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Ren P, Jiang B, Hassab A, Li G, Li W, Assi R, Tellides G. Heterogeneous Cardiac- and Neural Crest-Derived Aortic Smooth Muscle Cells have Similar Transcriptional Changes after TGFβ Signaling Disruption. bioRxiv 2024:2024.04.28.591539. [PMID: 38746256 PMCID: PMC11092432 DOI: 10.1101/2024.04.28.591539] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Abstract
Smooth muscle cells (SMCs) of cardiac and neural crest origin contribute to the developing proximal aorta and are linked to disease propensity in adults. We analyzed single-cell transcriptomes of SMCs from mature thoracic aortas in mice to determine basal states and changes after disrupting transforming growth factor-β (TGFβ) signaling necessary for aortic homeostasis. A minority of Myh11 lineage-marked SMCs differentially expressed genes suggestive of embryological origin. Additional analyses in Nkx2-5 and Wnt1 lineage-marked SMCs derived from cardiac and neural crest progenitors, respectively, showed both lineages contributed to a major common cluster and each lineage to a minor distinct cluster. Common cluster SMCs extended from root to arch, cardiac subset cluster SMCs from root to mid-ascending, while neural crest subset cluster SMCs were restricted to the arch. The neural crest subset cluster had greater expression of a subgroup of TGFβ-dependent genes suggesting specific responsiveness or skewed extracellular matrix synthesis. Nonetheless, deletion of TGFβ receptors in SMCs resulted in similar transcriptional changes among all clusters, primarily decreased extracellular matrix molecules and modulators of TGFβ signaling. Many embryological markers of murine aortic SMCs were not confirmed in adult human aortas. We conclude: (i) there are multiple subtypes of cardiac- and neural crest-derived SMCs with shared or distinctive transcriptional profiles, (ii) neural crest subset SMCs with increased expression of certain TGFβ-inducible genes are not spatially linked to the aortic root predisposed to aneurysms from aberrant TGFβ signaling, and (iii) loss of TGFβ responses after receptor deletion is uniform among SMCs of different embryological origins.
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Jiang B, Ren P, He C, Wang M, Murtada SI, Chen Y, Ramachandra AB, Li G, Qin L, Assi R, Schwartz MA, Humphrey JD, Tellides G. Short-Term Disruption of TGFβ Signaling in Adult Mice Renders the Aorta Vulnerable to Hypertension-Induced Dissection. bioRxiv 2024:2024.04.22.590484. [PMID: 38712205 PMCID: PMC11071440 DOI: 10.1101/2024.04.22.590484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/08/2024]
Abstract
Hypertension and transient increases in blood pressure from extreme exertion are risk factors for aortic dissection in patients with age-related vascular degeneration or inherited connective tissue disorders. Yet, the common experimental model of angiotensin II-induced aortopathy in mice appears independent of high blood pressure as lesions do not occur in response to an alternative vasoconstrictor, norepinephrine, and are not prevented by co-treatment with a vasodilator, hydralazine. We investigated vasoconstrictor administration to adult mice 1 week after disruption of TGFβ signaling in smooth muscle cells. Norepinephrine increased blood pressure and induced aortic dissection by 7 days and even within 30 minutes that was rescued by hydralazine; results were similar with angiotensin II. Changes in regulatory contractile molecule expression were not of pathological significance. Rather, reduced synthesis of extracellular matrix yielded a vulnerable aortic phenotype by decreasing medial collagen, most dynamically type XVIII, and impairing cell-matrix adhesion. We conclude that transient and sustained increases in blood pressure cause dissection in aortas rendered vulnerable by inhibition of TGFβ-driven extracellular matrix production by smooth muscle cells. A corollary is that medial fibrosis, a frequent feature of medial degeneration, may afford some protection against aortic dissection.
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Hassab AH, Hur DJ, Vallabhajosyula P, Tellides G, Assi R. Intimomedial tears of the aorta heal by smooth muscle cell-mediated fibrosis without atherosclerosis. JCI Insight 2024; 9:e172437. [PMID: 38592807 DOI: 10.1172/jci.insight.172437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 04/03/2024] [Indexed: 04/11/2024] Open
Abstract
BACKGROUNDDisease of the aorta varies from atherosclerosis to aneurysms, with complications including rupture, dissection, and poorly characterized limited tears. We studied limited tears without any mural hematoma, termed intimomedial tears, to gain insight into aortic vulnerability to excessive wall stresses. Our premise is that minimal injuries in aortas with sufficient medial resilience to prevent tear progression correspond to initial mechanisms leading to complete structural failure in aortas with significantly compromised medial resilience.METHODSIntimomedial tears were macroscopically identified in 9 of 108 ascending aortas after surgery and analyzed by histology and immunofluorescence confocal microscopy.RESULTSNonhemorrhagic, nonatheromatous tears correlated with advanced aneurysmal disease and most lacked distinctive symptoms or radiological signs. Tears traversed the intima and part of the subjacent media, while the resultant defects were partially or completely filled with neointima characterized by differentiated smooth muscle cells, scattered leukocytes, dense fibrosis, and absent elastic laminae despite tropoelastin synthesis. Healed lesions contained organized fibrin at tear edges without evidence of plasma and erythrocyte extravasation or lipid accumulation.CONCLUSIONThese findings suggest a multiphasic model of aortic wall failure in which primary lesions of intimomedial tears either heal if the media is sufficiently resilient or progress as dissection or rupture by medial delamination and tear completion, respectively. Moreover, mural incorporation of thrombus and cellular responses to injury, two historically important concepts in atheroma pathogenesis, contribute to vessel wall repair with adequate conduit function, but even together are not sufficient to induce atherosclerosis.FUNDINGNIH (R01-HL146723, R01-HL168473) and Yale Department of Surgery.
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Affiliation(s)
| | - David J Hur
- Department of Internal Medicine (Cardiovascular Medicine), Yale School of Medicine, New Haven, Connecticut, USA
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | | | - George Tellides
- Department of Surgery (Cardiac), and
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Program in Vascular Biology and Therapeutics, Yale School of Medicine, New Haven, Connecticut, USA
| | - Roland Assi
- Department of Surgery (Cardiac), and
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
- Program in Vascular Biology and Therapeutics, Yale School of Medicine, New Haven, Connecticut, USA
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Lee ME, Boules H, Steele J, Asnes J, Assi R. Thoracic aortic aneurysm in an adolescent with intraoperative discovery of contained rupture: a case report. AME Case Rep 2024; 8:36. [PMID: 38711883 PMCID: PMC11070988 DOI: 10.21037/acr-23-163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Accepted: 12/28/2023] [Indexed: 05/08/2024]
Abstract
Background As surgical recommendations in adults based on size criteria of ascending aortic aneurysms become more refined, criteria for childhood/adolescence remains less clear. Multiple pathologic factors may predispose younger patients to thoracic aortic aortopathy and increase the risk of rupture. An evolving field of research is how to identify thoracic aortic dilation earlier in patients, risk stratify, and to obtain objective measures beyond size for proceeding with surgical intervention in order to prevent catastrophic thoracic aortic dissection. Case Description We report an adolescent case of dilated ascending aortic aneurysm with a functionally unicuspid/bicuspid aortic valve. This patient was taken to surgery electively, given the gradual increasing size of the ascending aorta. Intraoperatively, there was an unexpected intraoperative finding of a contained aortic rupture. The patient underwent an aortic root replacement with mechanical valve composite graft and coronary artery reimplantation (modified Bentall) with ascending hemiarch replacement. The patient did well with no post-operative complications. Aortic pathology and genetic analysis were performed. The patient was discovered to have a heterozygous variant in PTPN11 which is typically associated with Noonan syndrome; however, this is not known to be associated with aortopathy. Conclusions As criteria for surgical intervention in adult thoracic ascending aortic aneurysms continues to evolve, this case illustrates challenges when determining the optimal criteria for surgical intervention in adolescent patients.
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Affiliation(s)
- Madonna E. Lee
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Heidi Boules
- Section of Pediatric Anesthesia, Department of Anesthesia, Yale School of Medicine, New Haven, CT, USA
| | - Jeremy Steele
- Section of Pediatric Cardiology, Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Jeremy Asnes
- Section of Pediatric Cardiology, Department of Pediatrics, Yale School of Medicine, New Haven, CT, USA
| | - Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
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Ram C, Yousef S, Ma WG, Vallabhajosyula I, Singh S, Agarwal R, Milewski RK, Assi R, Patel PA, Williams M, Geirsson A, Vallabhajosyula P. Living in disadvantaged neighborhoods linked to less intervention for severe aortic stenosis. Sci Rep 2024; 14:4952. [PMID: 38418864 PMCID: PMC10902341 DOI: 10.1038/s41598-024-52660-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/22/2024] [Indexed: 03/02/2024] Open
Abstract
To investigate the association between area deprivation index (ADI) and aortic valve replacement (AVR) in patients with severe aortic stenosis (AS). Patients aged 40-95 years with severe AS confirmed by echocardiography were included. The 9-digit zip code of patient residence address was used to identify the ADI ranking, based on which patients were divided into 5 groups (with Group E being most deprived). The rates of AV intervention were compared among 5 groups using competing risks analysis, with death as a competing event. We included 1751 patients with severe AS from 2013 to 2018 followed for a median 2.8 (interquartile range, 1.5-4.8) years. The more distressed ADI groups tended to be younger (P = 0.002), female (P < 0.001), and of African American race (P < 0.001), have higher presentation of sepsis (P = 0.031), arrhythmia (P = 0.022), less likely to have previous diagnosis of AS (P < 0.001); and were less likely to undergo AVR (52.5% vs 46.9% vs 46.1% vs 48.9% vs 39.7%, P = 0.023). Using competing risk analysis, the highest ADI group (E) were the least and the lowest ADI group (A) the most likely to undergo AVR (Gray's test, P = 0.025). The association between ADI ranking and AVR rates was influenced by sex and race. Within group analysis, there was significant association between race and AVR (Gray's test, P < 0.001), and between sex and AVR (Gray's test, P < 0.001). Patients with severe AS living in more deprived neighborhoods were less likely to undergo aortic valve interventions, which was influenced by female gender, and African American race.
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Affiliation(s)
- Chirag Ram
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
- Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Sameh Yousef
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Wei-Guo Ma
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Ishani Vallabhajosyula
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Saket Singh
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Ritu Agarwal
- Joint Data Analytics Team, Information Technology Service, Yale University, New Haven, USA
| | - Rita K Milewski
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Roland Assi
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Prakash A Patel
- Division of Cardiac Anesthesiology, Yale School of Medicine, New Haven, CT, USA
| | - Matthew Williams
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA
| | - Prashanth Vallabhajosyula
- Division of Cardiac Surgery, Yale Aortic Institute, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT, 06520, USA.
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Hameed I, Ahmed A, Pupovac S, Nassiri N, Assi R, Vallabhajosyula P. Aortic remodeling following hybrid arch repair with zone 0 to 5 thoracic endovascular aortic repairs for complex arch and descending thoracic aortic pathologies. JTCVS Open 2024; 17:23-36. [PMID: 38420535 PMCID: PMC10897673 DOI: 10.1016/j.xjon.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Revised: 11/21/2023] [Accepted: 12/04/2023] [Indexed: 03/02/2024]
Abstract
Objective For high-risk patients with aortic arch pathology, hybrid aortic arch repair with simultaneous or staged thoracic endovascular repair of the descending aorta may be a viable alternative to open repair. However, data on postintervention aortic remodeling remain limited. We report the short-term outcomes of remodeling of the thoracoabdominal aorta after hybrid arch repair + thoracic endovascular repair. Methods All patients undergoing hybrid arch repair with planned zones 0 to 5 thoracic endovascular repair from January 2020 to March 2022 were retrospectively reviewed. Computed tomography angiography scans preoperatively, after hybrid aortic arch repair, and on long-term follow-up were analyzed for thoracoabdominal aorta remodeling. Mean change in aortic true luminal diameter and full luminal diameter was calculated at every level, and paired-samples t test was used to compare means. Results Of 39 patients, 38 had follow-up data at a mean duration of 14.9 months. There were a total of 3 (7.7%) deaths, 0 (0.0%) strokes, and 0 (0.0%) paralysis. For the 35 patients undergoing thoracic endovascular repair for aortic dissection, at follow-up, there was a significant increase in the mean true luminal diameter at each level (P < .05), except at the aortic bifurcation and common iliac arteries. The largest increase in mean true luminal diameter (P < .01) was observed at the level of the left inferior pulmonary vein (mean difference +13.22 mm, 95% CI, 10.38-16.07), tracheal carina (mean difference +13.06 mm, 95% CI, 10.05-16.07), and inferior left atrium (mean difference +11.19 mm, 95% CI, 7.84-14.53). Conclusions Hybrid arch repair with zones 0 to 5 leads to improved true lumen augmentation in zones 0 to 8 with complete false lumen thrombosis down to zone 5 at short-term follow-up. Zones 9 to 11, if involved, may require adjunctive treatment strategies for total aortic remodeling and complete false lumen obliteration.
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Affiliation(s)
- Irbaz Hameed
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Adham Ahmed
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Stevan Pupovac
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Naiem Nassiri
- Division of Vascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Prashanth Vallabhajosyula
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
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Assi R, Geirsson A, Vallabhajosyula P. Commentary: The first operative risk score for contemporary aortic arch surgery. J Thorac Cardiovasc Surg 2024; 167:609-610. [PMID: 35489833 DOI: 10.1016/j.jtcvs.2022.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 03/20/2022] [Accepted: 03/21/2022] [Indexed: 11/24/2022]
Affiliation(s)
- Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Prashanth Vallabhajosyula
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn.
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Lamy A, Chertow GM, Jessen M, Collar A, Brown CD, Mack CA, Marzouk M, Scavo V, Washburn TB, Savage D, Smith J, Bennetts J, Assi R, Shults C, Arghami A, Butler J, Devereaux P, Zager R, Wang C, Snapinn S, Browne A, Rodriguez J, Ruiz S, Singh B. Effects of RBT-1 on preconditioning response biomarkers in patients undergoing coronary artery bypass graft or heart valve surgery: a multicentre, double-blind, randomised, placebo-controlled phase 2 trial. EClinicalMedicine 2024; 68:102364. [PMID: 38586479 PMCID: PMC10994969 DOI: 10.1016/j.eclinm.2023.102364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 11/20/2023] [Accepted: 11/22/2023] [Indexed: 04/09/2024] Open
Abstract
Background RBT-1 is a combination drug of stannic protoporfin (SnPP) and iron sucrose (FeS) that elicits a preconditioning response through activation of antioxidant, anti-inflammatory, and iron-scavenging pathways, as measured by heme oxygenase-1 (HO-1), interleukin-10 (IL-10), and ferritin, respectively. Our primary aim was to determine whether RBT-1 administered before surgery would safely and effectively elicit a preconditioning response in patients undergoing cardiac surgery. Methods This phase 2, double-blind, randomised, placebo-controlled, parallel-group, adaptive trial, conducted in 19 centres across the USA, Canada, and Australia, enrolled patients scheduled to undergo non-emergent coronary artery bypass graft (CABG) and/or heart valve surgery with cardiopulmonary bypass. Patients were randomised (1:1:1) to receive either a single intravenous infusion of high-dose RBT-1 (90 mg SnPP/240 mg FeS), low-dose RBT-1 (45 mg SnPP/240 mg FeS), or placebo within 24-48 h before surgery. The primary outcome was a preoperative preconditioning response, measured by a composite of plasma HO-1, IL-10, and ferritin. Safety was assessed by adverse events and laboratory parameters. Prespecified adaptive criteria permitted early stopping and enrichment. This trial is registered with ClinicalTrials.gov, NCT04564833. Findings Between Aug 4, 2021, and Nov 9, 2022, of 135 patients who were enrolled and randomly allocated to a study group (46 high-dose, 45 low-dose, 44 placebo), 132 (98%) were included in the primary analysis (46 high-dose, 42 low-dose, 44 placebo). At interim, the trial proceeded to full enrollment without enrichment. RBT-1 led to a greater preconditioning response than did placebo at high-dose (geometric least squares mean [GLSM] ratio, 3.58; 95% CI, 2.91-4.41; p < 0.0001) and low-dose (GLSM ratio, 2.62; 95% CI, 2.11-3.24; p < 0.0001). RBT-1 was generally well tolerated by patients. The primary drug-related adverse event was dose-dependent photosensitivity, observed in 12 (26%) of 46 patients treated with high-dose RBT-1 and in six (13%) of 45 patients treated with low-dose RBT-1 (safety population). Interpretation RBT-1 demonstrated a statistically significant cytoprotective preconditioning response and a manageable safety profile. Further research is needed. A phase 3 trial is planned. Funding Renibus Therapeutics, Inc.
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Affiliation(s)
- Andre Lamy
- Department of Perioperative Medicine and Surgery, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Glenn M. Chertow
- Departments of Medicine and Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Jessen
- Department of Cardiovascular and Thoracic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alonso Collar
- Department of Thoracic Surgery and Vascular Surgery, MyMichigan Health, Midland, MI, USA
| | - Craig D. Brown
- Department of Cardiac Surgery, New Brunswick Heart Centre, Saint John, New Brunswick, Canada
| | - Charles A. Mack
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY, USA
| | - Mohamed Marzouk
- Department of Cardiac Surgery, Québec Heart and Lung Institute, Québec, Québec, Canada
| | - Vincent Scavo
- Department of Cardiovascular and Thoracic Surgery, Lutheran Medical Group, Fort Wayne, Indiana, USA
| | - T Benton Washburn
- Department of Cardiothoracic Surgery, Huntsville Hospital Heart Center, Huntsville, AL, USA
| | - David Savage
- Department of Cardiothoracic Surgery, Indiana University Health, Bloomington, IN, USA
| | - Julian Smith
- Department of Surgery (School of Clinical Sciences at Monash Health), Monash University and Department of Cardiothoracic Surgery, Monash Health, Melbourne, Victoria, Australia
| | - Jayme Bennetts
- Department of Cardiothoracic Surgery, Flinders Medical Centre, Southern Adelaide Local Health Network, Adelaide, Australia
- Department of Surgery, College of Medicine and Public Health, Flinders University, Adelaide, Australia
| | - Roland Assi
- Department of Cardiac Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Christian Shults
- Department of Cardiac Surgery, MedStar Heart and Vascular Institute, Washington, DC, USA
| | - Arman Arghami
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
| | - P.J. Devereaux
- Department of Perioperative Medicine and Surgery, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Richard Zager
- Department of Drug Development & Medical Affairs, Renibus Therapeutics Inc, Southlake, TX, USA
| | - Chao Wang
- Pharma Data Associates LLC, Piscataway, NJ, USA
| | - Steve Snapinn
- Seattle-Quilcene Biostatistics LLC, Seattle, WA, USA
| | - Austin Browne
- Department of Perioperative Medicine and Surgery, Population Health Research Institute, Hamilton, Ontario, Canada
| | - Jeannette Rodriguez
- Department of Drug Development & Medical Affairs, Renibus Therapeutics Inc, Southlake, TX, USA
| | - Stacey Ruiz
- Department of Drug Development & Medical Affairs, Renibus Therapeutics Inc, Southlake, TX, USA
| | - Bhupinder Singh
- Department of Drug Development & Medical Affairs, Renibus Therapeutics Inc, Southlake, TX, USA
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Assi R, Geirsson A, Vallabhajosyula P. Commentary: Thoracic aortic surgery is all about the brain. J Thorac Cardiovasc Surg 2024; 167:63-64. [PMID: 35422322 DOI: 10.1016/j.jtcvs.2022.02.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 02/23/2022] [Accepted: 02/24/2022] [Indexed: 10/18/2022]
Affiliation(s)
- Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Prashanth Vallabhajosyula
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn.
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Singh S, Vallabhajosyula P, Geirsson A, Assi R. TAVR explant with aortic root replacement using a homograft for an aortic rupture. Multimed Man Cardiothorac Surg 2023; 2023. [PMID: 36644957 DOI: 10.1510/mmcts.2022.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
This case report describes the explantation of an Evolut PRO valve 9 months after implantation in a 69-year-old male presenting with an aortic rupture adjacent to the stent frame of the prosthesis. Imaging was consistent with aortic sinus pseudoaneurysm and a large haemopericardium. Degeneration of the aortic root compounded by the transcatheter prosthesis in addition to the aortic rupture required replacement of the aortic root. The complexity of the procedure also required a modified Cabrol extension of the left coronary button and reconstruction of the left coronary button with bovine pericardium. We describe the technical challenges posed by the self-expanding transcatheter aortic valve prosthesis and tips and tricks to circumvent these challenges.
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Affiliation(s)
- Saket Singh
- Section of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Prashanth Vallabhajosyula
- Section of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Arnar Geirsson
- Section of Cardiac Surgery, Yale University School of Medicine
| | - Roland Assi
- Section of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
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Lamy A, Assi R, Brown C, Arghami A, Mack C, Jessen M, Smith J, Marzouk M, Washburn TB, Savage D, Collar A, Scavo V, Bennetts J, Zager R, Wang C, Lavin P, Ruiz S, Singh B. 3: PHASE 2 STUDY INTERIM RESULTS OF RBT-1 EFFECT ON POSTOPERATIVE COURSE IN ELECTIVE CABG/VALVE SURGERY. Crit Care Med 2023. [DOI: 10.1097/01.ccm.0000905888.62846.0d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Kahler-Quesada AM, Vallabhajosyula I, Yousef S, Mori M, Amabile A, Assi R, Geirsson A, Vallabhajosyula P. Variability in surveillance practice for patients with diagnosis of bicuspid aortic valve syndrome. Sci Rep 2022; 12:22009. [PMID: 36539583 PMCID: PMC9768129 DOI: 10.1038/s41598-022-25571-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022] Open
Abstract
In patients with bicuspid aortic valves, guidelines call for regular follow-up to monitor disease progression and guide intervention. We aimed to evaluate how closely these recommendations are followed at a tertiary care center. Among 48,504 patients who received echocardiograms (2013-2018) at a tertiary care center, 245 patients were identified to have bicuspid aortic valve. Bivariate analyses compared characteristics between patients who did and did not receive follow-up by a cardiovascular specialist. During a median follow-up of 3.5 ± 2.2 years (mean age 55.2 ± 15.6 years, 30.2% female), 72.7% of patients had at least one visit with a cardiovascular specialist after diagnosis of bicuspid aortic valve. These patients had a higher proportion of surveillance by echocardiogram (78.7% vs. 34.3%, p < .0001), CT or MRI (41.0% vs. 3.0%, p < .0001), and were more likely to undergo surgery. Patients with moderate-severe valvular or aortic pathology were not more likely to be followed by a specialist or receive follow-up echocardiograms. Follow-up care for patients with bicuspid aortic valve was highly variable, and surveillance imaging was sparse despite guidelines. There is an urgent need for mechanisms to monitor this population with increased risk of progressive valvulopathy and aortopathy.
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Affiliation(s)
- Arianna M Kahler-Quesada
- Division of Cardiac Surgery, Yale Aortic Institute, Yale University School of Medicine, 330 Cedar Street, Boardman 204L, New Haven, CT, 0652, USA
| | - Ishani Vallabhajosyula
- Division of Cardiac Surgery, Yale Aortic Institute, Yale University School of Medicine, 330 Cedar Street, Boardman 204L, New Haven, CT, 0652, USA
| | - Sameh Yousef
- Division of Cardiac Surgery, Yale Aortic Institute, Yale University School of Medicine, 330 Cedar Street, Boardman 204L, New Haven, CT, 0652, USA
| | - Makoto Mori
- Division of Cardiac Surgery, Yale Aortic Institute, Yale University School of Medicine, 330 Cedar Street, Boardman 204L, New Haven, CT, 0652, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Andrea Amabile
- Division of Cardiac Surgery, Yale Aortic Institute, Yale University School of Medicine, 330 Cedar Street, Boardman 204L, New Haven, CT, 0652, USA
| | - Roland Assi
- Division of Cardiac Surgery, Yale Aortic Institute, Yale University School of Medicine, 330 Cedar Street, Boardman 204L, New Haven, CT, 0652, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale Aortic Institute, Yale University School of Medicine, 330 Cedar Street, Boardman 204L, New Haven, CT, 0652, USA
| | - Prashanth Vallabhajosyula
- Division of Cardiac Surgery, Yale Aortic Institute, Yale University School of Medicine, 330 Cedar Street, Boardman 204L, New Haven, CT, 0652, USA.
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13
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Yousef S, Amabile A, Ram C, Singh S, Agarwal R, Milewski R, Assi R, Patel PA, Krane M, Geirsson A, Vallabhajosyula P. Direct relationship between transvalvular velocity and cardiac dysfunction, morbidity, and mortality in patients with aortic stenosis. J Card Surg 2022; 37:5052-5062. [PMID: 36378856 DOI: 10.1111/jocs.17199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 10/29/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Current guidelines recommend intervention in subjects with severe symptomatic aortic stenosis (AS), even though any degree of AS is associated with a higher risk of mortality. We investigated the association between the degree of AS, delineated by transvalvular flow velocity, and patient morbidity and mortality. METHODS Medically managed patients aged 40-95 years with maximum flow velocity (Vmax ) by echocardiography between 2013 and 2018 were stratified into five groups (A-E) based on the 75th, 90th, 97.5th, and the 99th percentiles of Vmax distribution. Patient characteristics, cardiac structural changes, and end-organ disease were compared using Kruskal-Wallis and Cochran-Armitage tests. Mortality over a median of 2.8 (1.52-4.8) years was compared using Kaplan-Meier curves and risk estimates were derived from the Cox model. RESULTS The Vmax was reported in 37,131 patients. There was a steady increase (from Group A towards E) in age, Caucasian race, structural cardiac changes, end-organ morbidities, and all-cause mortality. In reference to Group A, there as an increased risk of mortality in Groups B (hazard ratio [HR] = 1.3; confidence interval [CI]: 1.2-1.35; p < .0001), C (HR = 1.5; CI: 1.4-1.6; p < .0001), and D (HR = 1.8; CI: 1.6-2; p < .0001), with an exponential increase in Group E (HR = 2.5; CI: 2.2-2.8; p < .0001). CONCLUSIONS A direct, strong correlation exists between the degree of AS and cardiac structural changes and mortality. Patients with Vmax ≥ 97.5th percentile (≥3.2 m/s) might benefit from early intervention.
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Affiliation(s)
- Sameh Yousef
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Andrea Amabile
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Chirag Ram
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Saket Singh
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ritu Agarwal
- Joint Data Analytics Team, Information Technology Service, Yale University, New Haven, Connecticut, USA
| | - Rita Milewski
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Roland Assi
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Prakash A Patel
- Division of Cardiac Anesthesiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Markus Krane
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, Connecticut, USA
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14
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Lee ME, Woodard GA, Assi R. Connection through cardiothoracic surgery subspecialty collaboration: Strategies for Early Faculty Peer Network Development. JTCVS Open 2022; 12:329-334. [PMID: 36590730 PMCID: PMC9801233 DOI: 10.1016/j.xjon.2022.07.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 06/15/2022] [Accepted: 06/29/2022] [Indexed: 01/04/2023]
Affiliation(s)
- Madonna E. Lee
- Division of Pediatric Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
- Address for reprints: Madonna E. Lee, MD, Division of Pediatric Cardiac Surgery, Department of Surgery, Yale School of Medicine, 330 Cedar St, Boardman Building 204, PO Box 208039, New Haven, CT 06510.
| | - Gavitt A. Woodard
- Division of Thoracic Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
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15
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Singh S, Pupovac SS, Assi R, Vallabhajosyula P. Comprehensive review of hybrid aortic arch repair with focus on zone 0 TEVAR and our institutional experience. Front Cardiovasc Med 2022; 9:991824. [PMID: 36187018 PMCID: PMC9520124 DOI: 10.3389/fcvm.2022.991824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/25/2022] [Indexed: 11/24/2022] Open
Abstract
Even with increasing operator experience and a better understanding of the disease and the operation, intervention for aortic arch pathologies continues to struggle with relatively higher mortality, reintervention, and neurologic complications. The hybrid aortic arch repair was introduced to simplify the procedure and improve the outcome. With recent industry-driven advances, hybrid repairs are not only offered to poor surgical candidates but have become mainstream. This review discusses the evolution of hybrid repair, terminology pertinent to this technique, and results. In addition, we aim to provide a pervasive review of hybrid aortic arch repairs with reference to relevant literature for a detailed understanding. We have also discussed our institutional experience with hybrid repairs.
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16
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Weininger G, Zafar M, Ziganshin BA, Mori M, Papanikolaou D, Sekar RB, Amabile A, Degife E, O'Marr J, Geirsson A, Elefteriades JA, Assi R, Vallabhajosyula P. Long-term risk of arch complications in Loeys Dietz syndrome patients undergoing proximal ascending aortic replacement. J Card Surg 2022; 37:3688-3692. [PMID: 35989525 DOI: 10.1111/jocs.16855] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2022] [Revised: 07/10/2022] [Accepted: 07/17/2022] [Indexed: 11/30/2022]
Abstract
PURPOSE Loeys-Dietz syndrome (LDS) is a rare connective tissue disorder. In LDS patients with normal arch morphology, whether the arch should be prophylactically replaced at the time of proximal aortic replacement remains unknown. We evaluated the risk of long-term arch complications in genetically confirmed LDS patients who underwent proximal ascending aortic replacement. METHODS We retrospectively reviewed the records of patients with LDS who have been followed at our institution between 1994 and 2020. Patients were only included if whole exome genetic testing confirmed a mutation in an LDS-causing gene (TGFBR1, TGFBR2, SMAD3, TGFB2, or TGFB3). Mutations were categorized as pathogenic, benign, or of unknown significance. We collected demographic information, aortic dimensions, comorbidities, mortality, and operative course from patients' charts. Descriptive statistics and freedom from reoperation plots were generated. RESULTS Of the 18 patients with a mutation in an LDS-causing gene, 15 had known pathogenic variants, two had mutations of unknown significance, and one had a benign genetic variant. For the 15 patients with confirmed pathogenic variants of LDS the median follow-up duration was 5 years (interquartile range [IQR]: 4-8). Eleven patients underwent ascending aortic replacements (AAR) ± aortic valve replacement. Two patients required an additional operation; one required arch and staged elephant trunk for a dissection 18 years post-AAR and the other patient required an isolated descending aortic replacement for dissection 5 years post-AAR. Among patients who underwent surgery, the median ascending aortic diameter at intervention was 5.0 cm (IQR: 4.3-5.3). There was no surgical or late follow-up mortality observed for any of the 18 patients in the study. CONCLUSION LDS patients who underwent proximal aortic replacement appeared to have low long-term risk of arch complications. While our study is somewhat limited by its sample size and follow-up duration, it suggests that routine prophylactic total arch replacement may not be warranted in LDS patients with nonaneurysmal aortic arches.
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Affiliation(s)
- Gabe Weininger
- Aortic Institute at Yale University School of Medicine, New Haven, Connecticut, USA
| | - Mohammad Zafar
- Aortic Institute at Yale University School of Medicine, New Haven, Connecticut, USA
| | - Bulat A Ziganshin
- Aortic Institute at Yale University School of Medicine, New Haven, Connecticut, USA
| | - Makoto Mori
- Aortic Institute at Yale University School of Medicine, New Haven, Connecticut, USA
| | - Dimitra Papanikolaou
- Aortic Institute at Yale University School of Medicine, New Haven, Connecticut, USA
| | - Rajesh B Sekar
- Aortic Institute at Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrea Amabile
- Aortic Institute at Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ellelan Degife
- Aortic Institute at Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jamieson O'Marr
- Aortic Institute at Yale University School of Medicine, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Aortic Institute at Yale University School of Medicine, New Haven, Connecticut, USA
| | - John A Elefteriades
- Aortic Institute at Yale University School of Medicine, New Haven, Connecticut, USA
| | - Roland Assi
- Aortic Institute at Yale University School of Medicine, New Haven, Connecticut, USA
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17
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Yousef S, Amabile A, Ram C, Huang H, Korutla V, Singh S, Agarwal R, Assi R, Milewski RK, Zhang Y, Patel PA, Krane M, Geirsson A, Vallabhajosyula P. Screening Tool to Identify Patients with Advanced Aortic Valve Stenosis. J Clin Med 2022; 11:jcm11154386. [PMID: 35956007 PMCID: PMC9369431 DOI: 10.3390/jcm11154386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 06/29/2022] [Accepted: 07/26/2022] [Indexed: 02/01/2023] Open
Abstract
(1) Background: The clinical burden of aortic stenosis (AS) remains high in Western countries. Yet, there are no screening algorithms for this condition. We developed a risk prediction model to guide targeted screening for patients with AS. (2) Methods: We performed a cross-sectional analysis of all echocardiographic studies performed between 2013 and 2018 at a tertiary academic care center. We included reports of unique patients aged from 40 to 95 years. A logistic regression model was fitted for the risk of moderate and severe AS, with readily available demographics and comorbidity variables. Model performance was assessed by the C-index, and its calibration was judged by a calibration plot. (3) Results: Among the 38,788 reports yielded by inclusion criteria, there were 4200 (10.8%) patients with ≥moderate AS. The multivariable model demonstrated multiple variables to be associated with AS, including age, male gender, Caucasian race, Body Mass Index ≥ 30, and cardiovascular comorbidities and medications. C-statistics of the model was 0.77 and was well calibrated according to the calibration plot. An integer point system was developed to calculate the predicted risk of ≥moderate AS, which ranged from 0.0002 to 0.7711. The lower 20% of risk was approximately 0.15 (corresponds to a score of 252), while the upper 20% of risk was about 0.60 (corresponds to a score of 332 points). (4) Conclusions: We developed a risk prediction model to predict patients' risk of having ≥moderate AS based on demographic and clinical variables from a large population cohort. This tool may guide targeted screening for patients with advanced AS in the general population.
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Affiliation(s)
- Sameh Yousef
- Division of Cardiac Surgery, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT 06511, USA; (S.Y.); (A.A.); (C.R.); (V.K.); (S.S.); (R.A.); (R.K.M.); (M.K.); (A.G.)
| | - Andrea Amabile
- Division of Cardiac Surgery, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT 06511, USA; (S.Y.); (A.A.); (C.R.); (V.K.); (S.S.); (R.A.); (R.K.M.); (M.K.); (A.G.)
| | - Chirag Ram
- Division of Cardiac Surgery, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT 06511, USA; (S.Y.); (A.A.); (C.R.); (V.K.); (S.S.); (R.A.); (R.K.M.); (M.K.); (A.G.)
| | - Huang Huang
- Section of Surgical Outcomes and Epidemiology, Yale School of Public Health, New Haven, CT 06511, USA; (H.H.); (Y.Z.)
| | - Varun Korutla
- Division of Cardiac Surgery, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT 06511, USA; (S.Y.); (A.A.); (C.R.); (V.K.); (S.S.); (R.A.); (R.K.M.); (M.K.); (A.G.)
| | - Saket Singh
- Division of Cardiac Surgery, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT 06511, USA; (S.Y.); (A.A.); (C.R.); (V.K.); (S.S.); (R.A.); (R.K.M.); (M.K.); (A.G.)
| | - Ritu Agarwal
- Joint Data Analytics Team, Information Technology Service, Yale University, New Haven, CT 06511, USA;
| | - Roland Assi
- Division of Cardiac Surgery, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT 06511, USA; (S.Y.); (A.A.); (C.R.); (V.K.); (S.S.); (R.A.); (R.K.M.); (M.K.); (A.G.)
| | - Rita K. Milewski
- Division of Cardiac Surgery, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT 06511, USA; (S.Y.); (A.A.); (C.R.); (V.K.); (S.S.); (R.A.); (R.K.M.); (M.K.); (A.G.)
| | - Yawei Zhang
- Section of Surgical Outcomes and Epidemiology, Yale School of Public Health, New Haven, CT 06511, USA; (H.H.); (Y.Z.)
| | - Prakash A. Patel
- Division of Cardiac Anesthesiology, Yale School of Medicine, New Haven, CT 06511, USA;
| | - Markus Krane
- Division of Cardiac Surgery, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT 06511, USA; (S.Y.); (A.A.); (C.R.); (V.K.); (S.S.); (R.A.); (R.K.M.); (M.K.); (A.G.)
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT 06511, USA; (S.Y.); (A.A.); (C.R.); (V.K.); (S.S.); (R.A.); (R.K.M.); (M.K.); (A.G.)
| | - Prashanth Vallabhajosyula
- Division of Cardiac Surgery, Yale School of Medicine, 330 Cedar Street BB204, New Haven, CT 06511, USA; (S.Y.); (A.A.); (C.R.); (V.K.); (S.S.); (R.A.); (R.K.M.); (M.K.); (A.G.)
- Correspondence: ; Tel.: +1-203-785-6214; Fax: +1-203-785-3346
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18
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Khosla A, Mojibian H, Assi R, Tantawy H, Singh I, Pollak J. Right heart thrombi (RHT) and clot in transit with concomitant PE management: Approach and considerations. Pulm Circ 2022; 12:e12080. [PMID: 35514771 PMCID: PMC9063956 DOI: 10.1002/pul2.12080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 01/04/2022] [Accepted: 04/06/2022] [Indexed: 11/06/2022] Open
Abstract
Right heart thrombi (RHT) continues to pose a clinical dilemma for multiple specialties and is especially concerning when present with concomitant pulmonary embolism (PE). Patients with PE and RHT are at an increased risk of poor outcomes compared to PE without RHT. Although the exact incidence of RHT is unknown, the increasing use of point-of-care ultrasound may lead to an increased detection and frequency of RHT. There are multiple treatment strategies available for RHT, including anticoagulation, systemic thrombolysis, and endovascular and surgical therapies. Given that these treatment strategies involve multiple medical specialties, the management of RHT with concomitant PE can be complex. Currently, there is limited clinical data and guidelines on the treatment and management of RHT. We aim to provide a review on RHT with concomitant PE, including risk stratification, treatment considerations, and our approach to the management of RHT.
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Affiliation(s)
- Akhil Khosla
- Department of Internal Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of MedicineYale New Haven HospitalNew‐HavenConnecticutUSA
| | - Hamid Mojibian
- Department of Radiology and Biomedical Imaging, Section of Vascular and Interventional RadiologyYale University School of MedicineNew HavenConnecticutUSA
| | - Roland Assi
- Division of Cardiac SurgeryYale University School of MedicineNew HavenConnecticutUSA
| | - Hossam Tantawy
- Department of AnesthesiologyYale University School of MedicineNew HavenConnecticutUSA
| | - Inderjit Singh
- Department of Internal Medicine, Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of MedicineYale New Haven HospitalNew‐HavenConnecticutUSA
| | - Jeffrey Pollak
- Department of Radiology and Biomedical Imaging, Section of Vascular and Interventional RadiologyYale University School of MedicineNew HavenConnecticutUSA
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19
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He C, Jiang B, Wang M, Ren P, Murtada SI, Caulk AW, Li G, Qin L, Assi R, Lovoulos CJ, Schwartz MA, Humphrey JD, Tellides G. mTOR inhibition prevents angiotensin II-induced aortic rupture and pseudoaneurysm but promotes dissection in Apoe-deficient mice. JCI Insight 2022; 7:155815. [PMID: 35132962 PMCID: PMC8855820 DOI: 10.1172/jci.insight.155815] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/23/2021] [Indexed: 01/04/2023] Open
Abstract
Aortic dissection and rupture are triggered by decreased vascular wall strength and/or increased mechanical loads. We investigated the role of mTOR signaling in aortopathy using a well-described model of angiotensin II–induced dissection, aneurysm, or rupture of the suprarenal abdominal aorta in Apoe-deficient mice. Although not widely appreciated, nonlethal hemorrhagic lesions present as pseudoaneurysms without significant dissection in this model. Angiotensin II–induced aortic tears result in free rupture, contained rupture with subadventitial hematoma (forming pseudoaneurysms), dilatation, or healing, while the media invariably thickens regardless of mural tears. Medial thickening results from smooth muscle cell hypertrophy and extracellular matrix accumulation, including matricellular proteins. Angiotensin II activates mTOR signaling in vascular wall cells, and inhibition of mTOR signaling by rapamycin prevents aortic rupture but promotes dissection. Decreased aortic rupture correlates with decreased inflammation and metalloproteinase expression, whereas extensive dissection correlates with induction of matricellular proteins that modulate adhesion of vascular cells. Thus, mTOR activation in vascular wall cells determines whether aortic tears progress to dissection or rupture. Previous mechanistic studies of aortic aneurysm and dissection by angiotensin II in Apoe-deficient mice should be reinterpreted as clinically relevant to pseudoaneurysms, and mTOR inhibition for aortic disease should be explored with caution.
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Affiliation(s)
- Changshun He
- Department of Surgery (Cardiac), Yale School of Medicine, New Haven, Connecticut, USA
| | - Bo Jiang
- Department of Surgery (Cardiac), Yale School of Medicine, New Haven, Connecticut, USA
| | - Mo Wang
- Department of Surgery (Cardiac), Yale School of Medicine, New Haven, Connecticut, USA
| | - Pengwei Ren
- Department of Surgery (Cardiac), Yale School of Medicine, New Haven, Connecticut, USA
| | - Sae-Il Murtada
- Department of Biomedical Engineering, Yale School of Engineering and Applied Science, New Haven, Connecticut, USA
| | - Alexander W Caulk
- Department of Biomedical Engineering, Yale School of Engineering and Applied Science, New Haven, Connecticut, USA
| | - Guangxin Li
- Department of Surgery (Cardiac), Yale School of Medicine, New Haven, Connecticut, USA
| | - Lingfeng Qin
- Department of Surgery (Cardiac), Yale School of Medicine, New Haven, Connecticut, USA
| | - Roland Assi
- Department of Surgery (Cardiac), Yale School of Medicine, New Haven, Connecticut, USA.,Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, Connecticut, USA.,Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Constantinos J Lovoulos
- Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA.,Department of Surgery, Frank H. Netter MD School of Medicine, Quinnipiac University, North Haven, Connecticut, USA
| | - Martin A Schwartz
- Department of Medicine (Cardiology).,Department of Cell Biology, and.,Yale Cardiovascular Research Center, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jay D Humphrey
- Department of Biomedical Engineering, Yale School of Engineering and Applied Science, New Haven, Connecticut, USA.,Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, Connecticut, USA
| | - George Tellides
- Department of Surgery (Cardiac), Yale School of Medicine, New Haven, Connecticut, USA.,Vascular Biology and Therapeutics Program, Yale School of Medicine, New Haven, Connecticut, USA.,Veterans Affairs Connecticut Healthcare System, West Haven, Connecticut, USA
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20
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Weininger G, Mori M, Yousef S, Hur DJ, Assi R, Geirsson A, Vallabhajosyula P. Growth rate of ascending thoracic aortic aneurysms in a non-referral-based population. J Cardiothorac Surg 2022; 17:14. [PMID: 35109884 PMCID: PMC8812194 DOI: 10.1186/s13019-022-01761-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 01/22/2022] [Indexed: 11/26/2022] Open
Abstract
Background Prior studies on ascending thoracic aortic aneurysm (ATAA) growth rates have reported approximately 1 mm of growth per year but these studies are based on referral-based study populations which are biased towards the highest risk patients who may not represent the true natural history of aortic aneurysm disease. We aimed to characterize the growth rate of ATAAs in a non-referral-based population, using a large institutional database of computed tomography (CT) scans. Methods We queried the 21,325 CT scans performed at our institution between 2013 and 2016 on patients ages 50–85 years old for radiologic diagnosis of aortic aneurysm or dilatation. 560 patients were identified to have aortic dilatation > 4 cm, of which 207 had follow-up scan intervals > 6 months. This comprised our non-referral-based study population. Linearized annual aneurysm growth rates were calculated by dividing the change in aortic size by the time interval between CT scans. Results The median time interval between scans was 2.7 years (interquartile range [IQR] 1.5–4.2) for the 207 patients included in the study. The median initial aneurysm size was 4.3 cm (IQR 4.1–4.5). 38.2% (n = 79) of patients did not experience aortic dilatation. The median growth rate was 0.13 mm/year (IQR − 0.24 to 0.49). Of patients in the top quartile of growth rates, 26.9% of patients were female whereas 12.9% of patients were female in the bottom three quartiles of growth rates. Conclusion While some patients’ ATAAs may grow at previously published rates of around 1 mm/year, this is not the predominant pattern in a non-referral-based population and may over-estimate the overall growth rate of ATAAs.
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Affiliation(s)
- Gabe Weininger
- Section of Cardiac Surgery, Yale University School of Medicine, 330 Cedar Street, Boardman Building 204L, New Haven, CT, 06520, USA
| | - Makoto Mori
- Section of Cardiac Surgery, Yale University School of Medicine, 330 Cedar Street, Boardman Building 204L, New Haven, CT, 06520, USA
| | - Sameh Yousef
- Section of Cardiac Surgery, Yale University School of Medicine, 330 Cedar Street, Boardman Building 204L, New Haven, CT, 06520, USA
| | - David J Hur
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Roland Assi
- Section of Cardiac Surgery, Yale University School of Medicine, 330 Cedar Street, Boardman Building 204L, New Haven, CT, 06520, USA
| | - Arnar Geirsson
- Section of Cardiac Surgery, Yale University School of Medicine, 330 Cedar Street, Boardman Building 204L, New Haven, CT, 06520, USA
| | - Prashanth Vallabhajosyula
- Section of Cardiac Surgery, Yale University School of Medicine, 330 Cedar Street, Boardman Building 204L, New Haven, CT, 06520, USA.
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21
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Ong SL, Tantawy H, Assi R, Chichra A, Treggiari MM. Combined Use of ECMO, Prone Positioning, and APRV in the Management of Severe COVID-19 Patients. Clin Med Insights Circ Respir Pulm Med 2022; 16:11795484221134451. [PMID: 36419562 PMCID: PMC9677293 DOI: 10.1177/11795484221134451] [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: 02/11/2022] [Accepted: 09/22/2022] [Indexed: 11/19/2022] Open
Abstract
Background Severe COVID-19-associated Acute Respiratory Distress Syndrome (ARDS) may
warrant extracorporeal membrane oxygenation (ECMO). We evaluated the safety
and physiologic changes in oxygenation and hemodynamic profile during ECMO,
prone positioning, and the two modalities combined in patients receiving
veno-venous (VV) ECMO. Methods Cohort study of consecutive adult patients with COVID-19-associated ARDS
requiring VV-ECMO, classified into three groups: ECMO support only; Prone
positioning only; and Prone positioning during ECMO. We collected
hemodynamic, respiratory and ventilation variables as follows:
pre-treatment, 1, 6, and 24 h post-treatment, and documented
treatment-related complications. On-treatment variables were compared with
pre-treatment using one-sample paired t-test with Bonferroni correction. Results Fourteen patients (mean age 48.1 [SD 9.3] years, male [100%]) received
VV-ECMO. Of those, 10 patients had data during prone positioning alone and
seven had data while proned on ECMO. While on ECMO, patients had improvement
in oxygen saturation, PaO2/FiO2 ratio, and minute
ventilation up to 24 h post-treatment. Vasopressor requirements increased
with ECMO at 1 h and 24 h post-treatment. Prone positioning was not
associated with clinically significant hemodynamic or respiratory changes,
either alone or during ECMO support. All patients sustained deep tissue
injuries, but only those on the face or chest were related to prone
positioning. Three patients required cannula replacement. In-hospital
mortality was 43%. Conclusions VV-ECMO and prone positioning in patients with COVID-19 ARDS was overall
well-tolerated; however, physiologic improvements were marginal, and
patients sustained deep tissue injuries. Although this was a selected
population with high mortality, our data call into question the benefits of
these management modalities in this severe COVID-19 population.
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Affiliation(s)
- Stephanie L Ong
- University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Department of Anesthesiology, Yale University, New Haven, CT, USA
| | - Hossam Tantawy
- Department of Anesthesiology, Yale University, New Haven, CT, USA
| | - Roland Assi
- Department of Surgery, Section of Cardiac Surgery, Yale University, New Haven, CT, USA
| | - Astha Chichra
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale University, New Haven, CT, USA
| | - Miriam M Treggiari
- Department of Anesthesiology, Yale University, New Haven, CT, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
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22
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Shang M, Weininger G, Mori M, Kahler-Quesada A, Degife E, Brooks C, Yousef S, Williams M, Assi R, Geirsson A, Vallabhajosyula P. Socioeconomic disparities in surveillance and follow-up of patients with thoracic aortic aneurysm. J Card Surg 2021; 37:831-839. [PMID: 34873754 DOI: 10.1111/jocs.16173] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2021] [Accepted: 09/22/2021] [Indexed: 12/27/2022]
Abstract
BACKGROUND Thoracic aortic aneurysm (TAA) is a significant risk factor for aortic dissection and rupture. Guidelines recommend referral of patients to a cardiovascular specialist for periodic surveillance imaging with surgical intervention determined primarily by aneurysm size. We investigated the association between socioeconomic status (SES) and surveillance practices in patients with ascending aortic aneurysms. METHODS We retrospectively reviewed records of 465 consecutive patients diagnosed between 2013 and 2016 with ascending aortic aneurysm ≥4 cm on computed tomography scans. Primary outcomes were clinical follow-up with a cardiovascular specialist and aortic surveillance imaging within 2 years following index scan. We stratified patients into quartiles using the area deprivation index (ADI), a validated percentile measure of 17 variables characterizing SES at the census block group level. Competing risks analysis was used to determine interquartile differences in risk of death before follow up with a cardiovascular specialist. RESULTS Lower SES was associated with significantly lower rates of surveillance imaging and referral to a cardiovascular specialist. On competing risks regression, the ADI quartile with lowest SES had lower hazard of follow-up with a cardiologist or cardiac surgeon before death (hazard ratio: 0.46 [0.34, 0.62], p < .001). Though there were no differences in aneurysm size at time of surgical repair, patients in the lowest socioeconomic quartile were more frequently symptomatic at surgery than other quartiles (92% vs. 23%-38%, p < .001). CONCLUSION Patients with lower SES receive less timely follow-up imaging and specialist referral for TAAs, resulting in surgical intervention only when alarming symptoms are already present.
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Affiliation(s)
- Michael Shang
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Gabe Weininger
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Makoto Mori
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Arianna Kahler-Quesada
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Ellelan Degife
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Cornell Brooks
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sameh Yousef
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Matthew Williams
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Roland Assi
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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Hameed I, Geirsson A, Assi R. Commentary: Type A aortic dissection with malperfusion syndrome-Staying true to true lumen perfusion. JTCVS Tech 2021; 10:6-7. [PMID: 34977694 PMCID: PMC8690293 DOI: 10.1016/j.xjtc.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 05/04/2021] [Accepted: 05/11/2021] [Indexed: 11/12/2022] Open
Affiliation(s)
- Irbaz Hameed
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
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24
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Einarsson A, Chiu AS, Mori M, Kahler-Quesada A, Assi R, Vallabhajosyula P, Geirsson A. Changing the default option in electronic medical records reduced postoperative opioid prescriptions after cardiac surgery. JTCVS Open 2021; 8:467-474. [PMID: 36004108 PMCID: PMC9390380 DOI: 10.1016/j.xjon.2021.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 11/22/2022]
Abstract
Objective Overprescribing of opioids has contributed to the opioid epidemic. Electronic medical records systems can auto-populate a default number of opioid pills that are prescribed at time of discharge. The aim of this study was to examine the association between lowered default pill counts with changed prescribing practices after cardiac surgery. Methods On May 18, 2017, the default number of pills prescribers see in electronic medical records in the Yale New Haven Health System was lowered from 30 to 12. Patients undergoing coronary artery grafts, valve surgeries, and thoracic aortic aneurysm surgeries were included in this study. Data were gathered and stratified into 2 groups: 1 year before and 1 year following the default change. The amount of opioid prescribed was compared between the 2 groups. Results A total of 1741 patient charts were reviewed, 832 before the change and 909 after the change. Significant changes were seen in prescribing practices, where the average amount of opioid prescribed was about 25% lower after the change. This amounted to about 15 fewer pills of 5 mg morphine for each patient. A linear regression model adjusting for other factors determined a prescribing difference of 75.2 morphine milligram equivalents per prescription (P < .01). In addition, a significant decrease in opioids prescribed was found for each type of procedure. Conclusions Lowering the default opioid pill count in electronic medical record systems is a simple intervention that may modify prescribing behavior to promote judicious prescribing of opioids after cardiac surgery.
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25
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Mori M, Gan G, Deng Y, Yousef S, Weininger G, Daggula KR, Agarwal R, Shang M, Assi R, Geirsson A, Vallabhajosyula P. Development and Validation of a Predictive Model to Identify Patients With an Ascending Thoracic Aortic Aneurysm. J Am Heart Assoc 2021; 10:e022102. [PMID: 34743563 PMCID: PMC8751931 DOI: 10.1161/jaha.121.022102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Background Screening protocols do not exist for ascending thoracic aortic aneurysms (ATAAs). A risk prediction algorithm may aid targeted screening of patients with an undiagnosed ATAA to prevent aortic dissection. We aimed to develop and validate a risk model to identify those at increased risk of having an ATAA, based on readily available clinical information. Methods and Results This is a cross‐sectional study of computed tomography scans involving the chest at a tertiary care center on unique patients aged 50 to 85 years between 2013 and 2016. These criteria yielded 21 325 computed tomography scans. The double‐oblique technique was used to measure the ascending thoracic aorta, and an ATAA was defined as >40 mm in diameter. A logistic regression model was fitted for the risk of ATAA, with readily available demographics and comorbidity variables. Model performance was characterized by discrimination and calibration metrics via split‐sample testing. Among the 21 325 patients, there were 560 (2.6%) patients with an ATAA. The multivariable model demonstrated that older age, higher body surface area, history of arrhythmia, aortic valve disease, hypertension, and family history of aortic aneurysm were associated with increased risk of an ATAA, whereas female sex and diabetes were associated with a lower risk of an ATAA. The C statistic of the model was 0.723±0.016. The regression coefficients were transformed to scores that allow for point‐of‐care calculation of patients' risk. Conclusions We developed and internally validated a model to predict patients' risk of having an ATAA based on demographic and clinical characteristics. This algorithm may guide the targeted screening of an undiagnosed ATAA.
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Affiliation(s)
- Makoto Mori
- Divison of Cardiac Surgery Yale School of Medicine New Haven CT.,Center for Outcomes Research and Evaluation Yale-New Haven Hospital New Haven CT
| | - Geliang Gan
- Yale Center for Analytical Sciences New Haven CT
| | - Yanhong Deng
- Yale Center for Analytical Sciences New Haven CT
| | - Sameh Yousef
- Divison of Cardiac Surgery Yale School of Medicine New Haven CT
| | - Gabe Weininger
- Divison of Cardiac Surgery Yale School of Medicine New Haven CT
| | | | - Ritu Agarwal
- Joint Data Analytics Team Yale New Haven Health System New Haven CT
| | - Michael Shang
- Divison of Cardiac Surgery Yale School of Medicine New Haven CT
| | - Roland Assi
- Divison of Cardiac Surgery Yale School of Medicine New Haven CT.,Yale Aortic Institute Yale School of Medicine New Haven CT
| | - Arnar Geirsson
- Divison of Cardiac Surgery Yale School of Medicine New Haven CT
| | - Prashanth Vallabhajosyula
- Divison of Cardiac Surgery Yale School of Medicine New Haven CT.,Yale Aortic Institute Yale School of Medicine New Haven CT
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26
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Mori M, Geirsson A, Vallabhajosyula P, Assi R. Is Intramural Hematoma a Complication of COVID-19 Disease? Aorta (Stamford) 2021; 9:41. [PMID: 34607385 PMCID: PMC8490002 DOI: 10.1055/s-0041-1724006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Makoto Mori
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | | | - Roland Assi
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
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27
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Mullan CW, Geirsson A, Assi R. Commentary: Radical root resection for prosthetic valve endocarditis. JTCVS Tech 2021; 9:28-29. [PMID: 34647048 PMCID: PMC8501240 DOI: 10.1016/j.xjtc.2021.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 07/09/2021] [Accepted: 07/16/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Clancy W. Mullan
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
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28
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Singh S, Yousef S, Assi R, Vallabhajosyula P. Frozen elephant trunk and hemiarch for type A aortic dissection. J Vis Surg 2021. [DOI: 10.21037/jovs-20-85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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29
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Hameed I, Geirsson A, Assi R. Commentary: Management of acute type A aortic dissection with patent false lumen: A rivalry between surgical data and philosophy. JTCVS Tech 2021; 9:13-14. [PMID: 34647044 PMCID: PMC8501187 DOI: 10.1016/j.xjtc.2021.06.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 06/06/2021] [Accepted: 06/18/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Irbaz Hameed
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
| | - Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn
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30
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Sallam A, Shang M, Vallabhajosyula I, Mori M, Chinian R, Assi R, Bonde P, Geirsson A, Vallabhajosyula P. Telemedicine in the era of coronavirus 19: Implications for postoperative care in cardiac surgery. J Card Surg 2021; 36:3731-3737. [PMID: 34338360 PMCID: PMC8446997 DOI: 10.1111/jocs.15875] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2021] [Accepted: 05/26/2021] [Indexed: 11/29/2022]
Abstract
Background The Coronavirus 19 (COVID‐19) pandemic forced an unprecedented shift of postoperative care for cardiac surgery patients to telemedicine. How patients and surgeons perceive telemedicine is unknown. We examined patient and provider satisfaction with postoperative telehealth visits following cardiac surgery. Methods Between April 2020 and September 2020, patients who underwent open cardiac surgery and had a postoperative appointment via telemedicine were administered a patient satisfaction survey over the phone. Time of survey administration ranged from 1 to 4 weeks following their appointment. Surgeons also completed a satisfaction survey following each telemedicine appointment they conducted. Results Fifty patients were surveyed. Of these, 36 (72%) had a postoperative appointment over the telephone, and 14 (28%) had a postoperative appointment via video‐chat. Overall, patients expressed satisfaction with the care that they received via our two telemedicine modalities (mean Likert scale agreement 4.8, SD 0.5). Despite this, 46% of patients said they would prefer their next postoperative appointment to be via telemedicine even if there was not a stay‐at‐home order in place. All surgeons surveyed reported (agree/strongly agree) that they would prefer to see their postoperative patients using telemedicine. Conclusions These findings highlight acceptability of continuing telemedicine use in the postoperative care of cardiac surgery patients.
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Affiliation(s)
- Aminah Sallam
- Department of General Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Michael Shang
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Makoto Mori
- Department of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Rachel Chinian
- Department of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Roland Assi
- Department of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Pramod Bonde
- Department of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Department of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Prashanth Vallabhajosyula
- Department of Cardiothoracic Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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31
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Daccache A, Feghali E, Assi R, Sleiman Z. Unplanned adnexectomy for ovarian cystadenoma with undiagnosed autoamputation of the contralateral ovary, lessons learned from medical mistakes. Facts Views Vis Obgyn 2021; 13:187-190. [PMID: 34184850 PMCID: PMC8291982 DOI: 10.52054/fvvo.13.2.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Autoamputation of the ovary is a rare occurrence of uncertain aetiology with only a few cases reported in literature. It usually develops following ovarian torsion or torsion of a dermoid cyst with subsequent necrosis of the pedicle and autoamputation. We present the case of a 42 year-old woman was admitted for a laparoscopic removal of a right ovarian cyst. The ultrasound showed a right ovarian cystic mass suggestive of a cystadenoma, and another heterogeneous small echogenic cyst of the left ovary. During laparoscopy, excessive bleeding from the ovarian cortex complicated the cyst stripping and, considering the age of the patient and the emerging technical difficulty of the procedure, a total adnexectomy for the right ovary was performed. While exploring the small cyst on the left ovary, a dermoid cyst was found in the Douglas pouch. This finding could be interpreted as an autoamputation of the adnexa due to an asymptomatic torsion of a previous ovarian cyst arising from the left ovary. Medical errors could occur due to lack of knowledge, expertise, as well as lack of training and surgical skills, but also due to an unfortunate association of very rare confounding factors. Even in the hands of experts, following the basic rules of surgery remains a milestone in teaching and preventing surgical complications.
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32
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Yousef S, Singh S, Alkukhun A, Alturkmani B, Mori M, Chen J, Mullan CW, Brooks CW, Assi R, Gruber PJ, Cortopassi I, Geirsson A, Vallabhajosyula P. Variants of the aortic arch in adult general population and their association with thoracic aortic aneurysm disease. J Card Surg 2021; 36:2348-2354. [PMID: 33855754 DOI: 10.1111/jocs.15563] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 02/25/2021] [Accepted: 03/17/2021] [Indexed: 01/16/2023]
Abstract
BACKGROUND Query a single institution computed tomography (CT) database to assess the prevalence of aortic arch anomalies in general adult population and their potential association with thoracic aortopathies. METHODS CT chest scan reports of patients aged 50-85 years old performed for any indication at a single health system between 2013 and 2016 were included in the analysis. Characteristics of patients with and without aortic arch anomalies were compared by t test and Fisher exact tests. Logistic regression analysis was performed to assess for independent risk factors of thoracic aortic aneurysm (TAA). RESULTS Of 21,336 CT scans, 603 (2.8%) described arch anomalies. Bovine arch (n = 354, 58.7%) was the most common diagnosis. Patients with arch anomalies were more likely to be female (p < .001), non-Caucasian(p < .001), and hypertensive (p < .001). Prevalence of TAA in arch anomalies group was 10.8% (n = 65) compared to 4.1% (n = 844) in the nonarch anomaly cohort (p < .001). The highest prevalence of thoracic aneurysm was associated with right-sided arch combined with aberrant left subclavian configuration (33%), followed by bovine arch (13%), and aberrant right subclavian artery (8.2%). On binary logistic regression, arch anomaly (OR = 2.85 [2.16-3.75]), aortic valve pathology (OR 2.93 [2.31-3.73]), male sex (OR 2.38 [2.01-2.80]), and hypertension (OR 1.47 [1.25-1.73]) were significantly associated with increased risk of thoracic aneurysm disease. CONCLUSIONS Reported prevalence of aortic arch anomalies by CT imaging in the older adult population is approximately 3%, with high association of TAA (OR = 2.85) incidence in this subgroup. This may warrant a more tailored surveillance strategy for aneurysm disease in this subpopulation.
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Affiliation(s)
- Sameh Yousef
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Saket Singh
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Abedalrazaq Alkukhun
- Division of Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Bilal Alturkmani
- Division of Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Makoto Mori
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Juliafayanne Chen
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Clancy W Mullan
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Cornell W Brooks
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Roland Assi
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Peter J Gruber
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Isabel Cortopassi
- Division of Radiology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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33
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Pichert M, Geirsson A, Assi R. Surgery for aortic dissection: An international case for universal coverage? J Card Surg 2021; 36:2044. [PMID: 33682946 DOI: 10.1111/jocs.15455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Accepted: 02/15/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Matthew Pichert
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Roland Assi
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut, USA
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34
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Weininger G, Mori M, Shang M, Degife E, Amick M, Yousef S, Assi R, Milewski R, Geirsson A, Vallabhajosyula P. Patterns of Surveillance Imaging for Incidentally Detected Ascending Aortic Aneurysms. Ann Thorac Surg 2021; 113:125-130. [PMID: 33609548 DOI: 10.1016/j.athoracsur.2021.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/16/2021] [Accepted: 02/03/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND Ascending aortic aneurysms (AsAA) remain a silent killer for which timely intervention and surveillance intervals are critical. Despite this, little is known about the follow-up care patients receive after incidental detection of an AsAA. We examined the pattern of surveillance and follow-up care for these high-risk patients. METHODS We identified patients at our institution with incidentally detected AsAAs (≥37 mm) between 2013 and 2016. We collected information on patients' aneurysms and clinical follow-up. Logistic regression models related aneurysm size and demographics to whether patients received follow-up imaging or referral. RESULTS From 2013 to 2016, 261 patients were identified to have incidentally detected AsAAs among the 21,336 computed tomography scans performed at our institution. The median aneurysm size was 4.2 cm (interquartile range, 4 to 4.4). Only 18 (6.9%) of the identified patients were referred to a cardiac surgeon for evaluation, and only 37.9% of the identified patients had a follow-up chest computed tomography scan within 1 year of detection; 34% had an echocardiogram. The median follow-up duration for the study was 5 years. Logistic regression models showed that aneurysm size and family history were significant predictors of whether a patient was referred to a cardiac surgeon (odds ratio 10.34; 95% confidence interval, 2.3 to 47.9), but not whether the patients received follow-up imaging. CONCLUSIONS Among 261 patients with incidentally detected AsAAs, only a third received any follow-up imaging within 1 year after detection, with very low clinical penetrance for expert referral. Surveillance of this high-risk patient population appears insufficient and may require standardization.
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Affiliation(s)
- Gabe Weininger
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Makoto Mori
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research and Evaluation, Yale New-Haven Hospital, New Haven, Connecticut
| | - Michael Shang
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Ellelan Degife
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Michael Amick
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Sameh Yousef
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Roland Assi
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Rita Milewski
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
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35
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Weininger G, Einarsson A, Mori M, Brooks C, Shang M, Assi R, Vallabhajosyula P, Geirsson A. The relationship between cardiac surgeon experience and average patient risk profile: CA and NY statewide analysis. J Card Surg 2021; 36:1189-1193. [PMID: 33462886 DOI: 10.1111/jocs.15333] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 12/03/2020] [Accepted: 12/26/2020] [Indexed: 12/01/2022]
Abstract
BACKGROUND It is unknown how high and low-risk cases are distributed among cardiac surgeons of different experience levels. The purpose of this study was to determine if high and low-risk coronary artery bypass grafting (CABG) cases are distributed among surgeons in such a way that would optimize outcomes in light of recent studies that show mid-career surgeons may obtain better patient outcomes on more complex cases. METHODS We performed a cross-sectional study using aggregated New York (NY) and California (CA) statewide surgeon-level outcome data, including 336 cardiac surgeons who performed 43,604 CABGs. The surgeon observed and expected mortality rates (OMR and EMR) were collected and the number of years-in-practice was determined by searching for surgeon training history on online registries. Loess and linear regression models were used to characterize the relationship between surgeon EMR and surgeon years-in-practice. RESULTS The median number of surgeon years-in-practice was 20 (interquartile range [IQR] 11-28) with a median annual case volume of 46 (IQR 19, 70.25). The median surgeon observed to expected mortality (O:E) ratio was 0.87 (IQR 0.19-1.4). Median EMR for CA surgeons was 2.42% and 1.44% for NY surgeons. Linear regression models showed EMR was similar across years in practice. Regression models also showed surgeon O:E ratios were similar across years-in-practice. CONCLUSION High and low-risk CABG cases are relatively equally distributed among surgeons of differing experience levels. This equal distribution of high and low-risk cases does not reflect a triaging of more complex cases to more experienced surgeons, which prior research shows may optimize patient outcomes.
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Affiliation(s)
- Gabe Weininger
- Division of Cardiac Surgery, Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Arnar Einarsson
- Faculty of Medicine, Department of Surgery, School of Health Sciences, University of Iceland, Reykjavík, Iceland
| | - Makoto Mori
- Division of Cardiac Surgery, Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Cornell Brooks
- Division of Cardiac Surgery, Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Michael Shang
- Division of Cardiac Surgery, Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Roland Assi
- Division of Cardiac Surgery, Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Prashanth Vallabhajosyula
- Division of Cardiac Surgery, Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, School of Medicine, Yale University, New Haven, Connecticut, USA
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Nussbaum EZ, Patel KK, Assi R, Raad RA, Malinis M, Azar MM. Clinicopathologic Features of Tissue Granulomas in Transplant Recipients: A Single Center Study in a Nontuberculosis Endemic Region. Arch Pathol Lab Med 2020; 145:988-999. [PMID: 33290524 DOI: 10.5858/arpa.2020-0271-oa] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2020] [Indexed: 11/06/2022]
Abstract
CONTEXT.— There is a paucity of literature about tissue granulomas in transplant patients. OBJECTIVE.— To characterize the clinicopathologic features of granulomas in this population and develop a clinically judicious approach to their evaluation. DESIGN.— We performed chart reviews of solid organ and allogeneic hematopoietic stem cell transplant recipients at Yale New Haven Hospital to identify patients with granulomas on biopsy obtained pathologic specimens. Pretransplant and posttransplant specimens were included. Data points included demographics, clinical presentation, epidemiologic risk factors, biopsy indication, location and timing, immunosuppression, histopathology, microbiology, and associated clinical diagnosis. Granuloma-related readmissions and mortality were recorded at 1, 3, and 12 months. RESULTS.— Biopsy proven granulomas were identified in 56 of 2139 (2.6%) patients. Of 56, 16 (29%) were infectious. Common infectious etiologies were bartonellosis (n = 3) and cytomegalovirus hepatitis (n = 3). Tuberculosis was not identified. Clinical symptoms prompted tissue biopsy in 27 of 56 (48.2%) cases while biopsies were obtained for evaluation of incidental findings or routine disease surveillance in 29 of 56 (51.8%). Presence of symptoms was significantly associated with infectious etiologies; 11 of 27 (40.7%) symptomatic patients compared with 5 of 29 (17.2%) asymptomatic patients had infectious causes. One death from granulomatous cryptogenic organizing pneumonia occurred. In pretransplant asymptomatic patients, no episodes of symptomatic disease occurred posttransplantation. CONCLUSIONS.— Granulomas were uncommon in a large transplant population; most were noninfectious but presence of symptoms was associated with infectious etiologies. Granulomas discovered pretransplant without clear infectious etiology likely do not require prolonged surveillance after transplantation. Symptomatology and epidemiologic risks factors should guide extent of microbiologic evaluation.
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Affiliation(s)
| | | | - Roland Assi
- Department of Surgery (Assi), New Haven, Connecticut
| | - Rita Abi Raad
- Department of Pathology (Raad), New Haven, Connecticut
| | - Maricar Malinis
- From the Department of Internal Medicine (Nussbaum, Malinis, Azar), New Haven, Connecticut.,The Section of Infectious Diseases (Malinis, Azar), New Haven, Connecticut
| | - Marwan M Azar
- From the Department of Internal Medicine (Nussbaum, Malinis, Azar), New Haven, Connecticut.,The Section of Infectious Diseases (Malinis, Azar), New Haven, Connecticut
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Yousef S, Mori M, Bin Mahmood SU, Assi R, Vallabhajosyula P, Geirsson A, Tellides G. Diagnosis of Thoracic Aortic Aneurysms by Computed Tomography Without Allometric Scaling. JAMA Netw Open 2020; 3:e2023689. [PMID: 33141157 PMCID: PMC7610193 DOI: 10.1001/jamanetworkopen.2020.23689] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
This diagnostic study of computed tomography scans at a single tertiary care center compares radiologist descriptions of abnormal size ascending aortas with definitions of aorta diameters defined by nomograms.
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Affiliation(s)
- Sameh Yousef
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Makoto Mori
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | | | - Roland Assi
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | | | - Arnar Geirsson
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - George Tellides
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
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Weininger G, Mori M, Brooks C, Shang M, Faggion Vinholo T, Zhang Y, Assi R, Geirsson A, Vallabhajosyula P. Association Between Cardiac Surgeons' Number of Years in Practice and Surgical Outcomes in New York Cardiac Centers. JAMA Netw Open 2020; 3:e2023671. [PMID: 33141159 PMCID: PMC7610186 DOI: 10.1001/jamanetworkopen.2020.23671] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Abstract
IMPORTANCE More than half of US cardiothoracic surgeons are older than 55 years, and the association between surgeon number of years in practice and surgical outcomes remains unclear. OBJECTIVE To assess the association between cardiac surgeons' time in practice and operative outcomes for coronary artery bypass grafting (CABG) and valve surgery. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional analysis performed of surgeon-level outcomes data from the 2014-2016 New York State Cardiac Data Reporting System across the 38 New York cardiac surgery centers. Years in practice were characterized as early career (<10 years) and late career (≥10 years). Participants were 120 cardiothoracic surgeons who performed CABG and 112 cardiothoracic surgeons who performed valve procedures between 2014 and 2016. Data were analyzed in April 2020. Surgeons who trained outside of the United States or had unclear training history were excluded. MAIN OUTCOMES AND MEASURES Risk-adjusted operative mortality rate (RAMR). Mortality was defined as all-cause death within 30 days of surgery or within the index hospitalization, whichever was longer. Risk adjustment was performed by a multivariable risk model developed by the New York State Department of Public Health. Restricted cubic spline curve identified the association between risk-adjusted mortality rate and surgeon number of years in practice. Linear regression models adjusted for surgeons' annual case volumes. RESULTS A total of 112 CABG surgeons and 120 valve surgeons performed 39 436 CABG and 18 596 valve procedures between 2014 and 2016. The median number of surgeon years in practice was 20.0 (interquartile range [IQR], 12.0-28.5) years. The median surgeon annual case volume was 160.0 (IQR, 92.5-245.0) for CABG procedures and 104.0 (IQR, 43.0-210.0) for valve procedures. The median RAMR was 1.3% (IQR, 0.2%-2.2%) for CABG procedures and 3.1% (IQR, 1.7%-5.1%) for valve procedures. Surgeons with less than 10 years of practice had higher RAMR for valve procedures compared with surgeons with more than 10 years of practice (4.0 [IQR, 1.5-7.7] vs 2.9 [IQR, 1.7-4.7]; P = .20), but the finding was not statistically signficant. The RAMR for surgeons with less than 10 years of practice was similar compared with surgeons with more than 10 years of practice for CABG procedures (1.3 [IQR, 0.3-2.1] vs 1.3 [IQR, 0.0-2.2]; P = .73). A lower number of years in practice was significantly associated with higher RAMR for valve procedures (RAMR estimates for linear term: -1.144; 95% CI, -1.955 to -0.332; P = .006; quadratic term: 0.059; 95% CI, 0.015 to 1.102; P = .008; and cubic term: -0.001; 95% CI, -0.002 to 0.000; P = .01). This association was not observed for CABG. CONCLUSIONS AND RELEVANCE In this cross-sectional study, compared with late-career cardiac surgeons, early-career cardiac surgeons were associated with worse risk-adjusted outcomes for valve operations but not for CABG. This finding suggests certain competence deficiency for valve surgery early after finishing training in cardiac surgery.
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Affiliation(s)
- Gabe Weininger
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Makoto Mori
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
| | - Cornell Brooks
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Michael Shang
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Thais Faggion Vinholo
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Yawei Zhang
- Section of Surgical Outcomes and Epidemiology, Yale School of Medicine, Yale School of Public Health, New Haven, Connecticut
| | - Roland Assi
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
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Mori M, Gan G, Bin Mahmood SU, Deng Y, Mullan CW, Assi R, Vallabhajosyula P, Badhwar V, Geirsson A. Variations in Anticoagulation Practice Following Bioprosthetic Aortic and Mitral Valve Replacement and Repair. J Am Coll Cardiol 2020; 76:2412-2413. [DOI: 10.1016/j.jacc.2020.08.083] [Citation(s) in RCA: 3] [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: 07/06/2020] [Revised: 07/30/2020] [Accepted: 08/11/2020] [Indexed: 11/17/2022]
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Assi R, Geirsson A. Commentary: Reverse elephant trunk procedure-staged by intention. J Thorac Cardiovasc Surg 2020; 163:1266-1267. [PMID: 33234250 DOI: 10.1016/j.jtcvs.2020.10.088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn.
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Singh S, Chen JF, Assi R, Nassiri N, Vallabhajosyula P. Intraoperative retrograde TEVAR to control endoleak after emergent total arch replacement and frozen elephant trunk repair for ruptured Kommerell's diverticulum. J Card Surg 2020; 35:3578-3580. [PMID: 33085131 DOI: 10.1111/jocs.14950] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We report an emergent complex hybrid repair of a type A intramural hematoma with a tear of the aortic arch at the site of Kommerell's diverticulum and an aberrant right subclavian artery. We identified a type IA endoleak intraoperatively, which was managed immediately with proximal extension. Performing this operation in the hybrid operating room facilitated optimal surgical management.
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Affiliation(s)
- Saket Singh
- Department of Surgery, Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Julia F Chen
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Roland Assi
- Department of Surgery, Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Naiem Nassiri
- Division of Vascular and Endovascular Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Prashanth Vallabhajosyula
- Department of Surgery, Section of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
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42
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Yousef S, Same H, Mori M, Agarwal R, Singh S, Brooks C, Mena-Hurtado C, Smolderen K, Nagpal S, Cleman M, Forrest J, Kaple R, Zhang Y, Assi R, Geirsson A. TCT CONNECT-107 Poor Survival in Patients With Aortic Stenosis Without Intervention. J Am Coll Cardiol 2020. [DOI: 10.1016/j.jacc.2020.09.121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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43
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Affiliation(s)
- Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
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Assi R, Geirsson A. Commentary: Handmade back-table aortic stent-graft modifications-a must-have skill for every aortic surgeon. JTCVS Tech 2020; 3:46. [PMID: 34317807 PMCID: PMC8302865 DOI: 10.1016/j.xjtc.2020.03.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2020] [Revised: 03/07/2020] [Accepted: 03/11/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
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Singh S, Assi R, Vallabhajosyula P. Aortic Root Surgery Will Benefit From Development of The Society of Thoracic Surgeons Risk Model: Reply. Ann Thorac Surg 2020; 110:1780-1781. [PMID: 32710842 DOI: 10.1016/j.athoracsur.2020.05.134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 05/29/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Saket Singh
- Division of Cardiac Surgery, Yale University School of Medicine, Boardman Bldg 204, 330 Cedar St, New Haven, CT 06510
| | - Roland Assi
- Division of Cardiac Surgery, Yale University School of Medicine, Boardman Bldg 204, 330 Cedar St, New Haven, CT 06510
| | - Prashanth Vallabhajosyula
- Division of Cardiac Surgery, Yale University School of Medicine, Boardman Bldg 204, 330 Cedar St, New Haven, CT 06510.
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46
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Assi R, Vallabhajosyula P. Bicuspid Aortic Valve Repair: The Art of Objective Valve Analysis. Ann Thorac Surg 2020; 111:1233. [PMID: 32673660 DOI: 10.1016/j.athoracsur.2020.06.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/06/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, 330 Cedar St, Boardman Bldg 204, New Haven, CT 06510
| | - Prashanth Vallabhajosyula
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, 330 Cedar St, Boardman Bldg 204, New Haven, CT 06510.
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Mori M, Geirsson A, Vallabhajosyula P, Assi R. Surgical management of thoracic aortic emergency with pre- and postoperative COVID-19 disease. J Card Surg 2020; 35:2832-2834. [PMID: 32667075 PMCID: PMC7405051 DOI: 10.1111/jocs.14865] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
The nuance of operative decision making for those in need of emergent operation during coronavirus disease 2019 (COVID‐19) pandemic is increasingly complex in the absence of robust data or guidelines. We present two cases of thoracic aortic emergencies with COVID‐19 disease who survived high‐risk operations to highlight the potential for successful outcomes even in situations compounding patient disease, morbid operation, and the added risk associated with virulent disease in the pandemic time.
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Affiliation(s)
- Makoto Mori
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
| | | | - Roland Assi
- Division of Cardiac Surgery, Yale University School of Medicine, New Haven, Connecticut
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48
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Assi R, Geirsson A, Vallabhajosyula P. Commentary: Managing thoracic aortic emergencies during a pandemic. J Thorac Cardiovasc Surg 2020; 161:S0022-5223(20)32077-8. [PMID: 32980147 PMCID: PMC7358757 DOI: 10.1016/j.jtcvs.2020.07.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 07/02/2020] [Accepted: 07/02/2020] [Indexed: 01/04/2023]
Affiliation(s)
- Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Prashanth Vallabhajosyula
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn.
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49
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Mullan C, Powierza C, Miller PE, Geirsson A, Vallabhajosyula P, Assi R. Spontaneous coronavirus disease 2019 (COVID-19)-associated luminal aortic thrombus. J Thorac Cardiovasc Surg 2020; 160:e13-e14. [PMID: 32534745 PMCID: PMC7280114 DOI: 10.1016/j.jtcvs.2020.05.024] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 05/07/2020] [Accepted: 05/18/2020] [Indexed: 11/30/2022]
Affiliation(s)
- Clancy Mullan
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Conn
| | - Camilla Powierza
- Department of Internal Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Conn
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine and Yale New Haven Health, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Conn
| | | | - Roland Assi
- Division of Cardiac Surgery, Yale School of Medicine and Yale New Haven Health, New Haven, Conn
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Assi R, Geirsson A. Commentary: Where and when do we land-Thoracic endovascular aortic repair for retrograde type A aortic hematoma? JTCVS Tech 2020; 2:23-24. [PMID: 34317738 PMCID: PMC8298910 DOI: 10.1016/j.xjtc.2020.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 02/27/2020] [Accepted: 03/08/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Roland Assi
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
| | - Arnar Geirsson
- Division of Cardiac Surgery, Department of Surgery, Yale University School of Medicine, New Haven, Conn
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