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Abstract
Perioperative care delivery is a patient-centered, multidisciplinary process. It relies heavily on synchronized teamwork from a well-coordinated team. Perioperative physicians-surgeons and anesthesiologists-face enormous challenges in surgical care delivery due to changing work environments, post-COVID consequences, shift work disorder, value conflict, escalating demands, regulatory complexity, and financial uncertainties. Physician burnout in this working environment has become increasingly prevalent. It is not only harmful to physicians' health and well-being, but it also affects the quality and safety of patient care. Additionally, the economic costs associated with physician burnout are untenable due to the high turnover rate, high recruitment expenses, and potential early permanent exit from medical practice. In this deteriorating environment of unbalanced physician supply/demand, recognizing, managing, and preventing physician burnout may help preserve the system's most valuable asset and contribute to higher quality and safety of patient care. Leaders in government agencies, health care systems, and organizations must work together to re-engineer the health care system for better physicians and patient care.
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Affiliation(s)
- Philip Shin
- Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
| | - Vimal Desai
- Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
| | - Janet Hobbs
- Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
| | - Chunyuan Qiu
- Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
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Desai V, Conte AH, Nguyen VT, Shin P, Sudol NT, Hobbs J, Qiu C. Veiled Harm: Impacts of Microaggressions on Psychological Safety and Physician Burnout. Perm J 2023:1-10. [PMID: 37292028 DOI: 10.7812/tpp/23.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Microaggression is widespread in the health care industry and occurs in every health care delivery setting. It comes in many forms, from subtle to obvious, unconscious to conscious, and verbal to behavioral. Women and minority groups (eg, race/ethnicity, age, gender, sexual orientation) are often marginalized during medical training and subsequent clinical practice. These contribute to the development of psychologically unsafe working environments and widespread physician burnout. Physicians experiencing burnout who work in unsafe psychological environments impact the safety and quality of patient care. In turn, these conditions impose high costs on the health care system and organizations. Microaggressions and psychological unsafe work environments are intricately related and mutually enhanced. Therefore, addressing both simultaneously is a good business practice and a responsibility for any health care organization. Additionally, addressing them can reduce physician burnout, decrease physician turnover, and improve the quality of patient care. To counter microaggression and psychological unsafe, it takes conviction, initiative, and sustainable efforts from individuals, bystanders, organizations, and government agencies.
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Affiliation(s)
- Vimal Desai
- Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
| | - Vu T Nguyen
- Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
| | - Philip Shin
- Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
| | - Neha T Sudol
- Department of OBGYN (Obstetrics Gynecology), The Permanente Medical Group, Redwood City, CA, USA
| | - Janet Hobbs
- Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
| | - Chunyuan Qiu
- Department of Anesthesiology, Southern California Permanente Medical Group, Pasadena, CA, USA
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Rettig RL, Rudikoff AG, Lo HYA, Lee CW, Vazquez WD, Rodriguez K, Shaul DB, Conte AH, Banzali FM, Sydorak RM. Same day discharge for pectus excavatum-is it possible? J Pediatr Surg 2022; 57:34-38. [PMID: 33678403 DOI: 10.1016/j.jpedsurg.2021.02.007] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 01/04/2021] [Accepted: 02/03/2021] [Indexed: 01/12/2023]
Abstract
PURPOSE The use of intercostal nerve cryoablation (INC) has been an effective modality for treating pain in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate if PE patients undergoing Nuss procedures with INC and intercostal nerve block (INB) could safely be discharged the same day of surgery. METHODS A prospective study with IRB approval of 15 consecutive patients undergoing PE Nuss repair with INC, INB, and an enhanced recovery after surgery (ERAS) protocol was conducted. The primary outcome measure was hospital length of stay (LOS) in hours. Secondary variables included same day discharge, postoperative complications, emergency department (ED) visits, urgent care (UC) visits, opioid use, and return to the operating room (OR). RESULTS LOS averaged 11.9 h amongst 15 patients. Ten patients (66.7%) went home on postoperative day (POD) 0, and the rest went home on POD 1. No patients stayed in the hospital due to pain. Reasons for failure to discharge included urinary retention, drowsiness, vomiting, and anxiety, but not pain. No patients were readmitted to the ED. One patient visited UC for constipation. One patient had bar migration requiring return to the OR for revision. Ten (66.7%) patients did not use opioids after discharge. CONCLUSIONS Same day discharge is feasible and safe in PE patients undergoing Nuss procedure with INC and INB. INC with INB can adequately control pain without significant complications. Same day discharge can be safely considered for PE patients undergoing Nuss procedure with INC with INB. TYPE OF STUDY Prognosis study LEVEL-OF-EVIDENCE RATING: Level II.
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Affiliation(s)
- R Luke Rettig
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Hoi Yee Annie Lo
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Constance W Lee
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Walter D Vazquez
- Department of Pediatric Surgery, Kaiser Permanente San Diego Medical Center, 9455 Clairemont Mesa Blvd, San Diego 92123, CA, United States
| | - Karen Rodriguez
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Donald B Shaul
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Franklin M Banzali
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States
| | - Roman M Sydorak
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles 90027, CA, United States.
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Rudikoff AG, Tieu DD, Banzali FM, Nguyen CV, Rettig RL, Nashed MM, Mora-Marquez J, Chen Q, Conte AH, Mason KP. Perioperative Acetaminophen and Dexmedetomidine Eliminate Post-Operative Opioid Requirement following Pediatric Tonsillectomy. J Clin Med 2022; 11:jcm11030561. [PMID: 35160013 PMCID: PMC8836354 DOI: 10.3390/jcm11030561] [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: 12/09/2021] [Revised: 01/18/2022] [Accepted: 01/21/2022] [Indexed: 02/01/2023] Open
Abstract
Administration of post-operative opioids following pediatric tonsillectomy can elicit respiratory events in this patient population that often arise as central and obstructive sleep apnea. The primary objective of this study was to determine whether a perioperative combination of dexmedetomidine and acetaminophen could eliminate post-operative (in recovery and at home) opioid requirements. Following IRB approval and a waiver for informed consent, the medical records of 681 patients who underwent tonsillectomy between 1 January 2013 and 31 December 2018 were evaluated. Between 1 January 2013 and 31 December 2015, all patients received a fentanyl-sevoflurane-based anesthetic, without acetaminophen or dexmedetomidine, and received opioids in recovery and for discharge home. On 1 January 2016, an institution-wide practice change replaced this protocol with a multimodal perioperative regimen of acetaminophen (intravenous or enteral) and dexmedetomidine and eliminated post-operative opioids. This is the first time that the effect of an acetaminophen and dexmedetomidine combination on the perioperative and home opioid requirement has been reported. Primarily, we compared the need for rescue opioids in the post-anesthesia care period and after discharge. The multi-modal protocol eliminated the need for post-tonsillectomy opioid administration. Dexmedetomidine in combination with acetaminophen eliminated the need for post-operative opioids in the recovery period.
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Affiliation(s)
- Andrew G. Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA 90027, USA; (A.G.R.); (F.M.B.)
| | - David D. Tieu
- Department of Head & Neck Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA 90027, USA; (D.D.T.); (C.V.N.)
| | - Franklin M. Banzali
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA 90027, USA; (A.G.R.); (F.M.B.)
| | - Carolyn V. Nguyen
- Department of Head & Neck Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA 90027, USA; (D.D.T.); (C.V.N.)
| | - Robert L. Rettig
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA 90027, USA;
| | - Marlene M. Nashed
- Department of Pharmacy, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA 90027, USA;
| | - Janet Mora-Marquez
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Avenue, Pasadena, CA 91101, USA; (J.M.-M.); (Q.C.)
| | - Qiaoling Chen
- Department of Research & Evaluation, Kaiser Permanente Southern California, 100 S. Los Robles Avenue, Pasadena, CA 91101, USA; (J.M.-M.); (Q.C.)
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA 90027, USA; (A.G.R.); (F.M.B.)
- Correspondence: ; Tel.: +1-323-573-3900
| | - Keira P. Mason
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, 300 Longwood Avenue, Boston, MA 02115, USA;
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Rettig RL, Rudikoff AG, Annie Lo HY, Lee CW, Vazquez WD, Rodriguez K, Shaul DB, Conte AH, Banzali FM, Sydorak RM. Same-day discharge following the Nuss repair: A comparison. J Pediatr Surg 2022; 57:135-140. [PMID: 34670678 DOI: 10.1016/j.jpedsurg.2021.09.023] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 09/08/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Intercostal Nerve Cryoablation (INC) has significantly improved pain control following the Nuss repair of pectus excavatum (PE). This study sought to evaluate patients undergoing the Nuss repair with INC compared to the Nuss repair with an ERAS protocol, INC, and intercostal nerve blocks (INB). METHODS In June 2020, a new protocol was implemented involving surgery, anesthesia, nursing, physical therapy, and child life with the goal of safe same day discharge for patients undergoing the Nuss repair. They were compared to a control group who underwent the Nuss repair with INC alone in 2017-2019. The primary outcome measure was hospital length of stay (LOS) in hours, secondary outcomes were number of patients discharged on postoperative day (POD) 0, and returns to the emergency department (ED), urgent care (UC), and operating room (OR). RESULTS The characteristics between the groups were the same (Table 1). The mean LOS was 11.8 h in the INB group versus 58.2 h in the INC group, p < 0.01. 10 of 15 patients in the INB group went home on POD 0 (average of 5.5 h postop), versus 0 patients in the INC only group, p < 0.01. Five patients in the INB stayed overnight. Two patients stayed owing to anxiety, one owing to urinary retention, one owing to nausea, and one owing to drowsiness. None stayed for pain control. Four patients in the INC group returned to the ED for pain control, versus 0 in the INB group, and 1 patient in the INB returned to UC for constipation. CONCLUSIONS The majority of patients undergoing the Nuss repair of PE with a multidisciplinary regimen of pre and postoperative nursing education, precise intraoperative anesthesia care, performance of direct vision INB and INC, as well as careful surgery can go home on the day of surgery without adverse outcomes or unanticipated returns to the hospital. LEVEL-OF-EVIDENCE Level II.
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Affiliation(s)
- R Luke Rettig
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA 90027 USA
| | - Hoi Yee Annie Lo
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Constance W Lee
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Walter D Vazquez
- Department of Pediatric Surgery, Kaiser Permanente San Diego Medical Center, 9455 Clairemont Mesa Blvd, San Diego, CA 92123 USA
| | - Karen Rodriguez
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Donald B Shaul
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA 90027 USA
| | - Franklin M Banzali
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. Los Angeles, CA 90027 USA
| | - Roman M Sydorak
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd. 3rd Floor Los Angeles, CA 90027 USA.
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Ferrara JT, Tehrany GM, Chen Q, Sheinbaum J, Mora-Marquez J, Hernandez Conte A, Rudikoff AG. Evaluation of an Enhanced Recovery After Surgery Protocol (ERAS) for Same-Day Discharge and Reduction of Opioid Use Following Bimaxillary Orthognathic Surgery. J Oral Maxillofac Surg 2021; 80:38-46. [PMID: 34339616 DOI: 10.1016/j.joms.2021.07.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE This study sought to evaluate the impact of implementation of a comprehensive enhanced recovery after surgery (ERAS) protocol upon patients undergoing maxillary and mandibular osteotomy (MMO). METHODS This study was a retrospective, observational study of patients undergoing MMO. The study intervention group consisted of patients who underwent MMO with utilization of ERAS protocol compared to control group without ERAS. The primary outcome measure was same-day discharge. Secondary outcome measures included hospital length-of-stay (LOS), overall dose of opioids administered, total operating room time, estimated blood loss, need for hospital admission, and complications. Descriptive statistics and multivariable analysis were computed and the P value was set at .05. RESULTS We compared 189 patients who underwent MMO with and without genioplasty and received a comprehensive surgical and multimodal analgesic regimen to 170 control patients who underwent MMO with or without genioplasty without receiving the above protocol. There was a statistically significant decrease in hospital admission post-surgery (83.5% - control vs 22.2% - intervention) and in overall hospital length-of-stay in the intervention group. There was no change in the overall operating room time, but there was a decrease in blood loss in the intervention group. CONCLUSION The results suggest that use of a comprehensive ERAS protocol for patients undergoing MMO will decrease hospital length-of-stay without an increase in readmissions or complications. Future studies are needed to evaluate if pain scores, postoperative nausea and vomiting, and other complications differed when using a ERAS protocol.
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Affiliation(s)
- Jammie T Ferrara
- Partner, Southern California Permanente Medical Group; Attending Anesthesiologist, Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.
| | - Gabriella M Tehrany
- Partner, Southern California Permanente Medical Group; Attending Surgeon, Department of Head & Neck Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Qiaoling Chen
- Biostatistician, Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Justin Sheinbaum
- Resident Physician, Department of Oral & Maxillofacial Surgery, University of California Los Angeles Medical Center, Los Angeles, CA
| | - Janet Mora-Marquez
- Biostatistician, Department of Research & Evaluation, Kaiser Permanente Southern California, Pasadena, CA
| | - Antonio Hernandez Conte
- Partner, Southern California Permanente Medical Group; Attending Anesthesiologist, Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Andrew G Rudikoff
- Partner, Southern California Permanente Medical Group; Attending Anesthesiologist, Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
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Rettig RL, Rudikoff AG, Lo HYA, Shaul DB, Banzali FM, Conte AH, Sydorak RM. Cryoablation is associated with shorter length of stay and reduced opioid use in pectus excavatum repair. Pediatr Surg Int 2021; 37:67-75. [PMID: 33210165 DOI: 10.1007/s00383-020-04778-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/04/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE The use of intercostal nerve cryoablation (INC) is becoming increasingly common in patients undergoing pectus excavatum (PE) repair. This study sought to evaluate the use of INC compared to traditional use of thoracic epidural (TE). METHODS A retrospective review of 79 patients undergoing PE repair with either INC or TE from May 2009 to December 2019 was conducted. The operations were performed by four surgeons who worked together at four different hospitals and have the same standardized practice. The primary outcome measure was hospital length of stay (LOS). Secondary variables included surgical time, total operating room time, operating room time cost, total hospital cost, inpatient opioid use, long-term opioid use after discharge, and postoperative complications. RESULTS LOS decreased to 2.5 days in the INC group compared to 5 days in the TE group (p < 0.0001). Surgical time was increased in the INC group, but there was no difference in total OR time. The INC group experienced significantly lower hospital costs. Total hospital opioid administration was significantly lower in INC group, and there was a significant decrease in long-term opioid use in the INC group. CONCLUSIONS INC is a newer modality that decreases LOS, controls pain, and results in overall cost savings. We recommend that INC be included in the current practice for postoperative pain control in PE patients undergoing Nuss procedure.
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Affiliation(s)
- R Luke Rettig
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Hoi Yee Annie Lo
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Donald B Shaul
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Franklin M Banzali
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA
| | - Roman M Sydorak
- Department of Pediatric Surgery, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd., Los Angeles, CA, 90027, USA. .,Kaiser Permanente Los Angeles Medical Center, 4760 Sunset Blvd, 3rd Floor, Los Angeles, CA, 90027, USA.
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Lin CA, Behrens PH, Paiement G, Hardy WD, Mirocha J, Rettig RL, Kiziah HL, Rudikoff AG, Hernandez Conte A. Metabolic factors and post-traumatic arthritis may influence the increased rate of surgical site infection in patients with human immunodeficiency virus following total hip arthroplasty. J Orthop Surg Res 2020; 15:316. [PMID: 32787972 PMCID: PMC7425402 DOI: 10.1186/s13018-020-01827-y] [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] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 07/29/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND The impact of CD4+ T-cell count and highly active antiretroviral therapy (HAART) on the rate of surgical site infection (SSI) in patients with human immunodeficiency virus (HIV) undergoing total hip arthroplasty is still unclear. The goals of this study were to assess the rate of perioperative infection at a large tertiary care referral center and to identify risk factors in HIV+ patients undergoing total hip arthroplasty (THA). METHODS This study was a prospective, observational study at a single medical center from 2000-2017. Patients who were HIV+ and underwent THA were followed from the preoperative assessment period, through surgery and for a 2-year follow-up period. RESULTS Sixteen of 144 HIV+ patients (11%) undergoing THA developed perioperative surgical site infections. Fourteen patients (10%) required revision THA within a range of 12 to 97 days after the initial surgery. The patients' mean age was 49.6 ± 4.5 years, and the most common diagnosis prompting THA was osteonecrosis (96%). Patients who developed SSI had a lower waist-hip ratio (0.86 vs. 0.93, p = 0.047), lower high density lipoprotein cholesterol (45.8 vs. 52.5, p = 0.015) and were more likely to have post-traumatic arthritis (12.5% vs. 0%, p = 0.008). Logistic regression analysis demonstrated that current alcohol use and higher waist-hip ratio were significant protectors against infection (p < 0.05). No other demographic, medical, immunologic parameters, or specific HAART regimens were associated with perioperative infection. CONCLUSIONS Immunologic status as measured by CD4+ cell count, HIV viral load, and medical therapy do not appear to influence the development of SSI in HIV+ patients undergoing THA. Metabolic factors and post-traumatic arthritis may influence the increased rate of infection in HIV+ patients following THA.
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Affiliation(s)
- Carol A Lin
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Phillip H Behrens
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Guy Paiement
- Department of Orthopedic Surgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - W David Hardy
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - James Mirocha
- Division of Biostatistics & Bioinformatics, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert L Rettig
- Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA, USA
| | - Heidi L Kiziah
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd, 3rd Floor, Suite 3017, Los Angeles, CA, 90027, USA
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd, 3rd Floor, Suite 3017, Los Angeles, CA, 90027, USA
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, 4867 Sunset Blvd, 3rd Floor, Suite 3017, Los Angeles, CA, 90027, USA.
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Rudikoff AG, Ganocy TK, Kansagra K, Torres FA, Humphries BD, Hernandez Conte A. Thoracolumbar Osteomyelitis Secondary to Systemic Mycobacterium Chimaera Infection Status Post Aortic Valve Replacement. J Cardiothorac Vasc Anesth 2019; 33:1704-1709. [DOI: 10.1053/j.jvca.2018.09.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Indexed: 11/11/2022]
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Patel SH, Banzali FM, Post RJ, Nguyen CV, Benoit RM, Tieu DD, Stranc DS, Hernandez Conte A, Rudikoff AG. Parturient With Barnes Syndrome (Thoracolaryngopelvic Dysplasia) Undergoing Cesarean Delivery of a Neonate With Barnes Syndrome: A Case Report. A A Pract 2018; 11:151-154. [PMID: 29634523 DOI: 10.1213/xaa.0000000000000765] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
This case describes a parturient with Barnes syndrome, a rare disorder characterized by subglottic stenosis, thoracic dystrophy, and small pelvic inlet, who underwent cesarean delivery of a neonate diagnosed with Barnes syndrome. Live simulation training was performed by multidisciplinary team to prepare for the spinal anesthetic, personnel flow between 2 operating rooms, and management of various airway scenarios for the newborn. After delivery, the neonate underwent laryngoscopy-bronchoscopy with successful intubation in the operating room because of labored breathing. Airway evaluation revealed subglottic stenosis, tracheomalacia/bronchomalacia. Collaboration among perinatologists, obstetric/pediatric anesthesiologists, pediatric head and neck surgeons, and neonatologists was integral to perioperative management of both the mother and child.
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Affiliation(s)
| | | | | | - Carolyn V Nguyen
- Head and Neck Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | | | - David D Tieu
- Head and Neck Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
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Akikwala T, Trivedi D, Kochamba G, Kansagra K, Sridhar S, Rudikoff AG, Hernandez Conte A. Perioperative Evaluation and Surgical Management of a Patient With a Pericardial Hemangioma Abutting the Right Ventricular Outflow Tract and Main Pulmonary Artery. J Cardiothorac Vasc Anesth 2018; 33:1362-1366. [PMID: 29807714 DOI: 10.1053/j.jvca.2018.04.050] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Tulsi Akikwala
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Dhaval Trivedi
- Department of Cardiac Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Gary Kochamba
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Kartik Kansagra
- Department of Radiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Sreevathsan Sridhar
- Department of Radiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.
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Hernandez Conte A, Hajj J, Yang SX, Passano E, Barone H, Thuraisingham DA, Moriguchi J, Kobashigawa J, Arabia F. Utilization of Transverse Abdominis Plexus Block for Treatment of HeartMate II Left Ventricular Assist Device-Associated Pain. J Cardiothorac Vasc Anesth 2018; 32:1866-1870. [PMID: 29395822 DOI: 10.1053/j.jvca.2017.11.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.
| | - Jennifer Hajj
- The Heart Institute & Cedars-Sinai Medical Center, Los Angeles, CA
| | - Stephen X Yang
- Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | - Heather Barone
- The Heart Institute & Cedars-Sinai Medical Center, Los Angeles, CA
| | - Dhilan A Thuraisingham
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Jaime Moriguchi
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Jon Kobashigawa
- The Heart Institute & Cedars-Sinai Medical Center, Los Angeles, CA
| | - Francisco Arabia
- The Heart Institute & Cedars-Sinai Medical Center, Los Angeles, CA
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13
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Kansagra K, Vatakencherry GG, Do J, Keny AV, Rudikoff AG, Hernandez Conte A. Utilization of Transesophageal Echocardiography for Extraction of an Inferior Vena Cava Filter Fragment in the Right Ventricle. J Cardiothorac Vasc Anesth 2017; 32:2628-2632. [PMID: 29249577 DOI: 10.1053/j.jvca.2017.11.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Indexed: 11/11/2022]
Affiliation(s)
- Kartik Kansagra
- Department of Radiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | | | - John Do
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Ameet V Keny
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Andrew G Rudikoff
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.
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14
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Barrus A, Afshar S, Sani S, LaBounty TG, Padilla C, Farber MK, Rudikoff AG, Hernandez Conte A. Acute Type A Aortic Dissection and Successful Surgical Repair in a Woman at 21 Weeks Gestational Pregnancy With Maternal and Fetal Survival: A Case Report. J Cardiothorac Vasc Anesth 2017; 32:1487-1493. [PMID: 29217246 DOI: 10.1053/j.jvca.2017.09.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Indexed: 02/06/2023]
Affiliation(s)
- Adam Barrus
- Department of Anesthesiology, University of Arizona, Banner University Medical Center, Tucson, AZ
| | - Sam Afshar
- Department of Anesthesiology, University of Arizona, Banner University Medical Center, Tucson, AZ
| | - Sara Sani
- Department of Medicine, University of Arizona, Banner University Medical Center, Tucson, AZ
| | - Troy G LaBounty
- Division of Cardiovascular Medicine, University of Michigan Medical Center, Ann Arbor, MI
| | - Cesar Padilla
- Division of of Obstetric Anesthesia, Department of Anesthesiology, Brigham & Women's Hospital, Boston, MA
| | - Michaela K Farber
- Division of of Obstetric Anesthesia, Department of Anesthesiology, Brigham & Women's Hospital, Boston, MA
| | - Andrew G Rudikoff
- Divisions of Cardiothoracic and Obstetric Anesthesiology, Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA
| | - Antonio Hernandez Conte
- Divisions of Cardiothoracic and Obstetric Anesthesiology, Department of Anesthesiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA.
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15
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Ram H, Gerlach RM, Hernandez Conte A, Ramzy D, Jaramillo-Huff AR, Gerstein NS. The AngioVac Device and Its Anesthetic Implications. J Cardiothorac Vasc Anesth 2017; 31:1091-1102. [DOI: 10.1053/j.jvca.2016.12.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Indexed: 11/11/2022]
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16
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Hernandez Conte A, Perotti D, Farac L. Thromboelastrography (TEG) Is Still Relevant in the 21st Century as a Point-of-Care Test for Monitoring Coagulation Status in the Cardiac Surgical Suite. Semin Cardiothorac Vasc Anesth 2017; 21:212-216. [DOI: 10.1177/1089253217699282] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Since their introduction into clinical practice in the early 1960s, viscoelastic point-of-care (POC) testing—thromboelastrography (TEG) and thromboelastrometry (ROTEM)—has become increasingly popular in intensive care units, operating rooms, and emergency room settings. As TEG has been an established POC viscoelastic testing modality for many years, there has been more research and analysis of its utility and ability to reduce transfusions in the general, cardiac, and liver surgical sectors compared with ROTEM. The role of TEG versus ROTEM has been greatly disputed, although both continue to be utilized in the cardiac suite to guide transfusion in cardiac surgery as these procedures produce a profoundly different form of bleeding compared to other surgical interventions.
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Affiliation(s)
| | | | - Lauren Farac
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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17
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Padilla C, Hernandez Conte A, Ramzy D, Lubin L, LaBounty T, Chung JH, Zeng Y. Utilization of “Stand-By” Extracorporeal Membrane Oxygenation in a High-Risk Parturient With Methamphetamine-Associated Cardiomyopathy Undergoing Dilation and Evacuation. ACTA ACUST UNITED AC 2017; 8:105-108. [DOI: 10.1213/xaa.0000000000000441] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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18
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LaBounty TM, Bhave N, Giri S, Balter J, Conte AH, Shah R, Murthy V. Comparison of ileofemoral arterial access size between noncontrast 3T MR angiography and contrast-enhanced computed tomographic angiography in patients referred for transcatheter aortic valve replacement. J Magn Reson Imaging 2017; 46:1847-1850. [PMID: 28165647 DOI: 10.1002/jmri.25651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Troy M LaBounty
- Department of Medicine, University of Michigan, Ann Arbor, Michigan.,Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | - Nicole Bhave
- Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | | | - James Balter
- Department of Radiology, University of Michigan, Ann Arbor, Michigan
| | | | - Ravi Shah
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Venkatesh Murthy
- Department of Medicine, University of Michigan, Ann Arbor, Michigan.,Department of Radiology, University of Michigan, Ann Arbor, Michigan
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19
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Elvir Lazo OL, White PF, Tang J, Yumul R, Cao X, Yumul F, Hausman J, Hernandez Conte A, Anand KK, Hemaya EG, Zhang X, Wender RH. Propofol versus midazolam for premedication: a placebo‑controlled, randomized double‑blinded study. Minerva Anestesiol 2016; 82:1170-1179. [PMID: 27611806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND It has been previously reported that subhypnotic doses of propofol could offer an advantage over midazolam for premedication. This study was designed to test the hypothesis that a 20 mg IV dose of propofol would be more effective than a standard 2 mg IV dose of midazolam for reducing acute anxiety prior to induction of anesthesia. METHODS One hundred twenty outpatients scheduled to undergo orthopedic surgery were randomly assigned to one of three study groups: control (saline); propofol (20 mg); or midazolam (2 mg). Immediately before administering the study medication, each patient evaluated their level of acute anxiety and sedation on 11‑point verbal rating scales (VRSs) 0=none- 10=highest, and they were also shown a picture. Upon arrival in the OR ~5 min after administering the study medication, anxiety and sedation levels were reassessed and a second picture was shown. At discharge from the recovery area, anxiety and sedation levels and their ability to recall the two pictures were reassessed. RESULTS Compared to the saline group, both propofol and midazolam produced significant increases in the patient's level of sedation upon entering the OR (+2.5±2.4 vs. +4.6±2.5 and +5.2±2.3, respectively [p<0.001]). Propofol was effective as midazolam compared to saline in reducing the patient's level of preinduction anxiety (from 3.2±2.2 to1.8±1.8 vs. 3.1±2.2 to 2.3±2.1 and 2.7±1.8 to 2.8±2.1, respectively). Propofol produced more pain on injection and midazolam significantly reduced recall of the second picture. CONCLUSIONS When administered ~5 min prior to entering the OR, propofol, 20mg IV, was as effective as midazolam 2mg IV in reducing anxiety.
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Affiliation(s)
- Ofelia L Elvir Lazo
- Department of Anesthesiology, Cedars‑Sinai Medical Center, Los Angeles, CA, USA -
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20
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Padilla C, Hernandez Conte A, Ramzy D, Sanchez M, Zhao M, Park D, Lubin L. Impella™ Left Ventricular Assist Device for Acute Peripartum Cardiomyopathy After Cesarean Delivery. ACTA ACUST UNITED AC 2016; 7:24-6. [DOI: 10.1213/xaa.0000000000000325] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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21
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Yumul R, Elvir-Lazo OL, White PF, Durra O, Ternian A, Tamman R, Naruse R, Ebba H, Yusufali T, Wong R, Hernandez Conte A, Farnad S, Pham C, Wender RH. Comparison of the C-MAC video laryngoscope to a flexible fiberoptic scope for intubation with cervical spine immobilization. J Clin Anesth 2016; 31:46-52. [DOI: 10.1016/j.jclinane.2015.12.045] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Revised: 12/16/2015] [Accepted: 12/28/2015] [Indexed: 01/31/2023]
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22
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Maher DP, Lee J, Woo P, Zhang X, White PF, Yumul R, Hernandez Conte A. Ritonavir Use in Human Immunodeficiency Virus-Positive Surgical Patients Is Not Associated with an Increase in Postoperative Critical Respiratory Events. J Pain Palliat Care Pharmacother 2016; 30:25-30. [PMID: 26861563 DOI: 10.3109/15360288.2015.1135846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
This study evaluated whether highly active antiretroviral therapy for human immunodeficiency virus (HIV) including ritonavir is independently associated with increased critical respiratory events after general anesthesia with opioid analgesia. The impact of ritonavir on hepatic microsomal enzymes was considered due to the effect of these enzymes on opioid metabolism. Medical records of over 1900 patients were reviewed, and those of 941 patients met inclusion criteria and were analyzed. Chronic treatment with ritonavir was not associated with critical respiratory events in HIV-positive patients.
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23
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Conte AH, Kittleson MM, Dilibero D, Hardy WD, Kobashigawa JA, Esmailian F. Successful Orthotopic Heart Transplantation and Immunosuppressive Management in 2 Human Immunodeficiency Virus-Seropositive Patients. Tex Heart Inst J 2016; 43:69-74. [PMID: 27047290 DOI: 10.14503/thij-14-4746] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Few orthotopic heart transplantations have been performed in patients infected with the human immunodeficiency virus since the first such case was reported in 2001. Since that time, advances in highly active antiretroviral therapy have resulted in potent and durable suppression of the causative human immunodeficiency virus-accompanied by robust immune reconstitution, reversal of previous immunodeficiency, a marked decrease in opportunistic and other infections, and near-normal long-term survival. Although human immunodeficiency virus infection is not an absolute contraindication, few centers in the United States and Canada have performed heart transplantations in this patient population; these patients have been de facto excluded from this procedure in North America. Re-evaluation of the reasons for excluding these patients from cardiac transplantation is warranted in light of such significant advances in antiretroviral therapy. This case report documents successful orthotopic heart transplantation in 2 patients infected with human immunodeficiency virus, and we describe their antiretroviral therapy and immunosuppressive management challenges. Both patients were doing well without sequelae 43 and 38 months after transplantation.
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24
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Diaz-Zamudio M, Dey D, LaBounty T, Nelson M, Fan Z, Szczepaniak LS, Hsieh BPC, Rajani R, Berman D, Li D, Dharmakumar R, Hardy WD, Conte AH. Increased pericardial fat accumulation is associated with increased intramyocardial lipid content and duration of highly active antiretroviral therapy exposure in patients infected with human immunodeficiency virus: a 3T cardiovascular magnetic resonance feasibility study. J Cardiovasc Magn Reson 2015; 17:91. [PMID: 26520571 PMCID: PMC4628336 DOI: 10.1186/s12968-015-0193-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 10/09/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND The aim of the current study was to examine whether the use of highly active antiretroviral therapy (HAART) in patients with HIV is associated with changes in pericardial fat and myocardial lipid content measured by cardiovascular magnetic resonance (CMR). METHODS In this prospective case-control study, we compared 27 HIV seropositive (+) male subjects receiving HAART to 22 control male subjects without HIV matched for age, ethnicity and body mass index. All participants underwent CMR imaging for determination of pericardial fat [as volume at the level of the origin of the left main coronary artery (LM) and at the right ventricular free wall] and magnetic resonance spectroscopy (MRS) for evaluation of intramyocardial lipid content (% of fat to water in a single voxel at the interventricular septum). All measurements were made by two experienced readers blinded to the clinical history of the study participants. Two-sample t-test, Spearman's correlation coefficient or Pearson's correlation coefficient and multivariable logistic regression were used for statistical analysis. RESULTS Pericardial fat volume at the level of LM origin was higher in HIV (+) subjects (33.4 cm(3) vs. 27.4 cm(3), p = 0.03). On multivariable analysis adjusted for age, Framingham risk score (FRS) and waist/hip ratio, pericardial fat remained significantly associated to HIV-status (OR 1.09, p = 0.047). For both HIV (+) and HIV (-) subjects, pericardial fat volume showed strong correlation with intramyocardial lipid content (r = 0.58, p < 0.0001) and FRS (r = 0.53, p = 0.0002). Among HIV (+) subjects, pericardial fat was significantly higher in patients with lipo-accumulation (37 cm(3) vs. 27.1 cm(3), p = 0.03) and showed significant correlation with duration of both HIV infection (r = 0.5, p = 0.01) and HAART (r = 0.46, p = 0.02). CONCLUSIONS Pericardial fat content is increased in HIV (+) subjects on chronic HAART (>5 years), who demonstrate HAART-related lipo-accumulation and prolonged HIV duration of infection. Further investigation is warranted to determine whether increased pericardial fat is associated with higher cardiovascular risk leading to premature cardiovascular events in this patient population.
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Affiliation(s)
- Mariana Diaz-Zamudio
- Division of Nuclear Medicine, Department of Imaging & Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Damini Dey
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Troy LaBounty
- Department of Medicine, Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA.
| | - Michael Nelson
- Diabetes and Obesity Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Zhaoyang Fan
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Lidia S Szczepaniak
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
- Diabetes and Obesity Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Bill Pei-Chin Hsieh
- Division of Nuclear Medicine, Department of Imaging & Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Ronak Rajani
- Division of Nuclear Medicine, Department of Imaging & Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Daniel Berman
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Debiao Li
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - Rohan Dharmakumar
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
| | - W David Hardy
- David-Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA.
| | - Antonio Hernandez Conte
- Department of Anesthesiology, Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Suite 8211, Los Angeles, CA, 90048, USA.
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25
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Gerlach RM, Barrus AB, Ramzy D, Hernandez Conte A, Khoche S, McCartney SL, Swaminathan M. CASE 7---2015: Perioperative Considerations for a Cardiac Paraganglioma...Not Just Another Cardiac Mass. J Cardiothorac Vasc Anesth 2015; 29:1065-70. [PMID: 25980595 DOI: 10.1053/j.jvca.2015.01.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2014] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Danny Ramzy
- Cedars Sinai Medical Center, Los Angeles, CA
| | | | - Swapnil Khoche
- University of California, San Diego Medical Center, San Diego, CA
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26
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Xie G, Bi X, Liu J, Yang Q, Natsuaki Y, Conte AH, Liu X, Li K, Li D, Fan Z. Three-dimensional coronary dark-blood interleaved with gray-blood (cDIG) magnetic resonance imaging at 3 tesla. Magn Reson Med 2015; 75:997-1007. [PMID: 25858528 DOI: 10.1002/mrm.25585] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2014] [Revised: 11/20/2014] [Accepted: 11/25/2014] [Indexed: 01/26/2023]
Abstract
PURPOSE Three-dimensional (3D) dark-blood MRI has shown great potential in coronary artery plaque evaluation. However, substantial variability in quantification could result from superficial calcification because of its low signal. To address this issue, a 3D coronary dark-blood interleaved with gray-blood (cDIG) technique was developed. METHODS cDIG is based on a balanced steady-state free precession readout combined with a local re-inversion-based double-inversion-recovery (LocReInv-DIR) preparation. The LocReInv-DIR is applied every two RR intervals. Dark-blood and gray-blood contrasts are collected in the first and second RR interval, respectively. To improve the respiratory gating efficiency, two independent navigators were developed to separately gate the respiratory motion for the two interleaved acquisitions. In vivo experiments in eight healthy subjects and one patient were conducted to validate the technique. RESULTS cDIG provided dual-contrasts without compromise in scan time. The dark-blood images with cDIG demonstrated excellent wall and lumen signal performances and morphological measurements. Advantageously, cDIG yielded a second contrast that was shown to help identify the superficial calcification in the coronary plaque of a patient. CONCLUSION A novel technique was developed for obtaining 3D coronary vessel wall and gray lumen images. The additional contrast may aid in identifying calcified nodules and thus potentially improve the evaluation of coronary plaque burden.
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Affiliation(s)
- Guoxi Xie
- Shenzhen Key Lab for MRI, BCMIIS, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, China.,Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Xiaoming Bi
- Siemens Healthcare, Los Angeles, California, USA
| | - Jiabin Liu
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qi Yang
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | | | | | - Xin Liu
- Shenzhen Key Lab for MRI, BCMIIS, Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, China
| | - Kuncheng Li
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Debiao Li
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Zhaoyang Fan
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
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27
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Nelson MD, Szczepaniak LS, LaBounty TM, Szczepaniak E, Li D, Tighiouart M, Li Q, Dharmakumar R, Sannes G, Fan Z, Yumul R, Hardy WD, Hernandez Conte A. Cardiac steatosis and left ventricular dysfunction in HIV-infected patients treated with highly active antiretroviral therapy. JACC Cardiovasc Imaging 2014; 7:1175-7. [PMID: 25459601 DOI: 10.1016/j.jcmg.2014.04.024] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 03/20/2014] [Accepted: 04/04/2014] [Indexed: 11/28/2022]
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28
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Ong L, Esmailian F, Conte AH. Pro: The benefits of utilizing expanded-criteria donors for orthotopic heart transplantation. J Cardiothorac Vasc Anesth 2014; 28:1686-7. [PMID: 25306521 DOI: 10.1053/j.jvca.2014.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Indexed: 11/11/2022]
Affiliation(s)
- Lawrence Ong
- Fellow in Adult Cardiothoracic Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Fardad Esmailian
- Division of Cardiothoracic Surgery, Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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29
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Fan Z, Yu W, Xie Y, Dong L, Yang L, Wang Z, Conte AH, Bi X, An J, Zhang T, Laub G, Shah PK, Zhang Z, Li D. Multi-contrast atherosclerosis characterization (MATCH) of carotid plaque with a single 5-min scan: technical development and clinical feasibility. J Cardiovasc Magn Reson 2014; 16:53. [PMID: 25184808 PMCID: PMC4222690 DOI: 10.1186/s12968-014-0053-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 07/08/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Multi-contrast weighted imaging is a commonly used cardiovascular magnetic resonance (CMR) protocol for characterization of carotid plaque composition. However, this approach is limited in several aspects including low slice resolution, long scan time, image mis-registration, and complex image interpretation. In this work, a 3D CMR technique, named Multi-contrast Atherosclerosis Characterization (MATCH), was developed to mitigate the above limitations. METHODS MATCH employs a 3D spoiled segmented fast low angle shot readout to acquire data with three different contrast weightings in an interleaved fashion. The inherently co-registered image sets, hyper T1-weighting, gray blood, and T2-weighting, are used to detect intra-plaque hemorrhage (IPH), calcification (CA), lipid-rich necrotic core (LRNC), and loose-matrix (LM). The MATCH sequence was optimized by computer simulations and testing on four healthy volunteers and then evaluated in a pilot study of six patients with carotid plaque, using the conventional multi-contrast protocol as a reference. RESULTS On MATCH images, the major plaque components were easy to identify. Spatial co-registration between the three image sets with MATCH was particularly helpful for the reviewer to discern co-existent components in an image and appreciate their spatial relation. Based on Cohen's kappa tests, moderate to excellent agreement in the image-based or artery-based component detection between the two protocols was obtained for LRNC, IPH, CA, and LM, respectively. Compared with the conventional multi-contrast protocol, the MATCH protocol yield significantly higher signal contrast ratio for IPH (3.1±1.3 vs. 0.4±0.3, p<0.001) and CA (1.6±1.5 vs. 0.7±0.6, p=0.012) with respect to the vessel wall. CONCLUSIONS To the best of our knowledge, the proposed MATCH sequence is the first 3D CMR technique that acquires spatially co-registered multi-contrast image sets in a single scan for characterization of carotid plaque composition. Our pilot clinical study suggests that the MATCH-based protocol may outperform the conventional multi-contrast protocol in several respects. With further technical improvements and large-scale clinical validation, MATCH has the potential to become a CMR method for assessing the risk of plaque disruption in a clinical workup.
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Affiliation(s)
- Zhaoyang Fan
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Wei Yu
- Department of Radiology, Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yibin Xie
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Bioengineering, University of California, Los Angeles, CA, USA
| | - Li Dong
- Department of Radiology, Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lixin Yang
- Department of Radiology, Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhanhong Wang
- Department of Radiology, Anzhen Hospital, Capital Medical University, Beijing, China
| | | | - Xiaoming Bi
- MR R&D, Siemens Healthcare, Los Angeles, CA, USA
| | - Jing An
- MR Collaborations NE Asia, Siemens Healthcare, Beijing, China
| | - Tianjing Zhang
- MR Collaborations NE Asia, Siemens Healthcare, Beijing, China
| | - Gerhard Laub
- MR R&D, Siemens Healthcare, Los Angeles, CA, USA
| | - Prediman Krishan Shah
- Oppenheimer Atherosclerosis Research Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Atherosclerosis Prevention and Management Center, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Zhaoqi Zhang
- Department of Radiology, Anzhen Hospital, Capital Medical University, Beijing, China
| | - Debiao Li
- Biomedical Imaging Research Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Department of Bioengineering, University of California, Los Angeles, CA, USA
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Yang HJ, Yumul R, Tang R, Cokic I, Klein M, Kali A, Sobczyk O, Sharif B, Tang J, Bi X, Tsaftaris SA, Li D, Conte AH, Fisher JA, Dharmakumar R. Assessment of myocardial reactivity to controlled hypercapnia with free-breathing T2-prepared cardiac blood oxygen level-dependent MR imaging. Radiology 2014; 272:397-406. [PMID: 24749715 DOI: 10.1148/radiol.14132549] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To examine whether controlled and tolerable levels of hypercapnia may be an alternative to adenosine, a routinely used coronary vasodilator, in healthy human subjects and animals. MATERIALS AND METHODS Human studies were approved by the institutional review board and were HIPAA compliant. Eighteen subjects had end-tidal partial pressure of carbon dioxide (PetCO2) increased by 10 mm Hg, and myocardial perfusion was monitored with myocardial blood oxygen level-dependent (BOLD) magnetic resonance (MR) imaging. Animal studies were approved by the institutional animal care and use committee. Anesthetized canines with (n = 7) and without (n = 7) induced stenosis of the left anterior descending artery (LAD) underwent vasodilator challenges with hypercapnia and adenosine. LAD coronary blood flow velocity and free-breathing myocardial BOLD MR responses were measured at each intervention. Appropriate statistical tests were performed to evaluate measured quantitative changes in all parameters of interest in response to changes in partial pressure of carbon dioxide. RESULTS Changes in myocardial BOLD MR signal were equivalent to reported changes with adenosine (11.2% ± 10.6 [hypercapnia, 10 mm Hg] vs 12% ± 12.3 [adenosine]; P = .75). In intact canines, there was a sigmoidal relationship between BOLD MR response and PetCO2 with most of the response occurring over a 10 mm Hg span. BOLD MR (17% ± 14 [hypercapnia] vs 14% ± 24 [adenosine]; P = .80) and coronary blood flow velocity (21% ± 16 [hypercapnia] vs 26% ± 27 [adenosine]; P > .99) responses were similar to that of adenosine infusion. BOLD MR signal changes in canines with LAD stenosis during hypercapnia and adenosine infusion were not different (1% ± 4 [hypercapnia] vs 6% ± 4 [adenosine]; P = .12). CONCLUSION Free-breathing T2-prepared myocardial BOLD MR imaging showed that hypercapnia of 10 mm Hg may provide a cardiac hyperemic stimulus similar to adenosine.
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Affiliation(s)
- Hsin-Jung Yang
- From the Biomedical Imaging Research Institute, Department of Biomedical Sciences, Cedars-Sinai Medical Center, 8700 Beverly Blvd, PACT Building, Suite 800, Los Angeles, CA 90048 (H.J.Y., R.T., I.C., A.K., B.S., D.L., R.D.); Departments of Bioengineering (H.J.Y., A.K., D.L.), Anesthesiology (R.Y.), and Medicine (D.L., R.D.), University of California, Los Angeles, Calif; Department of Physiology (O.S., M.K., J.A.F.) and Department of Anesthesiology, University Health Network (J.A.F.), University of Toronto, Toronto, Ontario, Canada; IMT Institute for Advanced Studies Lucca, Lucca, Italy (S.A.T.); Siemens Medical Solutions USA, Chicago, Ill (X.B.); and Department of Anesthesiology (R.Y., J.T., A.H.C.) and Cedars-Sinai Heart Institute (R.D.), Cedars-Sinai Medical Center, Los Angeles, Calif
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Ahmed W, Esmailian F, Hernandez Conte A. Con: the total artificial heart-is it an appropriate replacement to existing biventricular assist devices? J Cardiothorac Vasc Anesth 2013; 28:840-2. [PMID: 24200493 DOI: 10.1053/j.jvca.2013.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Indexed: 11/11/2022]
Affiliation(s)
- Waseemuddin Ahmed
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Fardad Esmailian
- Heart Transplantation, Cedars-Sinai Heart Institute, Los Angeles, California
| | - Antonio Hernandez Conte
- Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, California.
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Conte AH, Gurudevan SV, Lubin L, Shiota T, LaBounty T. Transesophageal Echocardiographic Evaluation of Left Main Coronary Artery Stent Protection During Transcatheter Aortic Valve Implantation. Anesth Analg 2013; 116:49-52. [DOI: 10.1213/ane.0b013e318274e082] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Conte AH, Esmailian F, LaBounty T, Lubin L, Hardy WD, Yumul R. The patient with the human immunodeficiency virus-1 in the cardiovascular operative setting. J Cardiothorac Vasc Anesth 2012; 27:135-55. [PMID: 22920840 DOI: 10.1053/j.jvca.2012.06.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2012] [Indexed: 01/01/2023]
Affiliation(s)
- Antonio Hernandez Conte
- Division of Cardiothoracic Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA, USA.
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Kar S, Ibebuogu UN, Conte AH. Utilization of 3 amplatzer occluders for closure of post-myocardial infarction ventricular septal defect. J Invasive Cardiol 2012; 24:E101-E103. [PMID: 22562925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
This case report describes a patient who sustained a post-myocardial infarction ventricular septal defect (VSD) with an associated left ventricular aneurysm who developed cardiogenic shock and required an intra-aortic balloon pump for hemodynamic stabilization. After deployment of a single Amplatzer occluder (AGA Medical), a residual VSD measuring 0.5 cm was noted. Therefore, a second Amplatzer occluder was deployed and a minimal residual VSD remained. The patient remained hemodynamically stable throughout the procedure and was subsequently extubated with removal of intra-aortic balloon pump. Post-discharge, the patient was readmitted with congestive heart failure. A third Amplatzer device was deployed to ameliorate the recurrent VSD shunt. At 9-week follow-up, transthoracic echocardiogram was performed and findings included: 1) left ventricular ejection fraction of 62%; 2) appearance of 3 Amplatzer devices along the interventrcular septum seated well with no motion and residual shunt; 3) moderate diastolic dysfunction with pseudonormal left ventricular filling pattern; and 4) no valvular abnormalities. The patient had increased exercise tolerance with no shortness of breath at rest or with exertion. This case demonstrates the utility and viability of multiple Amplatzer device deployment as a means of repairing a large post-myocardial infarction VSD and recurrent VSDs.
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Affiliation(s)
- Saibal Kar
- Heart Institutue at Cedars-Sinai Medical Center, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA.
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Kulkarni M, Conte AH, Huang A, Lubin L, Shiota T, Kar S. Coronary artery disease, acute myocardial infarction, and a newly developing ventricular septal defect: surgical repair or percutaneous closure? J Cardiothorac Vasc Anesth 2011; 25:1213-6. [PMID: 21955832 DOI: 10.1053/j.jvca.2011.08.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [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: 07/28/2011] [Indexed: 11/11/2022]
Affiliation(s)
- Mona Kulkarni
- Division of Cardiothoracic Anesthesiology and Cedars-Sinai Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA 90048, USA
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Affiliation(s)
- C Bell
- Department of Anesthesiology, Yale University School of Medicine, New Haven, CT 06510, USA
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