and 2.6±0.7, respectively. Anterolateral and posteromedial PM areas were 19.9±7 cm
2
and 17.1±6 cm
2
, respectively. PM mobility was 11±6°. On multivariable analysis, predictors of maximal LVOT gradient were basal septal thickness, bifid PM mobility, anterior mitral leaflet length, and abnormal chordal attachment to base of anterior mitral leaflet. Forty-five patients underwent surgery to relieve LVOT obstruction, of which 52% needed an additional nonmyectomy (MV repair/replacement or PM reorientation) approach.
Conclusions—
In hypertrophic cardiomyopathy patients without significant LV hypertrophy, in addition to basal septal thickness, anterior MV length, abnormal chordal attachment, and bifid PM mobility are associated with LVOT obstruction. In such patients, additional procedures on MV and PM (±myectomy) could be considered.
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Affiliation(s)
- Parag Patel
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Ashwat Dhillon
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Zoran B. Popovic
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Nicholas G. Smedira
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Jessica Rizzo
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Maran Thamilarasan
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Deborah Agler
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Bruce W. Lytle
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Harry M. Lever
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
| | - Milind Y. Desai
- From the Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, OH
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Parikh R, Goodman AL, Barr T, Sabik JF, Svensson LG, Rodriguez LL, Lytle BW, Grimm RA, Griffin BP, Desai MY. Outcomes of surgical aortic valve replacement for severe aortic stenosis: Incorporation of left ventricular systolic function and stroke volume index. J Thorac Cardiovasc Surg 2015; 149:1558-66.e1. [DOI: 10.1016/j.jtcvs.2015.03.008] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Revised: 02/25/2015] [Accepted: 03/07/2015] [Indexed: 11/16/2022]
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Johnston DR, Soltesz EG, Vakil N, Rajeswaran J, Roselli EE, Sabik JF, Smedira NG, Svensson LG, Lytle BW, Blackstone EH. Long-term durability of bioprosthetic aortic valves: implications from 12,569 implants. Ann Thorac Surg 2015; 99:1239-47. [PMID: 25662439 DOI: 10.1016/j.athoracsur.2014.10.070] [Citation(s) in RCA: 327] [Impact Index Per Article: 36.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Revised: 10/28/2014] [Accepted: 10/31/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND Increased life expectancy and younger patients' desire to avoid lifelong anticoagulation requires a better understanding of bioprosthetic valve failure. This study evaluates risk factors associated with explantation for structural valve deterioration (SVD) in a long-term series of Carpentier-Edwards PERIMOUNT aortic valves (AV). METHODS From June 1982 to January 2011, 12,569 patients underwent AV replacement with Edwards Lifesciences Carpentier-Edwards PERIMOUNT stented bovine pericardial prostheses, models 2700PM (n = 310) or 2700 (n = 12,259). Mean age was 71 ± 11 years (range, 18 to 98 years). 93% had native AV disease, 48% underwent concomitant coronary artery bypass grafting, and 26% had additional valve surgery. There were 81,706 patient-years of systematic follow-up data available for analysis. Demographics, intraoperative variables, and 27,386 echocardiographic records were used to identify risks for explant for SVD and assess longitudinal changes in transprosthesis gradients using time-varying covariable analyses. RESULTS Three hundred fifty-four explants were performed, with 41% related to endocarditis and 44% to SVD. Actuarial estimates of explant for SVD at 10 and 20 years were 1.9% and 15% overall, respectively, and in patients younger than 60 years, 5.6% and 46%, respectively. Younger age (p < 0.0001), lipid-lowering drugs (p = 0.002), prosthesis-patient mismatch (p = 0.001), and higher postoperative peak and mean AV gradients were associated with explant for SVD (p < 0.0001). The effect of gradient on SVD was greatest in patients younger than 60 years. CONCLUSIONS Durability of the Carpentier-Edwards PERIMOUNT aortic valve is excellent even in younger patients. Explant for SVD is related to gradient at implantation, especially in younger patients. Strategies to reduce early postoperative AV gradients, such as root enlargement or more efficient prostheses, should be considered.
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Affiliation(s)
- Douglas R Johnston
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Edward G Soltesz
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nakul Vakil
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jeevanantham Rajeswaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric E Roselli
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nicholas G Smedira
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bruce W Lytle
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
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15
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Roselli EE, Loor G, He J, Rafael AE, Rajeswaran J, Houghtaling PL, Svensson LG, Blackstone EH, Lytle BW. Distal aortic interventions after repair of ascending dissection: The argument for a more aggressive approach. J Thorac Cardiovasc Surg 2015; 149:S117-24.e3. [DOI: 10.1016/j.jtcvs.2014.11.029] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2014] [Revised: 11/01/2014] [Accepted: 11/07/2014] [Indexed: 12/27/2022]
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16
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Roselli EE, Idrees J, Greenberg RK, Johnston DR, Lytle BW. Endovascular stent grafting for ascending aorta repair in high-risk patients. J Thorac Cardiovasc Surg 2015; 149:144-51. [DOI: 10.1016/j.jtcvs.2014.07.109] [Citation(s) in RCA: 105] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Accepted: 07/13/2014] [Indexed: 10/24/2022]
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17
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Dhillon A, Sweet W, Popovic ZB, Smedira NG, Thamilarasan M, Lytle BW, Tan C, Starling RC, Lever HM, Moravec CS, Desai MY. Association of noninvasively measured left ventricular mechanics with in vitro muscle contractile performance: a prospective study in hypertrophic cardiomyopathy patients. J Am Heart Assoc 2014; 3:e001269. [PMID: 25389286 PMCID: PMC4338715 DOI: 10.1161/jaha.114.001269] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Hypertrophic cardiomyopathy (HCM) is a primary myopathic process in which regional left ventricular dysfunction may exist without overt global left ventricular dysfunction. In obstructive HCM patients who underwent surgical myectomy (SM), we sought to determine if there is a significant association between echocardiographic longitudinal strain, histopathology, and in vitro myocardial performance (resting tension and developed tension) of the surgical specimen. Methods and Results HCM patients (n=122, 54±14 years, 54% men) undergoing SM were prospectively recruited. Longitudinal systolic strain and diastolic strain rates were measured at that basal septum (partially removed at SM) by using velocity vector imaging on preoperative echocardiography. Semiquantitative histopathologic grading of myocyte disarray and fibrosis and in vitro measurements of resting tension and developed tension were made in septal tissue obtained at SM. Mean basal septal systolic strain and diastolic strain rate were −8.3±5% and 0.62±0.4/s, while mild or greater degree of myocyte disarray and interstitial fibrosis were present in 85% and 87%, respectively. Mean resting tension and developed tension were 2.8±1 and 1.4±0.8 g/mm2. On regression analysis, basal septal systolic strain, diastolic strain rate, disarray, and fibrosis were associated with developed tension (β=0.19, 0.20, −0.33, and −0.40, respectively, all P<0.01) and resting tension (β=0.21, 0.22, −0.25, and −0.28, respectively, all P<0.01). Conclusion In obstructive HCM patients who underwent SM, left ventricular mechanics (echocardiographic longitudinal systolic strain and diastolic strain rates), assessed at the basal septum (myocardium removed during myectomy) and histopathologic findings characteristic for HCM (disarray and fibrosis) were significantly associated with in vitro myocardial resting and developed contractile performance.
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Affiliation(s)
- Ashwat Dhillon
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Wendy Sweet
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Zoran B Popovic
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Nicholas G Smedira
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Maran Thamilarasan
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Bruce W Lytle
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Carmela Tan
- Pathology Institute, Cleveland Clinic, Cleveland, OH (C.T.)
| | - Randall C Starling
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Harry M Lever
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Christine S Moravec
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
| | - Milind Y Desai
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH (A.D., W.S., Z.B.P., N.G.S., M.T., B.W.L., R.C.S., H.M.L., C.S.M., M.Y.D.)
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18
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Monteleone PP, Shrestha NK, Jacob J, Gordon SM, Fraser TG, Rehm SJ, Bajzer CT, Kapadia SR, Pettersson GB, Lytle BW, Blackstone EH, Shishehbor MH. Clinical utility of cerebral angiography in the preoperative assessment of endocarditis. Vasc Med 2014; 19:500-6. [DOI: 10.1177/1358863x14557152] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Cerebral angiography is an invasive procedure utilized without supporting guidelines in preoperative evaluations of infective endocarditis (IE). It is used to identify mycotic intracranial aneurysm, which is suspected to increase the risk of intracranial bleeding during cardiac surgery. Our objectives were to: (1) assess the utility of cerebral angiography by determining which subset of IE patients benefit from its performance; and (2) identify clinical and noninvasive screening tests that can preclude the need for invasive cerebral angiography. Retrospective analysis was performed of all patients treated surgically for IE from 7/2007 to 1/2012 and discharged with medical treatment for IE from 7/2007 to 7/2009 presenting to a large academic center. Of the 151 patients who underwent cerebral angiography, mycotic aneurysm was identified in seven (prevalence=4.6%; 95% CI 2.3–9.3%). Five had viridans group streptococci as the causative IE microorganism ( p=0.0017). Noninvasive imaging and particularly absence of intracranial bleed on magnetic resonance imaging conveys a negative predictive value (NPV) of 0.977 (95% CI 0.879–0.996). Absence of a focal neurologic deficit or altered mental status convey a NPV of 0.990 (95% CI 0.945–0.998) and 0.944 (95% CI 0.883–0.974), respectively. Clinical suspicion for mycotic aneurysm and thus utilization of cerebral angiography is likely necessary only in the setting of acute neurologic deficits and when noninvasive imaging demonstrates acute intracranial bleed. A novel association between viridans group streptococci and intracranial mycotic aneurysm is demonstrated.
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Affiliation(s)
- Peter P Monteleone
- Departments of Cardiovascular Medicine, Infectious Disease, and Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Nabin K Shrestha
- Departments of Cardiovascular Medicine, Infectious Disease, and Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Jessen Jacob
- Departments of Cardiovascular Medicine, Infectious Disease, and Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Steven M Gordon
- Departments of Cardiovascular Medicine, Infectious Disease, and Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Thomas G Fraser
- Departments of Cardiovascular Medicine, Infectious Disease, and Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Susan J Rehm
- Departments of Cardiovascular Medicine, Infectious Disease, and Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Christopher T Bajzer
- Departments of Cardiovascular Medicine, Infectious Disease, and Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Samir R Kapadia
- Departments of Cardiovascular Medicine, Infectious Disease, and Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gosta B Pettersson
- Departments of Cardiovascular Medicine, Infectious Disease, and Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bruce W Lytle
- Departments of Cardiovascular Medicine, Infectious Disease, and Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Departments of Cardiovascular Medicine, Infectious Disease, and Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mehdi H Shishehbor
- Departments of Cardiovascular Medicine, Infectious Disease, and Thoracic and Cardiovascular Surgery, Heart & Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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19
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Aguirre J, Waskowski R, Poddar K, Kapadia S, Krishnaswamy A, McCullough R, Mick S, Navia JL, Roselli EE, Tuzcu ME, Sabik JF, Lytle BW, Svensson LG. Transcatheter aortic valve replacement: Experience with the transapical approach, alternate access sites, and concomitant cardiac repairs. J Thorac Cardiovasc Surg 2014; 148:1417-22. [DOI: 10.1016/j.jtcvs.2014.05.019] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2013] [Revised: 04/21/2014] [Accepted: 05/08/2014] [Indexed: 11/28/2022]
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20
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Desai MY, Karunakaravel K, Wu W, Agarwal S, Smedira NG, Lytle BW, Griffin BP. Pulmonary fibrosis on multidetector computed tomography and mortality in patients with radiation-associated cardiac disease undergoing cardiac surgery. J Thorac Cardiovasc Surg 2014; 148:475-81.e3. [DOI: 10.1016/j.jtcvs.2013.08.087] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2013] [Revised: 08/12/2013] [Accepted: 08/29/2013] [Indexed: 11/27/2022]
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21
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Raza S, Sabik JF, Masabni K, Ainkaran P, Lytle BW, Blackstone EH. Surgical revascularization techniques that minimize surgical risk and maximize late survival after coronary artery bypass grafting in patients with diabetes mellitus. J Thorac Cardiovasc Surg 2014; 148:1257-1264; discussion 1264-6. [PMID: 25260269 DOI: 10.1016/j.jtcvs.2014.06.058] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Revised: 06/17/2014] [Accepted: 06/27/2014] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To identify surgical revascularization techniques that minimize surgical risk and maximize late survival in patients with diabetes undergoing coronary artery bypass grafting (CABG). METHODS From January 1972 to January 2011, 11,922 patients with diabetes underwent primary isolated CABG. The revascularization techniques investigated included bilateral internal thoracic artery (BITA) grafting (n=938; 7.9%) versus single ITA (SITA) grafting, off-pump (n=602; 5.0%) versus on-pump CABG, and incomplete (n=2109; 18%) versus complete revascularization. The median follow-up was 7.8 years and total follow-up, 104,516 patient-years. Multivariable analyses were performed to assess the effects of surgical techniques on hospital outcomes and long-term mortality. RESULTS After adjusting for patient characteristics, BITA versus SITA grafting was associated with a 21% lower late mortality (68% confidence limits, 16%-26%). However, BITA grafting was also associated with more deep sternal wound infections (DSWIs), but the considerable mortality from DSWI minimally affected overall survival because of its rare occurrence. The risk factors for DSWI were female sex (80% increased risk), higher body mass index (7% increased risk per kg/m2), medically treated diabetes (73% increased risk), previous myocardial infarction (58% increased risk), and peripheral arterial disease (73% increased risk). Off-pump and on-pump CABG had similar results. Complete versus incomplete revascularization had similar hospital outcomes; however, complete revascularization was associated with 10% lower late mortality (68% confidence limits, 7.0%-13%). CONCLUSIONS BITA grafting with complete revascularization maximizes long-term survival and is recommended for patients with diabetes undergoing CABG. BITA grafting should be used in all patients with diabetes whose risk of DSWI is low. It might be best avoided in obese diabetic women with diffuse atherosclerotic burden-those at greatest risk of developing these infections.
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Affiliation(s)
- Sajjad Raza
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Khalil Masabni
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ponnuthurai Ainkaran
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bruce W Lytle
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
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22
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Pettersson GB, Hussain ST, Ramankutty RM, Lytle BW, Blackstone EH. Reconstruction of fibrous skeleton: technique, pitfalls and results. Multimed Man Cardiothorac Surg 2014; 2014:mmu004. [PMID: 24947975 DOI: 10.1093/mmcts/mmu004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Destruction of the mitral-aortic (or mitroaortic) intervalvular fibrosa (IVF) by infective endocarditis is a marker of advanced pathology. Patients are at high risk, as they are sicker, have more comorbidities and have more advanced pathology, requiring a difficult operation that includes debriding and reconstructing the IVF. The anatomy and surgical techniques for that reconstruction are presented and discussed. Operative risk is high and remains high for the first year, before becoming equivalent to that of conventional operations for endocarditis. Current outcomes are better than in the past, but there is room for further improvement.
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Affiliation(s)
- Gösta B Pettersson
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Syed T Hussain
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Rajesh M Ramankutty
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Bruce W Lytle
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
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23
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Kobayashi T, Dhillon A, Popovic Z, Bhonsale A, Smedira NG, Thamilarasan M, Lytle BW, Lever HM, Desai MY. Differences in global and regional left ventricular myocardial mechanics in various morphologic subtypes of patients with obstructive hypertrophic cardiomyopathy referred for ventricular septal myotomy/myectomy. Am J Cardiol 2014; 113:1879-85. [PMID: 24837268 DOI: 10.1016/j.amjcard.2014.03.020] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 03/06/2014] [Accepted: 03/06/2014] [Indexed: 11/24/2022]
Abstract
Patients with obstructive hypertrophic cardiomyopathy (HC) have various left ventricular (LV) shapes: reverse septal curvature (RSC, commonly familial), sigmoid septum (SS, common in hypertensives), and concentric hypertrophy (CH). Longitudinal (systolic and early diastolic) strain rate (SR) is sensitive in detecting regional myocardial dysfunction. We sought to determine differences in longitudinal SR of patients with obstructive HC, based on LV shapes. We studied 199 consecutive patients with HC (50% men) referred for surgical myectomy. Clinical and echocardiographic parameters were recorded. LV shapes were classified on echocardiography, using basal septal 1/3 to posterior wall ratio: RSC = ratio >1.3 (extending to mid and distal septum), SS = ratio >1.3 (extending only to basal 1/3), and concentric = ratio ≤1.3. Longitudinal systolic and early diastolic SRs were measured from apical 4- and 2-chamber views (VVI 2.0; Siemens, Erlangen). Distribution of RSC, SS, and CH was 50%, 28%, and 22%, respectively. Patients with RSC were significantly younger (47 ± 12 vs 64 ± 10 and 57 ± 11, respectively) with lower hypertension (40% vs 71% and 67%, respectively) than patients with SS or CH (both p <0.001). Patients with RSC had lower global systolic (-0.99 ± 0.3 vs -1.05 ± 0.3 and -1.17 ± 0.3) and early diastolic SR (0.95 ± 0.4 vs 0.98 ± 0.3 and 1.16 ± 0.4) versus patients with SS and CH (in 1/s, both p <0.01), despite being much younger and less hypertensive. RSC was associated with abnormal global LV systolic (beta 0.16) and early diastolic (beta -0.17) SR (both p <0.01). In conclusion, patients with HC with RCS have significantly abnormal LV mechanics, despite being younger and less hypertensive. A combination of LV mechanics and shapes could help differentiate between genetically mediated and other causes of obstructive HC.
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24
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Svensson LG, Al Kindi AH, Vivacqua A, Pettersson GB, Gillinov AM, Mihaljevic T, Roselli EE, Sabik JF, Griffin B, Hammer DF, Rodriguez L, Williams SJ, Blackstone EH, Lytle BW. Long-Term Durability of Bicuspid Aortic Valve Repair. Ann Thorac Surg 2014; 97:1539-47; discussion 1548. [DOI: 10.1016/j.athoracsur.2013.11.036] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 11/13/2013] [Accepted: 11/19/2013] [Indexed: 02/03/2023]
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25
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Kapadia SR, Svensson LG, Roselli E, Schoenhagen P, Popovic Z, Alfirevic A, Barzilai B, Krishnaswamy A, Stewart W, Mehta A, Lal Poddar K, Parashar A, Modi D, Ozkan A, Khot U, Lytle BW, Murat Tuzcu E. Single center TAVR experience with a focus on the prevention and management of catastrophic complications. Catheter Cardiovasc Interv 2014; 84:834-42. [PMID: 24407775 PMCID: PMC4231228 DOI: 10.1002/ccd.25356] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2013] [Revised: 12/13/2013] [Accepted: 01/03/2014] [Indexed: 11/08/2022]
Abstract
BACKGROUND Transcatheter aortic valve replacement (TAVR) is an important treatment option for patients with severe symptomatic aortic stenosis (AS) who are inoperable or at high risk for complications with surgical aortic valve replacement. We report here our single-center data on consecutive patients undergoing transfemoral (TF) TAVR since the inception of our program, with a special focus on minimizing and managing complications. METHODS The patient population consists of all consecutive patients who underwent an attempted TF-TAVR at our institution, beginning with the first proctored case in May 2006, through December 2012. Clinical, procedural, and echocardiographic data were collected by chart review and echo database query. All events are reported according to Valve Academic Research Consortium-2. RESULTS During the study period, 255 patients with AS had attempted TF-TAVR. The procedure was successful in 244 (95.7%) patients. Serious complications including aortic annular rupture (n = 2), coronary occlusion (n = 2), iliac artery rupture (n = 1), and ventricular embolization (n = 1) were successfully managed. Death and stroke rate at 30 days was 0.4% and 1.6%, respectively. One-year follow-up was complete in 171 (76%) patients. One-year mortality was 17.5% with a 3.5% stroke rate. Descending aortic rupture, while advancing the valve, was the only fatal procedural event. There were 24.4% patients with ≥2+ aortic regurgitation. CONCLUSIONS TAVR can be accomplished with excellent safety in a tertiary center with a well-developed infrastructure for the management of serious complications. The data presented here provide support for TAVR as an important treatment option, and results from randomized trials of patients with lower surgical risk are eagerly awaited.
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Affiliation(s)
- Samir R Kapadia
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
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26
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Starling RC, Moazami N, Silvestry SC, Ewald G, Rogers JG, Milano CA, Rame JE, Acker MA, Blackstone EH, Ehrlinger J, Thuita L, Mountis MM, Soltesz EG, Lytle BW, Smedira NG. Unexpected abrupt increase in left ventricular assist device thrombosis. N Engl J Med 2014; 370:33-40. [PMID: 24283197 DOI: 10.1056/nejmoa1313385] [Citation(s) in RCA: 596] [Impact Index Per Article: 59.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND We observed an apparent increase in the rate of device thrombosis among patients who received the HeartMate II left ventricular assist device, as compared with preapproval clinical-trial results and initial experience. We investigated the occurrence of pump thrombosis and elevated lactate dehydrogenase (LDH) levels, LDH levels presaging thrombosis (and associated hemolysis), and outcomes of different management strategies in a multi-institutional study. METHODS We obtained data from 837 patients at three institutions, where 895 devices were implanted from 2004 through mid-2013; the mean (±SD) age of the patients was 55±14 years. The primary end point was confirmed pump thrombosis. Secondary end points were confirmed and suspected thrombosis, longitudinal LDH levels, and outcomes after pump thrombosis. RESULTS A total of 72 pump thromboses were confirmed in 66 patients; an additional 36 thromboses in unique devices were suspected. Starting in approximately March 2011, the occurrence of confirmed pump thrombosis at 3 months after implantation increased from 2.2% (95% confidence interval [CI], 1.5 to 3.4) to 8.4% (95% CI, 5.0 to 13.9) by January 1, 2013. Before March 1, 2011, the median time from implantation to thrombosis was 18.6 months (95% CI, 0.5 to 52.7), and from March 2011 onward, it was 2.7 months (95% CI, 0.0 to 18.6). The occurrence of elevated LDH levels within 3 months after implantation mirrored that of thrombosis. Thrombosis was presaged by LDH levels that more than doubled, from 540 IU per liter to 1490 IU per liter, within the weeks before diagnosis. Thrombosis was managed by heart transplantation in 11 patients (1 patient died 31 days after transplantation) and by pump replacement in 21, with mortality equivalent to that among patients without thrombosis; among 40 thromboses in 40 patients who did not undergo transplantation or pump replacement, actuarial mortality was 48.2% (95% CI, 31.6 to 65.2) in the ensuing 6 months after pump thrombosis. CONCLUSIONS The rate of pump thrombosis related to the use of the HeartMate II has been increasing at our centers and is associated with substantial morbidity and mortality.
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Affiliation(s)
- Randall C Starling
- From the Departments of Cardiovascular Medicine (R.C.S., M.M.M.), Thoracic and Cardiovascular Surgery (N.M., E.H.B., E.G.S., B.W.L., N.G.S.), and Quantitative Health Sciences (E.H.B., J.E., L.T.) and Kaufman Center for Heart Failure (R.C.S., N.M., E.H.B., M.M.M., E.G.S., N.G.S.), Cleveland Clinic, Cleveland; the Division of Cardiovascular Surgery (S.C.S.) and the Cardiovascular Division (G.E.), Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis; the Cardiology Division (J.G.R.) and the Cardiovascular Surgery Division (C.A.M.), Duke University School of Medicine, Durham, NC; and the Divisions of Cardiology (J.E.R.) and Cardiovascular Surgery (M.A.A.), University of Pennsylvania, Philadelphia
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Albacker TB, Blackstone EH, Williams SJ, Gillinov AM, Navia JL, Roselli EE, Keshavamurthy S, Pettersson GB, Mihaljevic T, Johnston DR, Sabik JF, Lytle BW, Svensson LG. Should less-invasive aortic valve replacement be avoided in patients with pulmonary dysfunction? J Thorac Cardiovasc Surg 2014; 147:355-361.e5. [DOI: 10.1016/j.jtcvs.2012.12.014] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 10/30/2012] [Accepted: 12/05/2012] [Indexed: 11/30/2022]
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28
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Desai MY, Bhonsale A, Patel P, Naji P, Smedira NG, Thamilarasan M, Lytle BW, Lever HM. Exercise Echocardiography in Asymptomatic HCM. JACC Cardiovasc Imaging 2014; 7:26-36. [DOI: 10.1016/j.jcmg.2013.08.010] [Citation(s) in RCA: 93] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Revised: 08/15/2013] [Accepted: 08/22/2013] [Indexed: 11/29/2022]
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Roselli EE, Subramanian S, Sun Z, Idrees J, Nowicki E, Blackstone EH, Greenberg RK, Svensson LG, Lytle BW. Endovascular versus open elephant trunk completion for extensive aortic disease. J Thorac Cardiovasc Surg 2013; 146:1408-16; discussion 1416-7. [DOI: 10.1016/j.jtcvs.2013.07.070] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2010] [Revised: 07/15/2013] [Accepted: 07/30/2013] [Indexed: 12/01/2022]
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Raza S, Sabik JF, Ellis SG, Houghtaling PL, Rodgers KC, Stockins A, Lytle BW, Blackstone EH. Survival prediction models for coronary intervention: strategic decision support. Ann Thorac Surg 2013; 97:522-8. [PMID: 24021771 DOI: 10.1016/j.athoracsur.2013.06.099] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2013] [Revised: 06/10/2013] [Accepted: 06/20/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND For a given patient with coronary artery disease, it is uncertain which therapy, percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG), maximizes long-term survival. Hence, we developed survival models for CABG and PCI using bare-metal stents (BMS) or drug-eluting stents (DES), programmed a decision-support tool, and identified its potential usefulness. METHODS From 1995 to 2007, 23,182 patients underwent primary isolated CABG (n=13,114) or first-time PCI with BMS (n=6,964) or DES (n=3,104). Follow-up was 6.3±3.9 years. Survival models were developed independently for each therapy, then all factors appearing in any of the three models were forced into a final model for each. These were programmed into a decision-support tool. Predicted differences in 5-year survival for the same patient among the three therapies were calculated. RESULTS Unadjusted survival was 96%, 86%, and 68% at 1, 5, and 10 years after CABG, 94%, 83%, and 68% after BMS, and 95% and 84% (no 10-year estimate) after DES, respectively. Risk factors for early and mid-term mortality were identified, leading to variable-rich (25 variables) prediction models. Patients most likely to experience a 5-year survival benefit from DES were those undergoing emergency revascularization for acute infarction, and patients most likely to benefit from CABG had extensive coronary artery disease and numerous comorbidities. CONCLUSIONS Detailed prediction models for prognosis after PCI and CABG are useful for developing a clinically relevant, strategic decision-support tool that reveals who may experience a long-term survival benefit from each modality.
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Affiliation(s)
- Sajjad Raza
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Joseph F Sabik
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - Stephen G Ellis
- Department of Cardiovascular Medicine, Medicine Institute, Cleveland Clinic, Cleveland, Ohio
| | - Penny L Houghtaling
- Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Kerry C Rodgers
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Aleck Stockins
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Bruce W Lytle
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Research Institute, Cleveland Clinic, Cleveland, Ohio
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Kobayashi T, Popovic Z, Bhonsale A, Smedira NG, Tan C, Rodriguez ER, Thamilarasan M, Lytle BW, Lever HM, Desai MY. Association between septal strain rate and histopathology in symptomatic hypertrophic cardiomyopathy patients undergoing septal myectomy. Am Heart J 2013; 166:503-11. [PMID: 24016500 DOI: 10.1016/j.ahj.2013.06.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [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: 10/29/2012] [Accepted: 06/02/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) is histopathologically characterized by myocyte hypertrophy, disarray, interstitial fibrosis, and small intramural coronary arteriole dysplasia, which contribute to disease progression. Longitudinal systolic and early diastolic strain rate (SR) measurements by speckle tracking echocardiography are sensitive markers of regional myocardial function. We sought to determine the association between septal SR and histopathologic findings in symptomatic HCM patients who underwent surgical myectomy. METHODS We studied 171 HCM patients (documented on histopathology) who underwent surgical myectomy to relieve left ventricular outflow tract obstruction. Various clinical and echocardiographic parameters were recorded. Segmental longitudinal systolic and early diastolic SRs (of the septal segment removed at myectomy) were measured from apical 4- and 2-chamber views (VVI 2.0; Siemens, Erlangen, Germany). Histopathologic myocyte hypertrophy, disarray, small intramural coronary arteriole dysplasia, and interstitial fibrosis were classified as none, mild (1%-25%), moderate (26%-50%), and severe (>50%). RESULTS The mean age was 53 ± 14 years (52% men, ejection fraction 62% ± 5%, mean left ventricular outflow tract gradient 102 ± 39 mm Hg, and basal septal thickness of 2.2 ± 0.5 cm). Mean longitudinal systolic and early diastolic SRs were -0.91 ± 0.5 and 0.82 ± 0.5 (1/s), respectively. There was an inverse association between systolic and early diastolic septal SR and degree of myocyte hypertrophy, disarray, and interstitial fibrosis (all P < .05). There was no association between histopathologic characteristics and other echocardiography parameters. On multivariable regression analysis, myocyte disarray and echocardiographic septal hypertrophy were associated with systolic and early diastolic septal SR (P < .05). CONCLUSION In HCM patients, there is inverse association between various histopathologic findings and septal SR. Strain rate might potentially provide further insight into HCM pathophysiology.
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Abstract
The effectiveness of the left internal mammary artery graft to the anterior descending coronary artery as a surgical strategy has been shown to improve the survival rate and decrease the risk of adverse cardiac events in patients undergoing coronary bypass surgery. These clinical benefits appear to be related to the superior short and long-term patency rates of the internal thoracic artery graft. Although the advantages of using of both internal thoracic arteries (ITA) for bypass grafting have taken longer to prove, recent results from multiple data sets now support these findings. The major advantage of bilateral ITA grafting appears to be improved survival rate, while the disadvantages of complex ITA grafting include the increased complexity of operation, and an increased risk of wound complications. While these short-term disadvantages have been mitigated in contemporary surgical practice, they have not eliminated. Bilateral ITA grafting should be considered the procedure of choice for patients undergoing coronary bypass surgery that have a predicted survival rate of longer than ten years.
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Affiliation(s)
- Bruce W Lytle
- Cleveland Clinic, Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland, USA
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Svensson LG, Rushing GD, Valenzuela ES, Rafael AE, Batizy LH, Blackstone EH, Roselli EE, Gillinov AM, Sabik JF, Lytle BW. Modifications, Classification, and Outcomes of Elephant-Trunk Procedures. Ann Thorac Surg 2013; 96:548-58. [DOI: 10.1016/j.athoracsur.2013.03.082] [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: 11/12/2012] [Revised: 03/13/2013] [Accepted: 03/18/2013] [Indexed: 11/15/2022]
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Desai MY, Bhonsale A, Smedira NG, Naji P, Thamilarasan M, Lytle BW, Lever HM. Predictors of Long-Term Outcomes in Symptomatic Hypertrophic Obstructive Cardiomyopathy Patients Undergoing Surgical Relief of Left Ventricular Outflow Tract Obstruction. Circulation 2013; 128:209-16. [DOI: 10.1161/circulationaha.112.000849] [Citation(s) in RCA: 140] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background—
We report the predictors of long-term outcomes of symptomatic hypertrophic cardiomyopathy patients undergoing surgical relief of left ventricular outflow tract obstruction.
Methods and Results—
We studied 699 consecutive patients who have hypertrophic cardiomyopathy with severe symptomatic left ventricular outflow tract obstruction (47±11 years, 63% male) intractable to maximal medical therapy, who were referred to a tertiary hospital between January 1997 and December 2007 for the surgical relief of left ventricular outflow tract obstruction. We excluded patients <18 years of age, those with an ejection fraction <50%, those with hypertensive heart disease of the elderly, and those with more than mild aortic or mitral stenosis. Clinical, echocardiographic, and Holter data were recorded. A composite end point of death, appropriate internal cardioverter defibrillator discharges, resuscitated from sudden death, documented stroke, and admission for congestive heart failure was recorded. During a mean follow-up of 6.2±3 years, 86 patients (12%) met the composite end point with 30-day, 1-year, and 2-year event rates of 0.7%, 2.8%, and 4.7%, respectively. The hard event rate (death, defibrillator discharge, and resuscitated from sudden death) at 30 days, 1 year, and 2 years was 0%, 1.5%, and 3%, respectively. Stepwise multivariable analysis identified residual postoperative atrial fibrillation (hazard ratio, 2.12; confidence interval, 1.37–3.34;
P
=0.001) and increasing age (hazard ratio, 1.49; confidence interval, 1.22–1.82;
P
=0.001) as independent predictors of long-term composite outcomes.
Conclusions—
Symptomatic adult hypertrophic cardiomyopathy patients undergoing surgery for the relief of left ventricular outflow tract obstruction have low event rates during long-term follow-up; worse outcomes are predicted by increasing age and the presence of residual atrial fibrillation during follow-up.
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Affiliation(s)
- Milind Y. Desai
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Aditya Bhonsale
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | | | - Peyman Naji
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | | | - Bruce W. Lytle
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Harry M. Lever
- From the Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
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Mihaljevic T, Koprivanac M, Kelava M, Smedira NG, Lytle BW, Blackstone EH. Mitral valve replacement in patients with severely calcified mitral valve annulus: Surgical technique. J Thorac Cardiovasc Surg 2013; 146:233-5. [DOI: 10.1016/j.jtcvs.2013.02.034] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 02/06/2013] [Accepted: 02/13/2013] [Indexed: 11/28/2022]
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Goel SS, Ige M, Tuzcu EM, Ellis SG, Stewart WJ, Svensson LG, Lytle BW, Kapadia SR. Severe Aortic Stenosis and Coronary Artery Disease—Implications for Management in the Transcatheter Aortic Valve Replacement Era. J Am Coll Cardiol 2013; 62:1-10. [DOI: 10.1016/j.jacc.2013.01.096] [Citation(s) in RCA: 164] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 01/15/2013] [Indexed: 02/01/2023]
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Keshavamurthy S, Navia JL, Krishnamurthi V, Brozzi NA, Sinkewich MG, Blackstone EH, Lytle BW. Renal cell carcinoma with extensive cavoatrial involvement. J Heart Valve Dis 2013; 22:607. [PMID: 24224429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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Wu W, Masri A, Popovic ZB, Smedira NG, Lytle BW, Marwick TH, Griffin BP, Desai MY. Long-term survival of patients with radiation heart disease undergoing cardiac surgery: a cohort study. Circulation 2013; 127:1476-85. [PMID: 23569119 DOI: 10.1161/circulationaha.113.001435] [Citation(s) in RCA: 103] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Thoracic radiation results in radiation-associated heart disease (RAHD), often requiring cardiothoracic surgery (CTS). We sought to measure long-term survival in RAHD patients undergoing CTS, to compare them with a matched control population undergoing similar surgical procedures, and to identify potential predictors of long-term survival. METHODS AND RESULTS In this retrospective observational cohort study of patients undergoing CTS, matched on the basis of age, sex, and type/time of CTS, 173 RAHD patients (75% women; age, 63±14 years) and 305 comparison patients (74% women; age, 63±4 years) were included. The vast majority of RAHD patients had prior breast cancer (53%) and Hodgkin lymphoma (27%), and the mean time from radiation was 18±12 years. Clinical and surgical parameters were recorded. The preoperative EuroSCORE and all-cause mortality were recorded. The mean EuroSCOREs were similar in the RAHD and comparison groups (7.8±3 versus 7.4±3, respectively; P=0.1). Proximal coronary artery disease was higher in patients with RAHD versus the comparison patients (45% versus 38%; P=0.09), whereas redo CTS was lower in the RACD versus the comparison group (20% versus 29%; P=0.02). About two thirds of patients in either group had combination surgical procedures. During a mean follow-up of 7.6±3 years, a significantly higher proportion of patients died in the RAHD group than in the comparison group (55% versus 28%; P<0.001). On multivariable Cox proportional hazard analysis, RAHD (2.47; 95% confidence interval, 1.82-3.36), increasing EuroSCORE (1.22; 95% confidence interval, 1.16-1.29), and lack of β-blockers (0.66; 95% confidence interval, 0.47-0.93) were associated with increased mortality (all P<0.01). CONCLUSIONS In patients undergoing CTS, RAHD portends increased long-term mortality. Alternative treatment strategies may be required in RAHD to improve long-term survival.
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Affiliation(s)
- Willis Wu
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH 44195, USA
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Svensson LG, Adams DH, Bonow RO, Kouchoukos NT, Miller DC, O'Gara PT, Shahian DM, Schaff HV, Akins CW, Bavaria JE, Blackstone EH, David TE, Desai ND, Dewey TM, D'Agostino RS, Gleason TG, Harrington KB, Kodali S, Kapadia S, Leon MB, Lima B, Lytle BW, Mack MJ, Reardon M, Reece TB, Reiss GR, Roselli EE, Smith CR, Thourani VH, Tuzcu EM, Webb J, Williams MR. Aortic Valve and Ascending Aorta Guidelines for Management and Quality Measures. Ann Thorac Surg 2013; 95:S1-66. [DOI: 10.1016/j.athoracsur.2013.01.083] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2012] [Revised: 12/24/2012] [Accepted: 01/15/2013] [Indexed: 12/31/2022]
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Pettersson GB, Martino D, Blackstone EH, Nowicki ER, Houghtaling PL, Sabik JF, Lytle BW. Advising complex patients who require complex heart operations. J Thorac Cardiovasc Surg 2013; 145:1159-1169.e3. [DOI: 10.1016/j.jtcvs.2012.11.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Revised: 10/25/2012] [Accepted: 11/09/2012] [Indexed: 11/28/2022]
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41
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Trezzi M, Blackstone EH, Sun Z, Li L, Sabik JF, Lytle BW, Gordon SM, Koch CG. Statin therapy is associated with fewer infections after cardiac operations. Ann Thorac Surg 2013; 95:892-900. [PMID: 23380476 DOI: 10.1016/j.athoracsur.2012.11.071] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [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: 08/27/2012] [Revised: 10/30/2012] [Accepted: 11/27/2012] [Indexed: 02/03/2023]
Abstract
BACKGROUND Statins interact with multiple pathways involved in infection. Therefore, we examined the association between preoperative statin therapy and infections after cardiac operations and assessed whether statin therapy was associated with lower infection-related mortality. METHODS From January 2005 to January 2011, 12,741 patients underwent cardiac operations. Endpoints were (1) postoperative infections and (2) mortality after an infectious complication. A propensity score was developed on the probability of patients receiving statin therapy; patients were matched in part on this score. A multivariable logistic model was developed to examine mortality. Survival of infected patients was estimated using Kaplan-Meier and multiphase hazard function methodology. RESULTS A total of 6,113 patients (48%) were receiving statins and 6,628 (52%) were not. Five hundred fifteen patients had postoperative infections-260 (4.3%) in the statin group and 255 (3.8%) in the no-statin group. However, patients receiving statins were older with more comorbidities and less favorable operative characteristics. Among propensity-matched groups, postoperative infections were significantly lower in patients receiving statins (n = 102 [3.1%]) than in those who were not (n = 147 [4.5%]; p = 0.004). Among patients in whom infections developed, there was no significant difference in hospital mortality between the statin and no-statin groups either before or after propensity-score matching (odds ratio, 1.38; confidence limit [CL], 0.59, 3.22; p = 0.5). CONCLUSIONS We observed a protective effect of statin therapy against the development of infections after cardiac operations, but not on mortality from these infections. Prospective investigations are needed to determine optimal dose and duration of statin therapy and their relationship to infectious complications.
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Affiliation(s)
- Matteo Trezzi
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA
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42
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Svensson LG, Tuzcu M, Kapadia S, Blackstone EH, Roselli EE, Gillinov AM, Sabik JF, Lytle BW. A comprehensive review of the PARTNER trial. J Thorac Cardiovasc Surg 2013; 145:S11-6. [PMID: 23410766 DOI: 10.1016/j.jtcvs.2012.11.051] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [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: 04/26/2012] [Revised: 08/10/2012] [Accepted: 11/28/2012] [Indexed: 01/19/2023]
Affiliation(s)
- Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio, USA.
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Svensson LG, Adams DH, Bonow RO, Kouchoukos NT, Miller DC, O'Gara PT, Shahian DM, Schaff HV, Akins CW, Bavaria J, Blackstone EH, David TE, Desai ND, Dewey TM, D'Agostino RS, Gleason TG, Harrington KB, Kodali S, Kapadia S, Leon MB, Lima B, Lytle BW, Mack MJ, Reece TB, Reiss GR, Roselli E, Smith CR, Thourani VH, Tuzcu EM, Webb J, Williams MR. Aortic valve and ascending aorta guidelines for management and quality measures: executive summary. Ann Thorac Surg 2013; 95:1491-505. [PMID: 23291103 DOI: 10.1016/j.athoracsur.2012.12.027] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.7] [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: 12/24/2012] [Revised: 12/24/2012] [Accepted: 12/28/2012] [Indexed: 12/24/2022]
Abstract
The Society of Thoracic Surgeons Clinical Practice Guidelines are intended to assist physicians and other health care providers in clinical decision making by describing a range of generally acceptable approaches for the diagnosis, management, or prevention of specific diseases or conditions. These guidelines should not be considered inclusive of all proper methods of care or exclusive of other methods of care reasonably directed at obtaining the same results. Moreover, these guidelines are subject to change over time, without notice. The ultimate judgment regarding the care of a particular patient must be made by the physician in light of the individual circumstances presented by the patient.
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Affiliation(s)
- Lars G Svensson
- The Cleveland Clinic, 9500 Euclid Ave, Desk F-25 CT Surgery, Cleveland, OH 44195, USA.
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Sabik JF, Raza S, Blackstone EH, Houghtaling PL, Lytle BW. Value of Internal Thoracic Artery Grafting to the Left Anterior Descending Coronary Artery at Coronary Reoperation. J Am Coll Cardiol 2013; 61:302-10. [DOI: 10.1016/j.jacc.2012.09.045] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2011] [Revised: 08/22/2012] [Accepted: 09/11/2012] [Indexed: 11/29/2022]
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Albacker TB, Roselli EE, Pettersson GB, Vivacqua A, Keshavamurthy S, Smedira NG, Lytle BW, Clair DG, Svensson LG. Surgical management of right aortic arch with tailored surgical approach. J Card Surg 2012; 27:511-7. [PMID: 22784205 DOI: 10.1111/j.1540-8191.2012.01488.x] [Citation(s) in RCA: 4] [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] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND AIM OF STUDY Right-sided aortic arch is a rare congenital anomaly for which different surgical approaches have been reported. This study reviewed our experience with several techniques. METHODS We retrospectively reviewed 17 patients undergoing right-sided arch repair at the Cleveland Clinic from 2001 to 2010. Computed tomographic angiograms of the aorta and its branches were reviewed and correlated with patient presentation and surgical approach. RESULTS Fourteen patients had type II right aortic arch with aberrant left subclavian artery. Fifteen patients presented with obstructive symptoms. Surgical approach included right thoracotomy (11 patients), left thoracotomy (two patients), full sternotomy (one patient), and hybrid repair (three patients). Cardiopulmonary bypass (CPB) with deep hypothermic circulatory arrest was used in 11 patients, and two patients had partial CPB. Left subclavian artery bypass was performed in seven patients. Median duration of intubation was 1.9 days. Average length of intensive care unit stay was three days and average hospital stay 11 days. Postoperative outcomes included respiratory failure (one patient), renal failure (one patient), bloodstream infection (two patients), and death (one patient). No patient had stroke or paraplegia. In-hospital death occurred in one patient, and all survivors were alive and asymptomatic for a mean of 38 months. CONCLUSION The surgical treatment for right-sided aortic arch can be performed with excellent perioperative outcomes when tailored to patient presentation and anatomic configuration. Patients with obstructive symptoms benefit from open or hybrid surgical treatment, with immediate relief of compression. Patients with aneurysmal dilatation without compression symptoms can be managed with open, endovascular, or hybrid surgical intervention.
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Affiliation(s)
- Turki B Albacker
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
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Navia JL, Brozzi NA, Nowicki ER, Blackstone EH, Krishnamurthi V, Sinkewich MG, Rajeswaran J, Pattakos G, Lytle BW. Simplified perfusion strategy for removing retroperitoneal tumors with extensive cavoatrial involvement. J Thorac Cardiovasc Surg 2012; 143:1014-21. [DOI: 10.1016/j.jtcvs.2011.05.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2010] [Revised: 04/21/2011] [Accepted: 05/18/2011] [Indexed: 11/28/2022]
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Lima B, Nowicki ER, Blackstone EH, Williams SJ, Roselli EE, Sabik JF, Lytle BW, Svensson LG. Spinal cord protective strategies during descending and thoracoabdominal aortic aneurysm repair in the modern era: The role of intrathecal papaverine. J Thorac Cardiovasc Surg 2012; 143:945-952.e1. [DOI: 10.1016/j.jtcvs.2012.01.029] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2011] [Revised: 10/31/2011] [Accepted: 01/06/2012] [Indexed: 12/01/2022]
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Navia JL, Brozzi N, Chiu J, Blackstone EH, Atik FA, Svensson LG, Gillinov AM, Hanson GL, Al-Ruzzeh S, Feng J, Lytle BW. Endoscopic versus open radial artery harvesting for coronary artery bypass grafting. J Cardiovasc Surg (Torino) 2012; 53:257-263. [PMID: 22456650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
AIM The radial artery has become the artery of choice after the internal thoracic artery for coronary artery bypass grafting (CABG). This study compares wound healing and arm complications after endoscopic versus open radial artery harvesting for CABG. METHODS From January 2002 to July 2004, 509 patients underwent CABG in which a radial artery conduit was used. Thirty-nine had endoscopic and 470 had conventional open radial artery harvesting. A propensity score was used to obtain 1:3 matching of all endoscopic to 117 open-harvesting patients. Postoperative wound healing using the Hollander scale, local neurologic deficits, wound infection, and pain scores were compared. RESULTS Wound healing: 34 of 39 endoscopic wounds exhibited a perfect Hollander score versus 339 of 470 open-harvest wounds (P=0.01). Wound appearance in particular was better than for open harvesting (P=0.004), with no abnormal step-off borders, irregular contours, or abnormal scar width observed. Neurologic deficits. Three incomplete neurologic deficits were observed after open harvesting (two being distal sensitivity localized in the interspace between the first and second metacarpals); one complete neurologic deficit occurred after endoscopic harvesting, but improved remarkably prior to hospital discharge. Wound infection. Occurrence of wound infection was similar in the two groups (P=0.7), although infection was more severe with open harvesting. Pain: pain score was lower (P=0.006) with endoscopic harvesting. CONCLUSION Compared with conventional open harvesting, endoscopic radial artery harvesting was associated with better wound appearance and less pain. Occurrence of neurologic deficits and wound infection was infrequent in both groups.
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Affiliation(s)
- J L Navia
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH 44195, USA.
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Manne MB, Shrestha NK, Lytle BW, Nowicki ER, Blackstone E, Gordon SM, Pettersson G, Fraser TG. Outcomes after surgical treatment of native and prosthetic valve infective endocarditis. Ann Thorac Surg 2012; 93:489-93. [PMID: 22206953 DOI: 10.1016/j.athoracsur.2011.10.063] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2011] [Revised: 10/19/2011] [Accepted: 10/25/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND The risk of death and complications of infective endocarditis (IE) treated medically has to be balanced against those from surgery in constructing a therapeutic approach. Recent literature has drawn conflicting conclusions on the benefit of surgery for IE. We reviewed patients treated surgically for IE at the Cleveland Clinic from 2003 to 2007 to examine their outcomes. METHODS A retrospective review of consecutive patients who underwent surgery for native and prosthetic valve endocarditis between January 1, 2003, and December 31, 2007, was conducted. Surgical outcomes were reviewed to include survival and postoperative complications. Survival was evaluated at end of hospital stay, 30 days, 1 year, and at last follow-up. RESULTS Four hundred twenty-eight patients underwent surgery for IE during the study period: 248 (58%) had native valve endocarditis and 180 (42%) had prosthetic valve endocarditis. Overall 90% of patients survived to hospital discharge. When compared with patients with native valve infection, patients with prosthetic infection had significantly higher 30-day mortality (13% versus 5.6%; p<0.01), but long-term survival was not significantly different (35% versus 29%; p=0.19). Patients with IE caused by Staphylococcus aureus had significantly higher hospital mortality (15% versus 8.4%; p<0.05), 6-month mortality (23% versus 15%; p=0.05), and 1-year mortality (28% versus 18%; p=0.02) compared with non-S aureus IE. CONCLUSIONS Surgical treatment of IE was associated with 90% hospital survival. Outcomes within the 30 days were better for native valve than for prosthetic valve endocarditis. Long-term outcomes were similar. Finally, S aureus was associated with significantly higher mortality compared with other pathogens.
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Affiliation(s)
- Mahesh B Manne
- Department of Internal Medicine, Medicine Institute, The Cleveland Clinic, Cleveland, Ohio 44195, USA.
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