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Quintana EN, DeBose-Scarlett A, McLaren TA, Gondek SP, Smith MC, Alder MR, Baker MT, Shah AS, Absi TS. Acute cardiogenic shock secondary to blunt traumatic aortic valve injury. Trauma Case Rep 2024; 51:100995. [PMID: 38572422 PMCID: PMC10987328 DOI: 10.1016/j.tcr.2024.100995] [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] [Accepted: 03/20/2024] [Indexed: 04/05/2024] Open
Abstract
Background Blunt cardiac injuries rarely result in aortic valve cusp rupture, leading to acute aortic insufficiency and cardiogenic shock. This rare clinical entity carries a high mortality rate if left undiagnosed and not managed surgically, with few patients surviving beyond 24 h. It presents a diagnostic challenge in the polytrauma patient in shock, with multiple possible and complementary etiologies. Case presentation We present a 56-year-old male with persistent hypotension, a wide pulse pressure, and elevated serum troponin levels suggesting blunt cardiac injury after a motor vehicle accident. Transthoracic and transesophageal echocardiography revealed normal biventricular function but severe aortic insufficiency due to prolapse of the left coronary cusp.He was taken emergently to surgery, where aortic valve exploration revealed complete left coronary cusp avulsion from the aortic annulus with a mid-cusp tear, requiring aortic valve replacement with a bioprosthetic valve. Postoperative echocardiography showed normal biventricular function with a well-seated bioprosthetic aortic valve with no insufficiency. Conclusions Traumatic aortic valve injury can lead to torn or prolapsed cusps causing acute aortic insufficiency leading to cardiogenic shock, but early recognition with appropriate and targeted diagnostic imaging is vital to prevent rapid patient deterioration and demise.
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Affiliation(s)
- Eric N. Quintana
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Alexandra DeBose-Scarlett
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Thomas A. McLaren
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Stephen P. Gondek
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Michael C. Smith
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Madeleine R. Alder
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Michael T. Baker
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Ashish S. Shah
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Tarek S. Absi
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
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Bommareddi S, Lima B, Shah AS, Trahanas JM. Thoraco-abdominal normothermic regional perfusion for thoracic transplantation in the United States: current state and future directions. Curr Opin Organ Transplant 2024; 29:180-185. [PMID: 38483139 DOI: 10.1097/mot.0000000000001143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/30/2024]
Abstract
PURPOSE OF REVIEW To provide an update regarding the state of thoracoabdominal normothermic regional perfusion (taNRP) when used for thoracic organ recovery. RECENT FINDINGS taNRP is growing in its utilization for thoracic organ recovery from donation after circulatory death donors, partly because of its cost effectiveness. taNRP has been shown to yield cardiac allograft recipient outcomes similar to those of brain-dead donors. Regarding the use of taNRP to recover donor lungs, United Network for Organ Sharing (UNOS) analysis shows that taNRP recovered lungs are noninferior, and taNRP has been used to consistently recover excellent lungs at high volume centers. Despite its growth, ethical debate regarding taNRP continues, though clinical data now supports the notion that there is no meaningful brain perfusion after clamping the aortic arch vessels. SUMMARY taNRP is an excellent method for recovering both heart and lungs from donation after circulatory death donors and yields satisfactory recipient outcomes in a cost-effective manner. taNRP is now endorsed by the American Society of Transplant Surgeons, though ethical debate continues.
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Affiliation(s)
- Swaroop Bommareddi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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3
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Raphael J, Chae A, Feng X, Shotwell MS, Mazzeffi MA, Bollen BA, Pfeil D, Feduska E, Shah AS, Kertai MD. Red Blood Cell Transfusion and Pulmonary Complications: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis. Ann Thorac Surg 2024; 117:839-846. [PMID: 38216079 DOI: 10.1016/j.athoracsur.2023.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 11/09/2023] [Accepted: 12/19/2023] [Indexed: 01/14/2024]
Abstract
BACKGROUND Intraoperative packed red blood cell (PRBC) transfusion during cardiac surgery is associated with increased postoperative morbidity and mortality; however, data on the association between PRBC transfusion and postoperative pulmonary complications (PPCs) are somewhat conflicting. Using The Society of Thoracic Surgeons Adult Cardiac Surgery Database, we sought to determine whether intraoperative PRBC transfusion was associated with PPCs as well as with longer intensive care unit (ICU) stay after isolated coronary artery bypass grafting (CABG) surgery. METHODS A registry-based cohort study was performed on 751,893 patients with isolated CABG between January 1, 2015, to December 31, 2019. Using propensity score-weighted regression analysis, we analyzed the effect of intraoperative PRBC on the incidence of PPCs (hospital-acquired pneumonia [HAP], mechanical ventilation for >24 hours, or reintubation), ICU length of stay, and ICU readmission. RESULTS Transfusion of 1, 2, 3, and ≥4 units of PRBCs was associated with increased odds for HAP (odds ratios [ORs], 1.24 [95% CI, 1.21-1.26], 1.28 [95% CI, 1.26-1.32], 1.36 [95% CI, 1.33-1.39], 1.31 [95% CI, 1.28-1.34]), reintubation (ORs, 1.23 [95% CI, 1.21-1.25], 1.38 [95% CI, 1.35-1.40], 1.57 [95% CI, 1.55-1.60], 1.70 [95% CI, 1.67-1.73]), prolonged ventilation (ORs, 1.34 [95% CI, 1.33-1.36], 1.56 [95% CI, 1.53-1.58], 1.97 [95% CI, 1.94-2.00], 2.27 [95% CI, 2.24-2.30]), initial ICU length of stay (mean difference in hours, 6.79 [95% CI, 6.00-7.58], 9.55 [95% CI, 8.71-10.38], 17.26 [95% CI, 16.38-18.15], 22.14 [95% CI, 21.22-23.06]), readmission to ICU (ORs, 1.14 [95% CI, 1.12-1.64], 1.15 [95% CI, 1.12-1.17], 1.15 [95% CI, 1.13-1.18], 1.32 [95% CI, 1.29-1.35]), and additional ICU length of stay (mean difference in hours, 0.55 [95% CI, 0.18-0.92], 0.38 [95% CI, 0.00-0.77], 1.02 [95% CI, 0.61-1.43], 1.83 [95% CI, 1.40-2.26]), respectively. CONCLUSIONS Intraoperative PRBC transfusion was associated with increased incidence of PPCs, prolonged ICU stay, and ICU readmissions after isolated CABG surgery.
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Affiliation(s)
- Jacob Raphael
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Alice Chae
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia
| | | | - Douglas Pfeil
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Eric Feduska
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee.
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4
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Wu WK, Siegrist KK, Ziogas IA, Mishra KL, Matsuoka LK, Menachem JN, Izzy M, Shingina A, Do NL, Bacchetta M, Shah AS, Alexopoulos SP. Perioperative Characteristics and Outcomes of Fontan Versus Non-Fontan Patients Undergoing Combined Heart-Liver Transplantation: A Retrospective Cohort Study. J Cardiothorac Vasc Anesth 2024; 38:745-754. [PMID: 38172029 DOI: 10.1053/j.jvca.2023.11.043] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/24/2023] [Accepted: 11/29/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES Combined heart-liver transplantation (CHLT) is becoming increasingly frequent as a maturing population of patients with Fontan-palliated congenital heart disease develop advanced liver fibrosis or cirrhosis. The authors present their experience with CHLT for congenital and noncongenital indications, and identify characteristics associated with poor outcomes that may guide intervention in high-risk patients. DESIGN This was a single-center retrospective cohort study. SETTING This study was conducted at Vanderbilt University Medical Center in Nashville, Tennessee. PARTICIPANTS The study included 16 consecutive adult recipients of CHLT at the authors' institution between April 2017 and February 2022. INTERVENTIONS Eleven patients underwent transplantation for Fontan indications, and 5 were transplanted for non-Fontan indications. MEASUREMENTS AND MAIN RESULTS Compared with non-Fontan patients, Fontan recipients had longer cardiopulmonary bypass duration (199 v 119 minutes, p =m0.002), operative times (786 v 599 minutes, p = 0.01), and larger blood product transfusions (15.4 v 6.3 L, p = 0.18). Six of 16 patients required extracorporeal membrane oxygenation (ECMO), of whom 4 were Fontan patients who subsequently died. Patients who required ECMO had lower 5-hour lactate clearance (0.0 v 3.5 mmol/L, p = 0.001), higher number of vasoactive infusions, lower pulmonary artery pulsatility indices (0.58 v 1.77, p = 0.03), and higher peak inspiratory pressures (28.0 v 18.5 mmHg, p = 0.01) after liver reperfusion. CONCLUSIONS Combined heart-liver transplantation in patients with Fontan-associated end-organ disease is particularly challenging and associated with higher recipient morbidity compared with non-Fontan-related CHLT. Early hemodynamic intervention for signs of ventricular dysfunction may improve outcomes in this growing high-risk population.
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Affiliation(s)
- Wei Kelly Wu
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN; Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Kara K Siegrist
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
| | - Ioannis A Ziogas
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN
| | - Kelly L Mishra
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Lea K Matsuoka
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN; Transplant Center, University of California Davis Medical Center, Sacramento, CA
| | - Jonathan N Menachem
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Manhal Izzy
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Alexandra Shingina
- Division of Gastroenterology, Hepatology, and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Nhue L Do
- Division of Pediatric Cardiac Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, TN
| | - Matthew Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Sophoclis P Alexopoulos
- Department of Surgery, Division of Hepatobiliary Surgery and Liver Transplantation, Vanderbilt University Medical Center, Nashville, TN; Transplant Center, University of California Davis Medical Center, Sacramento, CA.
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Schroder JN, Patel CB, DeVore AD, Casalinova S, Koomalsingh KJ, Shah AS, Anyanwu AC, D'Alessandro DA, Mudy K, Sun B, Strueber M, Khaghani A, Shudo Y, Esmailian F, Liao K, Pagani FD, Silvestry S, Wang IW, Salerno CT, Absi TS, Madsen JC, Mancini D, Fiedler AG, Milano CA, Smith JW. Increasing Utilization of Extended Criteria Donor Hearts for Transplantation: The OCS Heart EXPAND Trial. JACC Heart Fail 2024; 12:438-447. [PMID: 38276933 DOI: 10.1016/j.jchf.2023.11.015] [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] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 11/09/2023] [Accepted: 11/28/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Extended criteria donor (ECD) hearts available with donation after brain death (DBD) are underutilized for transplantation due to limitations of cold storage. OBJECTIVES This study evaluated use of an extracorporeal perfusion system on donor heart utilization and post-transplant outcomes in ECD DBD hearts. METHODS In this prospective, single-arm, multicenter study, adult heart transplant recipients received ECD hearts using an extracorporeal perfusion system if hearts met study criteria. The primary outcome was a composite of 30-day survival and absence of severe primary graft dysfunction (PGD). Secondary outcomes were donor heart utilization rate, 30-day survival, and incidence of severe PGD. The safety outcome was the mean number of heart graft-related serious adverse events within 30 days. Additional outcomes included survival through 2 years benchmarked to concurrent nonrandomized control subjects. RESULTS A total of 173 ECD DBD hearts were perfused; 150 (87%) were successfully transplanted; 23 (13%) did not meet study transplantation criteria. At 30 days, 92% of patients had survived and had no severe PGD. The 30-day survival was 97%, and the incidence of severe PGD was 6.7%. The mean number of heart graft-related serious adverse events within 30 days was 0.17 (95% CI: 0.11-0.23). Patient survival was 93%, 89%, and 86% at 6, 12, and 24 months, respectively, and was comparable with concurrent nonrandomized control subjects. CONCLUSIONS Use of an extracorporeal perfusion system resulted in successfully transplanting 87% of donor hearts with excellent patient survival to 2 years post-transplant and low rates of severe PGD. The ability to safely use ECD DBD hearts could substantially increase the number of heart transplants and expand access to patients in need. (International EXPAND Heart Pivotal Trial [EXPANDHeart]; NCT02323321; Heart EXPAND Continued Access Protocol; NCT03835754).
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Affiliation(s)
| | | | - Adam D DeVore
- Duke University Hospital, Durham, North Carolina, USA
| | | | | | - Ashish S Shah
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Karol Mudy
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Benjamin Sun
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | | | | | - Yasuhiro Shudo
- Stanford University Medical Center, Stanford, California, USA
| | | | | | | | | | - I-Wen Wang
- Memorial Healthcare System, Hollywood, Florida, USA
| | | | - Tarek S Absi
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joren C Madsen
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Donna Mancini
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy G Fiedler
- University of California-San Francisco, San Francisco, California, USA
| | | | - Jason W Smith
- University of California-San Francisco, San Francisco, California, USA
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6
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Shah AS. Wherefore Art Thou Single-Center Study? Ann Thorac Surg 2024; 117:359-360. [PMID: 37931833 DOI: 10.1016/j.athoracsur.2023.10.030] [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: 10/07/2023] [Accepted: 10/19/2023] [Indexed: 11/08/2023]
Affiliation(s)
- Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Vanderbilt Medical Center East, 1215 21st Ave S, Ste 5025, Nashville, TN 37232.
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7
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Shah AS. Heart Transplantation and the Art of Probability. Ann Thorac Surg 2024; 117:411-412. [PMID: 37536488 DOI: 10.1016/j.athoracsur.2023.07.032] [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: 07/16/2023] [Accepted: 07/23/2023] [Indexed: 08/05/2023]
Affiliation(s)
- Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Vanderbilt Medical Center East, 1215 21st Ave S, Ste 5025, Nashville, TN 37232.
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8
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El-Sabawi B, Shah AS, Brinkley DM, Stevenson LW, Lindman BR, Barker CM, Goel K. Transcatheter Edge-to-Edge Repair in Patients With Hypertrophic Cardiomyopathy and Severe Mitral Regurgitation After Septal Myectomy. Can J Cardiol 2023; 39:1954-1956. [PMID: 37562540 DOI: 10.1016/j.cjca.2023.08.002] [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: 07/08/2023] [Revised: 07/25/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023] Open
Affiliation(s)
- Bassim El-Sabawi
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - D Marshall Brinkley
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lynne W Stevenson
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Brian R Lindman
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Colin M Barker
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kashish Goel
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
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9
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Shah AS. Pyrrhic Victories and Impossible Missions. Ann Thorac Surg 2023; 116:1089-1090. [PMID: 37479132 DOI: 10.1016/j.athoracsur.2023.07.005] [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: 06/24/2023] [Accepted: 07/09/2023] [Indexed: 07/23/2023]
Affiliation(s)
- Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Vanderbilt Medical Center East, 1215 21st Ave S, Ste 5025, Nashville, TN 37232.
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10
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Menachem JN, Patel CB, Schlendorf KH, Shah AS, Schroder JN, DeVore AD. Expanding the donor pool to improve outcomes for adults with complex congenital heart disease. J Heart Lung Transplant 2023; 42:1485-1488. [PMID: 37422145 DOI: 10.1016/j.healun.2023.06.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 06/08/2023] [Accepted: 06/22/2023] [Indexed: 07/10/2023] Open
Affiliation(s)
- Jonathan N Menachem
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Chetan B Patel
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Kelly H Schlendorf
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jacob N Schroder
- Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina
| | - Adam D DeVore
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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11
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Amancherla K, Feurer ID, Rega SA, Cluckey A, Salih M, Davis J, Pedrotty D, Ooi H, Rali AS, Siddiqi HK, Menachem J, Brinkley DM, Punnoose L, Sacks SB, Zalawadiya SK, Wigger M, Balsara K, Trahanas J, McMaster WG, Hoffman J, Pasrija C, Lindenfeld J, Shah AS, Schlendorf KH. Early Assessment of Cardiac Allograft Vasculopathy Risk Among Recipients of Hepatitis C Virus-infected Donors in the Current Era. J Card Fail 2023:S1071-9164(23)00381-0. [PMID: 37907147 PMCID: PMC11056484 DOI: 10.1016/j.cardfail.2023.09.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 09/22/2023] [Accepted: 09/27/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Transplantation of hearts from hepatitis C virus (HCV)-positive donors has increased substantially in recent years following development of highly effective direct-acting antiviral therapies for treatment and cure of HCV. Although historical data from the pre-direct-acting antiviral era demonstrated an association between HCV-positive donors and accelerated cardiac allograft vasculopathy (CAV) in recipients, the relationship between the use of HCV nucleic acid test-positive (NAT+) donors and the development of CAV in the direct-acting antiviral era remains unclear. METHODS AND RESULTS We performed a retrospective, single-center observational study comparing coronary angiographic CAV outcomes during the first year after transplant in 84 heart transplant recipients of HCV NAT+ donors and 231 recipients of HCV NAT- donors. Additionally, in a subsample of 149 patients (including 55 in the NAT+ cohort and 94 in the NAT- cohort) who had serial adjunctive intravascular ultrasound examination performed, we compared development of rapidly progressive CAV, defined as an increase in maximal intimal thickening of ≥0.5 mm in matched vessel segments during the first year post-transplant. In an unadjusted analysis, recipients of HCV NAT+ hearts had reduced survival free of CAV ≥1 over the first year after heart transplant compared with recipients of HCV NAT- hearts. After adjustment for known CAV risk factors, however, there was no significant difference between cohorts in the likelihood of the primary outcome, nor was there a difference in development of rapidly progressive CAV. CONCLUSIONS These findings support larger, longer-term follow-up studies to better elucidate CAV outcomes in recipients of HCV NAT+ hearts and to inform post-transplant management strategies.
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Affiliation(s)
- Kaushik Amancherla
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Irene D Feurer
- Departments of Surgery and Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Scott A Rega
- Vanderbilt Transplant Center, Nashville, Tennessee
| | - Andrew Cluckey
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mohamed Salih
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Davis
- Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Dawn Pedrotty
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Henry Ooi
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aniket S Rali
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Hasan K Siddiqi
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Menachem
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Douglas M Brinkley
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lynn Punnoose
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Suzanne B Sacks
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandip K Zalawadiya
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark Wigger
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Keki Balsara
- Department of Cardiac Surgery, Medstar Washington Hospital Center, Washington, DC
| | - John Trahanas
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - William G McMaster
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jordan Hoffman
- Division of Cardiothoracic Surgery, University of Colorado, Aurora, Colorado
| | - Chetan Pasrija
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Joann Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly H Schlendorf
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee.
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12
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Staben R, Vnencak-Jones CL, Shi Y, Shotwell MS, Absi T, Shah AS, Wanderer JP, Beller M, Kertai MD. Preemptive Pharmacogenetic-Guided Metoprolol Management for Postoperative Atrial Fibrillation in Cardiac Surgery: The Preemptive Pharmacogenetic-Guided Metoprolol Management for Atrial Fibrillation in Cardiac Surgery Pilot Trial. J Cardiothorac Vasc Anesth 2023; 37:1974-1982. [PMID: 37407326 DOI: 10.1053/j.jvca.2023.06.017] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Revised: 05/23/2023] [Accepted: 06/09/2023] [Indexed: 07/07/2023]
Abstract
OBJECTIVES To test the hypothesis that implementation of a cytochrome P-450 2D6 (CYP2D6) genotype-guided perioperative metoprolol administration will reduce the risk of postoperative atrial fibrillation (AF), the authors conducted the Preemptive Pharmacogenetic-Guided Metoprolol Management for Atrial Fibrillation in Cardiac Surgery pilot study. DESIGN Clinical pilot trial. SETTING Single academic center. PARTICIPANTS Seventy-three cardiac surgery patients. MEASUREMENTS AND MAIN RESULTS Patients were classified as normal, intermediate, poor, or ultrarapid metabolizers after testing for their CYP2D6 genotype. A clinical decision support tool in the electronic health record advised providers on CYP2D6 genotype-guided metoprolol dosing. Using historical data, the Bayesian method was used to compare the incidence of postoperative AF in patients with altered metabolizer status to the reference incidence. A logistic regression analysis was performed to study the association between the metabolizer status and postoperative AF while controlling for the Multicenter Study of Perioperative Ischemia AF Risk Index. Of the 73 patients, 30% (n = 22) developed postoperative AF; 89% (n = 65) were normal metabolizers; 11% (n = 8) were poor/intermediate metabolizers; and there were no ultrarapid metabolizer patients identified. The estimated rate of postoperative AF in patients with altered metabolizer status was 30% (95% CI 8%-60%), compared with the historical reference incidence (27%). In the risk-adjusted analysis, there was insufficient evidence to conclude that modifying metoprolol dosing based on poor/intermediate metabolizer status was associated significantly with the odds of postoperative AF (odds ratio 0.82, 95% CI 0.15-4.55, p = 0.82). CONCLUSIONS A CYP2D6 genotype-guided metoprolol management was not associated with a reduction of postoperative AF after cardiac surgery.
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Affiliation(s)
- Rae Staben
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Cindy L Vnencak-Jones
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew S Shotwell
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Tarek Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Marc Beller
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, TN
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
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Raphael J, Feng X, Shotwell MS, Mazzeffi MA, Bollen BA, Shah AS, Kertai MD. Association of Intraoperative Red Blood Cell Transfusions With Venous Thromboembolism and Adverse Outcomes After Cardiac Surgery. Ann Surg 2023; 278:e650-e660. [PMID: 36538645 DOI: 10.1097/sla.0000000000005733] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE We determined whether intraoperative packed red blood cell (PRBC) transfusion was associated with a higher incidence of hospital-acquired venous thromboembolic (HA-VTE) complications and adverse outcomes after isolated coronary artery bypass grafting (CABG) surgery. BACKGROUND Intraoperative PRBC has been associated with increased risk for postoperative deep venous thrombosis after cardiac surgery, but validation of these findings in a large, multi-institutional, national cohort of cardiac surgery patients has been lacking. METHODS A registry-based cohort study of 751,893 patients with isolated CABG between January 1, 2015, to December 31, 2019. Using propensity score-weighted regression analysis, we analyzed the effect of intraoperative PRBC on the incidence of HA-VTE and adverse outcomes. RESULTS Administration of 1, 2, 3, and ≥4 units of PRBC transfusion was associated with increased odds for HA-VTE [odds ratios (ORs): 1.27 (1.22-1.32), 1.21 (1.16-1.26), 1.93 (1.85-2.00), 1.82 (1.75-1.89)], deep venous thrombosis [ORs: 1.39 (1.33-1.46), 1.38 (1.32-1.44), 2.18 (2.09-2.28), 1.82 (1.74-1.91], operative mortality [ORs: 1.11 (1.08-1.14), 1.16 (1.13-1.19), 1.29 (1.26-1.32), 1.47 (1.43-1.50)], readmission within 30 days [ORs: 1.05 (1.04-1.06), 1.16 (1.13-1.19), 1.29 (1.26-1.32), 1.47 (1.43-1.50)], and a prolonged postoperative length of stay [mean difference in days, 0.23 (0.19-0.27), 0.34 (0.30-0.39), 0.69 (0.64-0.74), 0.77 (0.72-0.820]. The odds of pulmonary venous thromboembolism were lower for patients transfused with 1 or 2 units [ORs: 0.98 (0.91-1.06), 0.75 (0.68-0.81)] of PRBC but remained significantly elevated for those receiving 3 and ≥4 units [ORs: 1.19 (1.09-1.29), 1.35 (1.25-1.48)]. CONCLUSIONS Intraoperative PRBC transfusion was associated with HA-VTE and adverse outcomes after isolated CABG surgery.
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Affiliation(s)
- Jacob Raphael
- Department of Anesthesiology, Thomas Jefferson University Hospitals, Philadelphia, PA
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Michael A Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
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14
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Shah AS, Sobolewski B, Chon S, Cruse B, Glisson MD, Zackoff MW, Davis D, Zhang Y, Schumacher DJ, Geis GL. Just-in-Time, Just-in-Place Virtual Training in the Pediatric Emergency Department: A Novel Approach to Impact the Perfusion Exam. Adv Med Educ Pract 2023; 14:901-911. [PMID: 37614829 PMCID: PMC10443635 DOI: 10.2147/amep.s414022] [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: 04/12/2023] [Accepted: 08/02/2023] [Indexed: 08/25/2023]
Abstract
Background Early identification of shock is vital in decreasing morbidity and mortality in the pediatric population. Although residents are taught the perfusion portion of the rapid cardiopulmonary assessment at our institution, they perform it at the bedside with 8.4% completing 1 part of the assessment and 9.7% verbalizing their findings. Newer technologies, including virtual reality (VR), offer immersive training to close this clinical gap. Objective To assess senior pediatric residents' performance of a perfusion exam and verbalization of their perfusion assessment following VR-based Just-in-Time/Just-in-Place (JITP) training compared to video-based JITP training. We hypothesized that JITP media training was feasible, and VR JITP was more effective than video-based training. Methods Residents were randomized to VR or video-based training during shifts in the emergency department. Clinical performance was assessed by review of a video-recorded patient encounter using a standardized assessment tool and by an in-person, two question shock assessment. Residents completed a survey assessing attitudes toward their intervention at the time of training. Results Eighty-five senior pediatric residents were enrolled; 84 completed training. Sixty-four (76%) residents had a patient encounter available for video review (VR 33; Video 31). Fourteen residents in the VR group (42.4%, 95% CI 25.5% to 60.8%) and 13 residents in the video group (41.9%, 95% CI 24.6% to 60.9%) completed a perfusion exam AND verbalized an assessment during their next clinical encounter (X2 p-value 1.00). Fifty-one of 64 residents (79.7%) completed the two-step shock assessment; 50 (98%) agreed with supervising physician's assessment. VR was rated more effective than reading, low-fidelity manikin, standardized patient encounters, traditional didactic teaching, and online learning. Video was rated more effective than online learning, traditional didactic teaching, and reading. Conclusion Novel video and VR JITP perfusion exam and assessment trainings are impactful and well-received by senior pediatric residents.
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Affiliation(s)
- Ashish S Shah
- Department of Pediatrics, University of California – San Diego, San Diego, CA, USA
- Division of Emergency Medicine, Rady Children’s Hospital, San Diego, CA, USA
| | - Brad Sobolewski
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Sabina Chon
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Bradly Cruse
- Center for Simulation and Research, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Mike D Glisson
- Center for Simulation and Research, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Matthew W Zackoff
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Center for Simulation and Research, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - David Davis
- Center for Simulation and Research, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Yin Zhang
- Emergency Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Daniel J Schumacher
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
| | - Gary L Geis
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
- Center for Simulation and Research, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA
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15
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Shah AS. Current State of Cardiac Donation After Circulatory Death in Clinical Heart Transplantation. Circulation 2023; 148:379-380. [PMID: 37314220 DOI: 10.1161/circulationaha.123.064394] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Affiliation(s)
- Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Vanderbilt Medical Center East, Nashville, TN
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16
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Shah AS. The Price of Being Mostly Right. Ann Thorac Surg 2023; 116:391. [PMID: 36940897 DOI: 10.1016/j.athoracsur.2023.03.014] [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: 03/10/2023] [Accepted: 03/11/2023] [Indexed: 03/23/2023]
Affiliation(s)
- Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Vanderbilt Medical Center East, 1215 21st Ave S, Ste 5025, Nashville, TN 37232.
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17
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Rali AS, Tran LE, Auvil B, Xu M, Huang S, Labrada L, Schlendorf KH, Bacchetta MD, Shah AS, Hernandez A, Lindenfeld J. Modifiable Mechanical Ventilation Targets Are Associated With Improved Survival in Ventilated VA-ECLS Patients. JACC Heart Fail 2023; 11:961-968. [PMID: 37178085 PMCID: PMC10171237 DOI: 10.1016/j.jchf.2023.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/29/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND In acute respiratory distress syndrome (ARDS), lung protective ventilation (LPV) improves patient outcomes by minimizing ventilator-induced lung injury. The value of LPV in ventilated patients with cardiogenic shock (CS) requiring venoarterial extracorporeal life support (VA-ECLS) is not known, but the extracorporeal circuit provides a unique opportunity to modify ventilatory parameters to improve outcomes. OBJECTIVES The authors hypothesized that CS patients on VA-ECLS who require mechanical ventilation (MV) may benefit from low intrapulmonary pressure ventilation (LPPV), which has the same end goals as LPV. METHODS The authors queried the ELSO (Extracorporeal Life Support Organization) registry for hospital admissions between 2009 and 2019 for CS patients on VA-ECLS and MV. They defined LPPV as peak inspiratory pressure at 24 hours on ECLS of <30 cm H2O. Positive end-expiration pressure and dynamic driving pressure (DDP) at 24 hours were also studied as continuous variables. Their primary outcome was survival to discharge. Multivariable analyses were performed that adjusted for baseline Survival After Venoarterial Extracorporeal Membrane Oxygenation score, chronic lung conditions, and center extracorporeal membrane oxygenation volume. RESULTS A total of 2,226 CS patients on VA-ECLS were included: 1,904 received LPPV. The primary outcome was higher in the LPPV group vs the no-LPPV group (47.4% vs 32.6%; P < 0.001). Median peak inspiratory pressure (22 vs 24 cm H2O; P < 0.001) as well as DDP (14.5 vs 16 cm H2O; P < 0.001) were also significantly lower in those surviving to discharge. The adjusted OR for the primary outcome with LPPV was 1.69 (95% CI: 1.21-2.37; P = 0.0021). CONCLUSIONS LPPV is associated with improved outcomes in CS patients on VA-ECLS requiring MV.
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Affiliation(s)
- Aniket S Rali
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Lena E Tran
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Bryan Auvil
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Meng Xu
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Shi Huang
- Department of Biostatistics, Vanderbilt University, Nashville, Tennessee, USA
| | - Lyana Labrada
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly H Schlendorf
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew D Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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18
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Armstrong DWJ, Riley LA, Su YR, Shah AS, Absi T, Gupta DK, Wells QS, Brinkley DM, Stevenson LW, Merryman WD. Myocardial Neprilysin Is Increased in Hypertrophic Cardiomyopathy. Circulation 2023; 148:167-169. [PMID: 37428831 DOI: 10.1161/circulationaha.123.064153] [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] [Indexed: 07/12/2023]
Affiliation(s)
- David W J Armstrong
- From the Division of Cardiovascular Medicine (D.W.J.A., Y.R.S., D.K.G., Q.S.W., D.M.B., L.W.S.), Vanderbilt University, Nashville, TN
| | - Lance A Riley
- Departments of Biomedical Engineering (L.A.R., W.D.M.), Vanderbilt University, Nashville, TN
- Foresight Diagnostics Inc., Aurora, CO (L.A.R.)
| | - Yan Ru Su
- From the Division of Cardiovascular Medicine (D.W.J.A., Y.R.S., D.K.G., Q.S.W., D.M.B., L.W.S.), Vanderbilt University, Nashville, TN
| | - Ashish S Shah
- Cardiac Surgery (A.S.S., T.A.), Vanderbilt University, Nashville, TN
| | - Tarek Absi
- Cardiac Surgery (A.S.S., T.A.), Vanderbilt University, Nashville, TN
| | - Deepak K Gupta
- From the Division of Cardiovascular Medicine (D.W.J.A., Y.R.S., D.K.G., Q.S.W., D.M.B., L.W.S.), Vanderbilt University, Nashville, TN
| | - Quinn S Wells
- From the Division of Cardiovascular Medicine (D.W.J.A., Y.R.S., D.K.G., Q.S.W., D.M.B., L.W.S.), Vanderbilt University, Nashville, TN
- Biomedical Informatics (Q.S.W.), Vanderbilt University, Nashville, TN
- Pharmacology (Q.S.W.), Vanderbilt University, Nashville, TN
| | - D Marshall Brinkley
- From the Division of Cardiovascular Medicine (D.W.J.A., Y.R.S., D.K.G., Q.S.W., D.M.B., L.W.S.), Vanderbilt University, Nashville, TN
| | - Lynne W Stevenson
- From the Division of Cardiovascular Medicine (D.W.J.A., Y.R.S., D.K.G., Q.S.W., D.M.B., L.W.S.), Vanderbilt University, Nashville, TN
| | - W David Merryman
- Departments of Biomedical Engineering (L.A.R., W.D.M.), Vanderbilt University, Nashville, TN
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19
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Rali AS, Larson EE, Tran LE, Rahaman ZM, Charles LJ, Stokes JW, Chin C, Hilton A, Gannon WD, Bacchetta MD, Shah AS. Area Deprivation Index and Distress Community Index Scores Are Not Associated With Short-Term and Long-Term Extracorporeal Life Support Outcomes. ASAIO J 2023; 69:583-587. [PMID: 36807257 DOI: 10.1097/mat.0000000000001888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Distressed Communities Index (DCI) and Area Deprivation Index (ADI) are two composite ranking scores that report community level socioeconomic status (SES) by ZIP codes. The objective of this study was to evaluate the impact of SES as estimated by DCI and ADI scores on short-term and long-term outcomes after extracorporeal life support (ECLS) at a quaternary medical center. All patients on ECLS between January 1, 2015 and August 31, 2020 (N = 428) at Vanderbilt University Medical Center in Nashville, Tennessee, had their ADI and DCI scores calculated. Primary outcome was mortality during index hospitalization, and secondary outcome was survival to end of study follow-up. There was no significant difference in primary outcome between the top 25% ADI vs . bottom 75% ADI (53.8% vs . 50.6%; p = 0.56) or between top 25% DCI vs . bottom 75% DCI (56.1 vs . 49.2; p = 0.21). Adjusted odds ratio for the primary outcome with ADI and DCI was 1.13 (95% CI, 0.63-2.0; p = 0.67) and 1.28 (95% CI, 0.70-2.34; p = 0.41), respectively. Additionally, there was no significant difference in long-term survival curves based on their ADI or DCI scores. In conclusion, SES as estimated by baseline DCI and ADI scores does not appear to impact short- or long-term survival post-ECLS at a large volume center. http://links.lww.com/ASAIO/A951.
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Affiliation(s)
- Aniket S Rali
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Emilee E Larson
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lena E Tran
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Zakiur M Rahaman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lawrence J Charles
- From the Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John W Stokes
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Clifford Chin
- Vanderbilt University School of Medical, Nashville, Tennessee
| | - Alistair Hilton
- Vanderbilt University School of Medical, Nashville, Tennessee
| | - Whitney D Gannon
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew D Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Pasrija C, Tipograf Y, Shah AS, Trahanas JM. Normothermic regional perfusion for donation after circulatory death donors. Curr Opin Organ Transplant 2023; 28:71-75. [PMID: 36409266 DOI: 10.1097/mot.0000000000001038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
PURPOSE OF REVIEW This review is intended to provide an update on the logistics, technique, and outcomes associated with normothermic regional perfusion (NRP), as well as provide a discussion of the associated ethical issues. RECENT FINDINGS There has been renewed interest in utilizing NRP to increase quality and availability of organs from donation after circulatory death (DCD) donors. Our institution has increasing experience with thoraco-abdominal NRP (TA-NRP) in controlled DCD donors (cDCD), whereas abdominal NRP (A-NRP) has been used with success in both cDCD and uncontrolled DCD (uDCD). There is increasing evidence that NRP can be conducted in a practical and cost-efficient manner, and that the organ yield may be of better quality than standard direct procurement and perfusion (DPP). SUMMARY NRP is increasingly successful and will likely prove to be a superior method for cDCD recovery. However, before TA-NRP can be widely accepted the ethical debate surrounding this technique must be settled. VIDEO ABSTRACT http://links.lww.com/COOT/A11.
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Affiliation(s)
- Chetan Pasrija
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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21
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Raphael J, Feng X, Shotwell MS, Mazzeffi MA, Bollen BA, Shah AS, Kertai MD. Response to: Association of Intraoperative Red Blood Cell Transfusions With Venous Thromboembolism and Adverse Outcomes After Cardiac Surgery. Ann Surg Open 2023; 4:e268. [PMID: 37600870 PMCID: PMC10431503 DOI: 10.1097/as9.0000000000000268] [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: 01/20/2023] [Accepted: 01/24/2023] [Indexed: 02/22/2023] Open
Affiliation(s)
- Jacob Raphael
- From the Department of Anesthesiology, Thomas Jefferson University Hospitals, Philadelphia, PA
| | - Xiaoke Feng
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew S. Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Michael A. Mazzeffi
- Department of Anesthesiology and Critical Care Medicine, George Washington University School of Medicine and Health Sciences, Washington DC
| | | | - Ashish S. Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Miklos D. Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
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22
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Shah AS. Canaries, Coal Mines, and Kidneys. Ann Thorac Surg 2023; 115:509-510. [PMID: 36030834 DOI: 10.1016/j.athoracsur.2022.08.022] [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: 08/14/2022] [Accepted: 08/15/2022] [Indexed: 02/07/2023]
Affiliation(s)
- Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Vanderbilt Medical Center East, 1215 21st Ave S, Ste 5025, Nashville, TN 37232.
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Shah AS, Pitt M, Norton L. ESCAPE the Boring Lecture: Tips and Tricks on Building Puzzles for Medical Education Escape Rooms. J Med Educ Curric Dev 2023; 10:23821205231211200. [PMID: 38025020 PMCID: PMC10664428 DOI: 10.1177/23821205231211200] [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] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 10/13/2023] [Indexed: 12/01/2023]
Abstract
Escape rooms in medical education are a novel, game-based learning approach for teaching medical topics. In these escape rooms, learners complete a sequential series of medical-themed puzzles leading them to "escape" a specific story. Designing puzzles can be anxiety-provoking and may be the gatekeeper for educators in medicine to create their own escape rooms. Though there have been publications on the importance and methods of building a healthcare-themed-escape room, there is a gap in the literature on designing puzzles to teach specific learning objectives successfully. In this Scholarly Perspective, the authors share puzzle ideas and support tools and use Bloom's taxonomy as the framework to teach educators how to design challenging and engaging escape room puzzles.
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Affiliation(s)
- Ashish S Shah
- Department of Pediatrics and Rady Children's Hospital, University of California, San Diego, CA, USA
| | - Michael Pitt
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Laura Norton
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
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24
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DeBose-Scarlett A, Hardin M, Bacchetta M, Shah AS. Unique Extracorporeal Membrane Oxygenator Configuration for Isolated Right Ventricular Failure. JTCVS Tech 2023; 18:81-83. [PMID: 37096094 PMCID: PMC10122157 DOI: 10.1016/j.xjtc.2023.01.015] [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: 01/20/2022] [Revised: 12/15/2022] [Accepted: 01/05/2023] [Indexed: 01/29/2023] Open
Affiliation(s)
| | | | | | - Ashish S. Shah
- Address for reprints: Ashish S. Shah, MD, 1215 21st Ave S, Nashville, TN 37232.
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Patel Y, Stokes JW, Gannon WD, Zorn JT, Hoffman J, Shah AS, Bacchetta M. Bridge to Transplant: Central Extracorporeal Membrane Oxygenation With Pulmonary Artery Drainage. Ann Thorac Surg 2022; 114:e427-e429. [PMID: 35257674 DOI: 10.1016/j.athoracsur.2022.02.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 02/10/2022] [Accepted: 02/20/2022] [Indexed: 12/31/2022]
Abstract
Providing optimal support in patients with concomitant cardiac and pulmonary failure presents multiple challenges. We report a novel approach to central extracorporeal membrane oxygenation support using a minimal access approach to successfully bridge a patient to heart-lung transplant.
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Affiliation(s)
- Yatrik Patel
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John W Stokes
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Whitney D Gannon
- Department of Pulmonary, Allergy, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - James T Zorn
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jordan Hoffman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Bacchetta
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Biomedical Engineering, Vanderbilt University Medical Center, Nashville, Tennessee.
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Freundlich RE, Wanderer JP, French B, Moore RP, Hernandez A, Shah AS, Byrne DW, Pandharipande PP. Protocol for a randomised controlled trial: reducing reintubation among high-risk cardiac surgery patients with high-flow nasal cannula (I-CAN). BMJ Open 2022; 12:e066007. [PMID: 36428016 PMCID: PMC9703331 DOI: 10.1136/bmjopen-2022-066007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
INTRODUCTION Heated, humidified, high-flow nasal cannula oxygen therapy has been used as a therapy for hypoxic respiratory failure in numerous clinical settings. To date, limited data exist to guide appropriate use following cardiac surgery, particularly among patients at risk for experiencing reintubation. We hypothesised that postextubation treatment with high-flow nasal cannula would decrease the all-cause reintubation rate within the 48 hours following initial extubation, compared with usual care. METHODS AND ANALYSIS Adult patients undergoing cardiac surgery (open surgery on the heart or thoracic aorta) will be automatically enrolled, randomised and allocated to one of two treatment arms in a pragmatic randomised controlled trial at the time of initial extubation. The two treatment arms are administration of heated, humidified, high-flow nasal cannula oxygen postextubation and usual care (treatment at the discretion of the treating provider). The primary outcome will be all-cause reintubation within 48 hours of initial extubation. Secondary outcomes include all-cause 30-day mortality, hospital length of stay, intensive care unit length of stay and ventilator-free days. Interaction analyses will be conducted to assess the differential impact of the intervention within strata of predicted risk of reintubation, calculated according to our previously published and validated prognostic model. ETHICS AND DISSEMINATION Vanderbilt University Medical Center IRB approval, 15 March 2021 with waiver of written informed consent. Plan for publication of study protocol prior to study completion, as well as publication of results. TRIAL REGISTRATION NUMBER clinicaltrials.gov, NCT04782817 submitted 25 February 2021. DATE OF PROTOCOL 29 August 2022. Version 2.0.
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Affiliation(s)
- Robert E Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
- Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Benjamin French
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ryan P Moore
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Antonio Hernandez
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Daniel W Byrne
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Pratik P Pandharipande
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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27
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Rali AS, Taduru SS, Tran LE, Ranka S, Schlendorf KH, Barker CM, Shah AS, Lindenfeld J, Zalawadiya SK. Transcatheter Aortic Valve Replacement and Surgical Aortic Valve Replacement Outcomes in Left Ventricular Assist Device Patients with Aortic Insufficiency. Card Fail Rev 2022; 8:e30. [PMID: 36644645 PMCID: PMC9819997 DOI: 10.15420/cfr.2022.21] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 05/20/2022] [Accepted: 07/15/2022] [Indexed: 01/17/2023] Open
Abstract
Background: Worsening aortic insufficiency (AI) is a known sequela of prolonged continuous-flow left ventricular assist device (LVAD) support with a significant impact on patient outcomes. While medical treatment may relieve symptoms, it is unlikely to halt progression. Surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR) are among non-medical interventions available to address post-LVAD AI. Limited data are available on outcomes with either SAVR or TAVR for the management of post-LVAD AI. Methods: The National Inpatient Sample data collected for hospital admissions between the years 2015 and 2018 for patients with pre-existing continuous-flow LVAD undergoing TAVR or SAVR for AI were queried. The primary outcome of interest was a composite of in-hospital mortality, stroke, transient ischaemic attack, MI, pacemaker implantation, need for open aortic valve surgery, vascular complications and cardiac tamponade. Results: Patients undergoing TAVR were more likely to receive their procedure during an elective admission (57.1 versus 30%, p=0.002), and a significantly higher prevalence of comorbidities, as assessed by the Elixhauser Comorbidity Index, was observed in the SAVR group (29 versus 18; p=0.0001). We observed a significantly higher prevalence of the primary composite outcome in patients undergoing SAVR (30%) compared with TAVR (14.3%; p=0.001). Upon multivariable analysis adjusting for the type of admission and Elixhauser Comorbidity Index, TAVR was associated with significantly lower odds of the composite outcome (odds ratio 0.243; 95% CI [0.06-0.97]; p=0.045). Conclusion: In this nationally representative cohort of LVAD patients with post-implant AI, it was observed that TAVR was associated with a lower risk of adverse short-term outcomes compared with SAVR.
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Diseases, Vanderbilt University Medical CenterNashville, Tennessee, US
| | - Siva S Taduru
- Department of Cardiovascular Diseases, University of Kansas Medical CenterKansas City, Kansas, US
| | - Lena E Tran
- Department of Internal Medicine, Vanderbilt University Medical CenterNashville, Tennessee, US
| | - Sagar Ranka
- Department of Cardiovascular Diseases, University of Kansas Medical CenterKansas City, Kansas, US
| | - Kelly H Schlendorf
- Division of Cardiovascular Diseases, Vanderbilt University Medical CenterNashville, Tennessee, US
| | - Colin M Barker
- Division of Cardiovascular Diseases, Vanderbilt University Medical CenterNashville, Tennessee, US
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical CenterNashville, Tennessee, US
| | - JoAnn Lindenfeld
- Division of Cardiovascular Diseases, Vanderbilt University Medical CenterNashville, Tennessee, US
| | - Sandip K Zalawadiya
- Division of Cardiovascular Diseases, Vanderbilt University Medical CenterNashville, Tennessee, US
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Brijith KVR, Aishwarya JG, Shah AS, Nair S. Modified CT Scan Scoring System for Evaluating Symptom Severity of Chronic Rhinosinusitis. Indian J Otolaryngol Head Neck Surg 2022; 74:1178-1182. [PMID: 36452666 PMCID: PMC9702113 DOI: 10.1007/s12070-020-02259-0] [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: 10/23/2020] [Accepted: 10/31/2020] [Indexed: 11/29/2022] Open
Abstract
There are various subjective as well as objective tools to evaluate the severity of chronic rhinosinusitis (CRS). SNOT-22 is the most commonly used subjective scoring system to determine the severity of CRS. Lund-Mackay (LM) CT scan scoring is widely used as an objective tool in CRS. However LM scores does not correlate well with the subjective tools. We evaluated the modified CT scan scoring system (SN score) for its efficacy in determining the severity of CRS in both subjective as well as objective manner. To correlate the severity of symptoms and CT scan findings in adult patients with chronic rhinosinusitis by estimating the strength of correlation of severity of symptoms of CRS assessed by SNOT-22 scorings with CT scan findings by Lund Mackay scoring system and SN CT scan scoring system. A prospective, observational study was conducted in the tertiary care center from June 2019 to August 2020. The study included 150 adult patients diagnosed with Chronic Rhino Sinusitis resistant to primary medical therapy, who were subjected to CT scan imaging. The symptom severity of CRS was assessed by the SNOT 22 scores. CT scan was done and Lund Mackay scores and SN CT scan scores by the senior author were calculated. The correlation of SNOT 22 score with LM score and Modified CT score were assessed. The correlation of LM score with SNOT 22 score was assessed by plotting Scattered plot diagram, which showed a moderate positive, statistically significant correlation (Person correlation co-efficient: 0.466; p value: 0.032). The correlation of SN CT score with SNOT 22 was assessed by Chi Square test which showed a highly significant, positive correlation (p value of 0.000793). Our study shows a positive correlation of symptoms assessed by SNOT 22 system with radiological findings analyzed by both LM system as well as SN CT scan scoring system. However, SN CT scan scoring system showed a highly significant positive correlation over LM system as it correlates well with symptoms and also provides a grading of disease severity. SN CT scan scoring system can be considered as a tool for assessing the disease severity both in subjective and objective manner. It can be used in place of subjective tools like SNOT 22 for assessing the severity of symptoms in CRS where subjective analysis of the disease is difficult.
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Affiliation(s)
- K. V. R. Brijith
- Department of ENT-HNS, Apollo Hospitals, Opp. IIM, Bannerghatta Road, Bangalore, Karnataka 560076 India
| | - J. G. Aishwarya
- Department of ENT-HNS, Apollo Hospitals, Opp. IIM, Bannerghatta Road, Bangalore, Karnataka 560076 India
| | - Ashish S. Shah
- Department of ENT-HNS, Apollo Hospitals, Opp. IIM, Bannerghatta Road, Bangalore, Karnataka 560076 India
| | - Satish Nair
- Department of ENT-HNS, Apollo Hospitals, Opp. IIM, Bannerghatta Road, Bangalore, Karnataka 560076 India
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29
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Shah AS. Grading Imperfection. Ann Thorac Surg 2022; 114:456-457. [PMID: 34780763 DOI: 10.1016/j.athoracsur.2021.09.071] [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: 09/26/2021] [Accepted: 09/28/2021] [Indexed: 11/24/2022]
Affiliation(s)
- Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Vanderbilt Medical Center East, 1215 21st Ave S, Ste 5025, Nashville, TN 37232.
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30
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Rali AS, Ranka S, Butcher A, Shah Z, Tonna JE, Anders MM, Brinkley MD, Siddiqi H, Punnoose L, Wigger M, Sacks SB, Pedrotty D, Ooi H, Bacchetta MD, Hoffman J, McMaster W, Balsara K, Shah AS, Menachem JN, Schlendorf KH, Lindenfeld J, Zalawadiya SK. Early Blood Pressure Variables Associated With Improved Outcomes in VA-ECLS: The ELSO Registry Analysis. JACC Heart Fail 2022; 10:397-403. [PMID: 35654524 PMCID: PMC9214574 DOI: 10.1016/j.jchf.2022.04.003] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 03/14/2022] [Accepted: 04/01/2022] [Indexed: 06/03/2023]
Abstract
BACKGROUND As utilization of veno-arterial extracorporeal life support (VA-ECLS) in treatment of cardiogenic shock (CS) continues to expand, clinical variables that guide clinicians in early recognition of myocardial recovery and therefore, improved survival, after VA-ECLS are critical. There remains a paucity of literature on early postinitiation blood pressure measurements that predict improved outcomes. OBJECTIVES The objective of this study is to help identify early blood pressure variables associated with improved outcomes in VA-ECLS. METHODS The authors queried the ELSO (Extracorporeal Life Support Organization) registry for cardiogenic shock patients treated with VA-ECLS or venovenous arterial ECLS between 2009 and 2020. Their inclusion criteria included treatment with VA-ECLS or venovenous arterial ECLS; absence of pre-existing durable right, left, or biventricular assist devices; no pre-ECLS cardiac arrest; and no surgical or percutaneously placed left ventricular venting devices during their ECLS runs. Their primary outcome of interest was the survival to discharge during index hospitalization. RESULTS A total of 2,400 CS patients met the authors' inclusion criteria and had complete documentation of blood pressures. Actual mortality during index hospitalization in their cohort was 49.5% and survivors were younger and more likely to be Caucasian, intubated for >30 hours pre-ECLS initiation, and had a favorable baseline SAVE (Survival After Veno-arterial ECMO) score (P < 0.05 for all). Multivariable regression analyses adjusting for SAVE score, age, ECLS flow at 4 hours, and race showed that every 10-mm Hg increase in baseline systolic blood pressure (HR: 0.92 [95% CI: 0.89-0.95]; P < 0.001), and baseline pulse pressure (HR: 0.88 [95% CI: 0.84-0.91]; P < 0.001) at 24 hours was associated with a statistically significant reduction in mortality. CONCLUSIONS Early (within 24 hours) improvements in pulse pressure and systolic blood pressure from baseline are associated with improved survival to discharge among CS patients treated with VA-ECLS.
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | - Sagar Ranka
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Amy Butcher
- Department of Cardiovascular Anesthesia and Critical Care, Baylor College of Medicine, Houston, Texas, USA
| | - Zubair Shah
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Joseph E Tonna
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah Health, Salt Lake City, Utah, USA
| | - Marc M Anders
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Marshal D Brinkley
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Hasan Siddiqi
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lynn Punnoose
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark Wigger
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Suzanne B Sacks
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Dawn Pedrotty
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Henry Ooi
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew D Bacchetta
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jordan Hoffman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William McMaster
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keki Balsara
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan N Menachem
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly H Schlendorf
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandip K Zalawadiya
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Sellers MT, Nassar A, Alebrahim M, Sasaki K, Lee DD, Bohorquez H, Cannon RM, Selvaggi G, Neidlinger N, McMaster WG, Hoffman JRH, Shah AS, Montenovo MI. Early United States experience with liver donation after circulatory determination of death using thoraco-abdominal normothermic regional perfusion: A multi-institutional observational study. Clin Transplant 2022; 36:e14659. [PMID: 35362152 DOI: 10.1111/ctr.14659] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [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: 01/04/2022] [Revised: 03/07/2022] [Accepted: 03/25/2022] [Indexed: 11/28/2022]
Abstract
Mortality on the liver waitlist remains unacceptably high. Donation after circulatory determination of death (DCD) donors are considered marginal but are a potentially underutilized resource. Thoraco-abdominal normothermic perfusion (TA-NRP) in DCD donors might result in higher quality livers and offset waitlist mortality. We retrospectively reviewed outcomes of the first 13 livers transplanted from TA-NRP donors in the US. Nine centers transplanted livers from 8 organ procurement organizations. Median donor age was 25 years; median agonal phase was 13 minutes. Median recipient age was 60 years; median lab MELD score was 21. Three patients (23%) met early allograft dysfunction (EAD) criteria. Three received simultaneous liver-kidney transplants; neither had EAD nor delayed renal allograft function. One recipient died 186 days post-transplant from sepsis but had normal pre-sepsis liver function. One patient developed a biliary anastomotic stricture, managed endoscopically; no recipient developed clinical evidence of ischemic cholangiopathy (IC). Twelve of 13 (92%) patients are alive with good liver function at 439 days median follow-up; 1 patient has extrahepatic recurrent HCC. TA-NRP DCD livers in these recipients all functioned well, particularly with respect to IC, and provide a valuable option to decrease deaths on the waiting list. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Marty T Sellers
- Department of Surgery, Emory University, Atlanta, Georgia.,Tennessee Donor Services, Nashville, Tennessee
| | - Ahmed Nassar
- Department of Surgery, Emory University, Atlanta, Georgia
| | - Musab Alebrahim
- Department of Surgery, The Ohio State University, Columbus, Ohio
| | - Kazunari Sasaki
- Department of General Surgery, Cleveland Clinic, Cleveland, Ohio.,Department of Surgery, Stanford University
| | - David D Lee
- Department of Surgery, Loyola University, Chicago, Illinois
| | - Humberto Bohorquez
- Department of Surgery, Ochsner School of Medicine, New Orleans, Louisiana
| | - Robert M Cannon
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - William G McMaster
- Department of Cardiac Surgery, Vanderbilt University, Nashville, Tennessee
| | - Jordan R H Hoffman
- Department of Cardiac Surgery, Vanderbilt University, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University, Nashville, Tennessee
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Shah AS, McMaster WG. Sympathectomy is back. Again. Ann Thorac Surg 2022; 114:e321. [PMID: 35339448 DOI: 10.1016/j.athoracsur.2022.02.075] [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: 02/12/2022] [Accepted: 02/19/2022] [Indexed: 11/01/2022]
Affiliation(s)
- Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Vanderbilt Medical Center, East 1215 21st Avenue South, Suite 5025, Nashville, TN, 37232.
| | - William G McMaster
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Vanderbilt Medical Center, East 1215 21st Avenue South, Suite 5025, Nashville, TN, 37232
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Gray JM, Schnadower D, LaFollette R, Shah AS, Sobolewski B. Going viral: A scoping review of the current state and impact of online research dissemination in emergency medicine. AEM Educ Train 2022; 6:e10725. [PMID: 35224409 PMCID: PMC8855629 DOI: 10.1002/aet2.10725] [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] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 12/29/2021] [Accepted: 01/04/2022] [Indexed: 05/30/2023]
Abstract
BACKGROUND The use of free open-access medical education (FOAM) and other online knowledge dissemination methods has increased over the past decade. However, the role and impact of these tools in the knowledge translation continuum are poorly understood, potentially limiting the ability of knowledge generators to fully harness and exploit their potential. Here, we aim to comprehensively map and synthesize the literature describing the use of online tools for the dissemination of emergency medicine research. METHODS Using scoping review methodology, we searched the traditional literature via PubMed, CINAHL, EMBASE, ERIC, SCOPUS, and the gray literature for publications exploring online methods to disseminate new research findings. We synthesized the results and constructed a conceptual model of current research dissemination methods. RESULTS We included 79 out of 655 unique abstracts and articles identified in our search, 62 of which were from the traditional literature. We describe six primary domains: integration with traditional literature, measurement of dissemination, online organizations and communities of practice, professional development, quality assurance tools and techniques, and advantages and disadvantages of FOAM. For each domain we present an exemplar article and prevailing gaps in knowledge. Finally, we propose a current conceptual framework for dissemination of new research findings that describes both traditional and novel methods of dissemination. CONCLUSIONS This comprehensive review of the literature and current dissemination framework will empower researchers, research networks, and granting organizations to maximize their use of FOAM and other online methods to disseminate new knowledge as well as provide clinicians a better understanding of the tools and methods by which to access and implement new research findings.
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Affiliation(s)
- James M. Gray
- Division of Emergency MedicineCincinnati Children’s Hospital Medical CenterCincinnatiOhioUSA
| | - David Schnadower
- Division of Emergency MedicineCincinnati Children’s Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Ryan LaFollette
- Department of Emergency MedicineUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
| | - Ashish S. Shah
- Division of Emergency MedicineRady Children’s HospitalSan DiegoCaliforniaUSA
- Department of PediatricsUniversity of California–San DiegoSan DiegoCaliforniaUSA
| | - Brad Sobolewski
- Division of Emergency MedicineCincinnati Children’s Hospital Medical CenterCincinnatiOhioUSA
- Department of PediatricsUniversity of Cincinnati College of MedicineCincinnatiOhioUSA
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Shah AS. Commentary: What will be the denouement for mobile ECLS? JTCVS Tech 2022; 12:93. [PMID: 35403064 PMCID: PMC8987604 DOI: 10.1016/j.xjtc.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 01/31/2022] [Accepted: 02/15/2022] [Indexed: 12/02/2022] Open
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35
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Alexopoulos SP, Wu WK, Ziogas IA, Matsuoka LK, Rauf MA, Izzy M, Perri R, Schlendorf KH, Menachem JN, Shah AS. Adult Combined Heart-Liver Transplantation: The United States Experience. Transpl Int 2022; 35:10036. [PMID: 35185360 PMCID: PMC8842230 DOI: 10.3389/ti.2021.10036] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/12/2021] [Indexed: 12/11/2022]
Abstract
Background: We aimed to review the indications and outcomes of adults undergoing combined heart-liver transplantation (CHLT) in the US using national registry data. Methods: Adult (≥18 years) CHLT recipients in the United Network for Organ Sharing database were included (09/1987–09/2020; era 1 = 1989–2000, era 2 = 2001–2010, era 3 = 2011–2020). Survival analysis was conducted by means of Kaplan-Meier method, log-rank test, and Cox regression. Results: We identified 369 adults receiving CHLT between 12/1989–08/2020. The number of adult CHLT recipients (R2 = 0.75, p < 0.001) and centers performing CHLT (R2 = 0.80, p < 0.001) have increased over the study period. The most common cardiac diagnosis in the first two eras was restrictive/infiltrative cardiomyopathy, while the most common in era 3 was congenital heart disease (p = 0.03). The 1-, 3-, and 5-years patient survival was 86.8, 80.1, and 77.9%, respectively. In multivariable analysis, recipient diabetes [adjusted hazard ratio (aHR) = 2.35, 95% CI: 1.23–4.48], CHLT between 1989-2000 compared with 2011–2020 (aHR = 5.00, 95% CI: 1.13–22.26), and sequential-liver first CHLT compared with sequential-heart first CHLT (aHR = 2.44, 95% CI: 1.15–5.18) were associated with increased risk of mortality. Higher left ventricular ejection fraction was associated with decreased risk of mortality (aHR = 0.96, 95% CI: 0.92–0.99). Conclusion: CHLT is being increasingly performed with evolving indications. Excellent outcomes can be achieved with multidisciplinary patient and donor selection and surgical planning.
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Affiliation(s)
- Sophoclis P. Alexopoulos
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
- *Correspondence: Sophoclis P. Alexopoulos,
| | - W. Kelly Wu
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ioannis A. Ziogas
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Lea K. Matsuoka
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Muhammad A. Rauf
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Manhal Izzy
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Roman Perri
- Division of Gastroenterology, Hepatology and Nutrition, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Kelly H. Schlendorf
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jonathan N. Menachem
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Ashish S. Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, United States
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Rali AS, Hall EJ, Dieter R, Ranka S, Civitello A, Bacchetta MD, Shah AS, Schlendorf K, Lindenfeld J, Chatterjee S. Left Ventricular Unloading during Extracorporeal Life Support: Current Practice. J Card Fail 2021; 28:1326-1336. [PMID: 34936896 DOI: 10.1016/j.cardfail.2021.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/24/2021] [Accepted: 12/06/2021] [Indexed: 11/29/2022]
Abstract
Veno-arterial extracorporeal life support (VA-ECLS) is a powerful tool that can provide complete cardiopulmonary support for patients with refractory cardiogenic shock. However, VA-ECLS increases left ventricular afterload resulting in greater myocardial oxygen demand, which can impair myocardial recovery and worsen pulmonary edema. These complications can be ameliorated by various LV venting strategies to unload the LV. Evidence suggests that LV venting improves outcomes in VA-ECLS, but there is a paucity of randomized trials to help guide optimal strategy and the timing of venting. In this review, we discuss the available evidence regarding LV venting in VA-ECLS, explain important hemodynamic principles involved, and propose a practical approach to LV venting in VA-ECLS.
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Key Words
- Atrial septal defect, BNP
- Brain natriuretic peptide, CS
- Cardiogenic shock, IABP
- Extracorporeal life support, left ventricular unloading, left ventricular venting, cardiogenic shock, Abbreviations, ASD
- Intra-aortic balloon pump, LA
- Left atrium, LV
- Left ventricle, LVAD
- Left ventricular assist device, MCS
- Mechanical circulatory support, PAC
- Percutaneous ventricular assist device, RV
- Pulmonary artery catheter, PCWP
- Pulmonary capillary wedge pressure, P-VAD
- Right ventricle, VA-ECLS
- Veno-arterial extracorporeal life support
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Affiliation(s)
- Aniket S Rali
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - Eric J Hall
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Raymond Dieter
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sagar Ranka
- Department of Cardiovascular Diseases, University of Kansas Medical Center, Kansas City, Kansas
| | - Andrew Civitello
- Division of Cardiology, Department of Medicine, Baylor College of Medicine, Houston, Texas; Department of Cardiology, Texas Heart Institute, Houston, Texas
| | - Matthew D Bacchetta
- Division of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Division of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly Schlendorf
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - JoAnn Lindenfeld
- Division of Cardiovascular Diseases, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Subhasis Chatterjee
- Divisions of General and Cardiothoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College Medicine, Houston, Texas; Department of Cardiovascular Surgery, Texas Heart Institute, Houston, Texas
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Shah AS. Normothermic regional perfusion in donor heart recovery: Establishing a new normal. J Thorac Cardiovasc Surg 2021; 164:142-146. [PMID: 34952705 DOI: 10.1016/j.jtcvs.2021.11.084] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 11/03/2021] [Accepted: 11/29/2021] [Indexed: 11/17/2022]
Affiliation(s)
- Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Vanderbilt Medical Center East, Nashville, Tenn.
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Shah AS. Commentary: Primary graft dysfunction is leaving us curiouser and curiouser. JTCVS Open 2021; 8:134. [PMID: 36004123 PMCID: PMC9390429 DOI: 10.1016/j.xjon.2021.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 05/18/2021] [Accepted: 05/21/2021] [Indexed: 11/28/2022]
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Shah AS. Commentary: Obesity in the time of coronavirus disease 2019 (COVID-19). JTCVS Tech 2021; 10:350-351. [PMID: 34604816 PMCID: PMC8479538 DOI: 10.1016/j.xjtc.2021.09.022] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Revised: 09/06/2021] [Accepted: 09/10/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Vanderbilt Medical Center East, Nashville, Tenn
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Stokes JW, Gannon WD, Tipograf Y, Ukita R, Warhoover M, Rice TW, Shah AS, Bacchetta M. Disposable Component Selection in Extracorporeal Life Support: A Cost Analysis. ASAIO J 2021; 67:995-999. [PMID: 33315654 DOI: 10.1097/mat.0000000000001346] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Extracorporeal life support (ECLS) is a resource-intensive technology. Disposable components are modifiable through device selection. Cost analysis tools are needed to inform cost-conscious device selection. We generated a disposable cost analysis to forecast estimated costs of device disposables that included an assumption table, net present value (NPV) analysis, and sensitivity analysis to examine device disposable costs over 5 years with different case volumes and device mixes. To demonstrate the function of the analysis, we included four device options using the following assumptions: 100 cases in year 1, 2.5% case growth rate, 10% discount rate, and $5,000 incremental cost (Device 4 only). Using estimated device costs of $3,000, $12,000, $13,000, and $20,000 and device mix percentages of 65%, 8%, 25%, and 2% for Device 1, 2, 3, and 4, respectively, the 5 year unadjusted and NPV of disposable device costs were $3,691,000 and $2,765,000, respectively. The sensitivity analysis incorporated six separate models with different device mix percentages. The highest and lowest estimated costs were found in Model F (75% Device 3 and 25% Device 4; NPV = $6,64,400) and Model B (100% Device 1; NPV = 1,246,000) respectively. Extracorporeal life support programs may apply this disposable cost analysis tool to reduce programmatic costs.
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Affiliation(s)
- John W Stokes
- From the Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Whitney D Gannon
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yuliya Tipograf
- Department of Surgery, Columbia University Medical Center, New York, New York
| | - Rei Ukita
- From the Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Warhoover
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd W Rice
- Department of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew Bacchetta
- From the Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Biomedical Engineering, Vanderbilt University Medical Center, Nashville, Tennessee
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Hoffman JRH, McMaster WG, Rali AS, Rahaman Z, Balsara K, Absi T, Levack M, Brinkley M, Menachem J, Punnoose L, Sacks S, Wigger M, Zalawadiya S, Stevenson L, Schlendorf K, Lindenfeld J, Shah AS. Early US experience with cardiac donation after circulatory death (DCD) using normothermic regional perfusion. J Heart Lung Transplant 2021; 40:1408-1418. [PMID: 34334301 DOI: 10.1016/j.healun.2021.06.022] [Citation(s) in RCA: 93] [Impact Index Per Article: 31.0] [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: 02/01/2021] [Revised: 06/21/2021] [Accepted: 06/29/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Given the shortage of suitable donor hearts for cardiac transplantation and the growing interest in donation after circulatory death (DCD), our institution recently began procuring cardiac allografts from DCD donors. METHODS Between October 2020 and March 2021, 15 patients with heart failure underwent cardiac transplantation using DCD allografts. Allografts were procured using a modified extracorporeal membrane oxygenation circuit for thoracic normothermic regional perfusion (TA-NRP) and were subsequently transported using cold static storage. Data collection and analysis were performed with institutional review board approval. RESULTS The mean age of the DCD donors was 23 ± 7 years and average time on TA-NRP was 56 ± 8 minutes. Total ischemic time was 183 ± 31 minutes and distance from transplant center was 373 ± 203 nautical miles. Recipient age was 55 ± 14 years, with 8 (55.3%) recipients on durable left ventricular assist device support. Post-transplant, 6 (40%) recipients experienced mild left ventricle primary graft dysfunction (PGD-LV), 3 (20%) recipients experienced moderate PGD-LV, and no recipients experienced severe PGD-LV. Postoperative transthoracic echocardiogram demonstrated left ventricular ejection fraction >55% in all recipients. One recipient (6.6%) developed International Society for Heart and Lung Transplantation 2R acute cellular rejection on first biopsy. At last follow-up, all 15 recipients were alive past 30-days. CONCLUSIONS Cardiac DCD provides an opportunity to increase the availability of donor hearts for transplantation. Utilizing TA-NRP with cold static storage, we have extended the cold ischemic time of DCD allografts to almost 3 hours, allowing for inter-hospital organ transport.
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Affiliation(s)
- Jordan R H Hoffman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
| | - William G McMaster
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Aniket S Rali
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Zakiur Rahaman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Keki Balsara
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tarek Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melissa Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Marshall Brinkley
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Menachem
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lynn Punnoose
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Suzanne Sacks
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mark Wigger
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandip Zalawadiya
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lynne Stevenson
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kelly Schlendorf
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - JoAnn Lindenfeld
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
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Hoffman JRH, Larson EE, Rahaman Z, Absi T, Levack M, Balsara KR, McMaster W, Brinkley M, Menachem JN, Punnoose LR, Sacks SB, Wigger MA, Zalawadiya SK, Stevenson LW, Schlendorf KH, Lindenfeld J, Shah AS. Impact of increased donor distances following adult heart allocation system changes: A single center review of 1-year outcomes. J Card Surg 2021; 36:3619-3628. [PMID: 34235763 DOI: 10.1111/jocs.15795] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 05/26/2021] [Revised: 06/07/2021] [Accepted: 06/10/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND On October 18, 2018, several changes to the donor heart allocation system were enacted. We hypothesize that patients undergoing orthotopic heart transplantation (OHT) under the new allocation system will see an increase in ischemic times, rates of primary graft dysfunction, and 1-year mortality due to these changes. METHODS In this single-center retrospective study, we reviewed the charts of all OHT patients from October 2017 through October 2019. Pre- and postallocation recipient demographics were compared. Survival analysis was performed using the Kaplan-Meier method. RESULTS A total of 184 patients underwent OHT. Recipient demographics were similar between cohorts. The average distance from donor increased by more than 150 km (p = .006). Patients in the postallocation change cohort demonstrated a significant increase in the rate of severe left ventricle primary graft dysfunction from 5.4% to 18.7% (p = .005). There were no statistically significant differences in 30-day mortality or 1-year survival. Time on the waitlist was reduced from 203.8 to 103.7 days (p = .006). CONCLUSIONS Changes in heart allocation resulted in shorter waitlist times at the expense of longer donor distances and ischemic times, with an associated negative impact on early post-transplantation outcomes. No significant differences in 30-day or 1-year mortality were observed.
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Affiliation(s)
- Jordan R H Hoffman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emilee E Larson
- Section of Surgical Science, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Zakiur Rahaman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tarek Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Melissa Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Keki R Balsara
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William McMaster
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Marshall Brinkley
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan N Menachem
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lynn R Punnoose
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Suzanne B Sacks
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark A Wigger
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandip K Zalawadiya
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lynne W Stevenson
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly H Schlendorf
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - JoAnn Lindenfeld
- Department of Medicine, Division of Cardiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Siegrist KK, Woolard AA, Hillenbrand KD, Shah AS, Eagle SS. An Unusual Finding in a Patient Presenting for Pulmonary Thromboendarterectomy: Pulmonary Venous Thrombosis. J Cardiothorac Vasc Anesth 2021; 36:2046-2050. [PMID: 34272116 DOI: 10.1053/j.jvca.2021.06.019] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 06/10/2021] [Accepted: 06/15/2021] [Indexed: 11/11/2022]
Abstract
Pulmonary venous thrombosis (PVT) is a rare but potentially devastating disease state with a largely unknown incidence. The most common etiologies of PVT are secondary to complications of lung surgery, malignancy, catheter ablation for atrial fibrillation, and idiopathic causes. Diagnosis can be challenging because presenting symptoms often are vague and nonspecific, or even asymptomatic, and traditional diagnostic modalities, such as chest radiography and arterial phase computed tomography scans, are poor techniques for diagnosis. The authors present a case of a patient presenting for pulmonary thromboendarterectomy for a presumed diagnosis of chronic thromboembolic pulmonary hypertension who was found incidentally to have a PVT, on intraoperative transesophageal echocardiography. Due to significant thrombus burden, the new finding of PVT, and known association of PVT and malignancy, a biopsy of mediastinal lymph nodes was obtained, which revealed metastatic cervical carcinoma. The pulmonary endarterectomy procedure was aborted.
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Affiliation(s)
- Kara K Siegrist
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN.
| | - Austin A Woolard
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Karl D Hillenbrand
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Susan S Eagle
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
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Balsara KR, Rahaman Z, Sandhaus E, Hoffman J, Zalawadiya S, McMaster W, Lindenfeld J, Wigger M, Absi T, Brinkley DM, Menachem J, Punnoose L, Sacks S, Schlendorf K, Shah AS. Prioritizing heart transplantation during the COVID-19 pandemic. J Card Surg 2021; 36:3217-3221. [PMID: 34137079 PMCID: PMC8447084 DOI: 10.1111/jocs.15731] [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] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/20/2021] [Accepted: 05/17/2021] [Indexed: 12/13/2022]
Abstract
Background Coronavirus disease 2019 (COVID‐19) has significantly impacted the healthcare landscape in the United States in a variety of ways including a nation‐wide reduction in operative volume. The impact of COVID‐19 on the availability of donor organs and the impact on solid organ transplant remains unclear. We examine the impact of COVID‐19 on a single, large‐volume heart transplant program. Methods A retrospective chart review was performed examining all adult heart transplants performed at a single institution between March 2020 and June 2020. This was compared to the same time frame in 2019. We examined incidence of primary graft dysfunction, continuous renal replacement therapy (CRRT) and 30‐day survival. Results From March to June 2020, 43 orthotopic heart transplants were performed compared to 31 performed during 2019. Donor and recipient demographics demonstrated no differences. There was no difference in 30‐day survival. There was a statistically significant difference in incidence of postoperative CRRT (9/31 vs. 3/43; p = .01). There was a statistically significant difference in race (23 W/8B/1AA vs. 30 W/13B; p = .029). Conclusion We demonstrate that a single, large‐volume transplant program was able to grow volume with little difference in donor variables and clinical outcomes following transplant. While multiple reasons are possible, most likely the reduction of volume at other programs allowed us to utilize organs to which we would not have previously had access. More significantly, our growth in volume was coupled with no instances of COVID‐19 infection or transmission amongst patients or staff due to an aggressive testing and surveillance program.
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Affiliation(s)
- Keki R Balsara
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Zakiur Rahaman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Emily Sandhaus
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jordan Hoffman
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Sandip Zalawadiya
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William McMaster
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joann Lindenfeld
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Mark Wigger
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Tarek Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Douglas M Brinkley
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Jonathan Menachem
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Lynn Punnoose
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Suzie Sacks
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Kelly Schlendorf
- Division of Cardiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Lorusso R, Whitman G, Milojevic M, Raffa G, McMullan DM, Boeken U, Haft J, Bermudez CA, Shah AS, D'Alessandro DA. 2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-cardiotomy Extracorporeal Life Support in Adult Patients. ASAIO J 2021; 67:e1-e43. [PMID: 33021558 DOI: 10.1097/mat.0000000000001301] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.
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Affiliation(s)
- Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart & Vascular Centre, Maastricht University Medical Centre, Cardiovascular Research Institute Maastricht, Maastricht, Netherlands
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit, Johns Hopkins Hospital, Baltimore, MD, USA
| | - Milan Milojevic
- Department of Anaesthesiology and Critical Care Medicine, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiovascular Research, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Giuseppe Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per i Trapianti e Terapie ad Alta Specializzazione), Palermo, Italy
| | - David M McMullan
- Department of Cardiac Surgery, Seattle Children Hospital, Seattle, WA, USA
| | - Udo Boeken
- Department of Cardiac Surgery, Heinrich Heine University, Dusseldorf, Germany
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Christian A Bermudez
- Department of Cardiovascular Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ashish S Shah
- Department of Cardio-Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David A D'Alessandro
- Department of Cardio-Thoracic Surgery, Massachusetts General Hospital, Boston, MA, USA
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46
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Pal N, Abernathy JH, Taylor MA, Bollen BA, Shah AS, Feng X, Shotwell MS, Kertai MD. Dexmedetomidine, Delirium, and Adverse Outcomes: Analysis of the STS Adult Cardiac Surgery Database. Ann Thorac Surg 2021; 112:1886-1892. [PMID: 33901455 DOI: 10.1016/j.athoracsur.2021.03.098] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 02/24/2021] [Accepted: 03/01/2021] [Indexed: 11/15/2022]
Abstract
BACKGROUND We tested the hypothesis that dexmedetomidine was associated with a reduced incidence of postoperative delirium (POD) and adverse outcomes in cardiac surgery patients from the Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database (ACSD) including the Adult Cardiac Anesthesiology subsection. METHODS We identified 55905 patients in the STS ACSD who underwent cardiac surgery between July 2014 and December 2018. Using propensity score weighted regression analysis, we analyzed the effect of intraoperative dexmedetomidine (intraDex) on the primary (POD) and secondary outcomes (highest pain score on day 3 and at discharge, stroke, prolonged ventilation, postoperative intubation/reintubation, additional postoperative hours ventilated, renal failure, atrial fibrillation, and 30-day mortality). In separate propensity score weighted analyses, we examined the effect of postoperative dexmedetomidine (postopDex) on the highest postoperative pain score at discharge and 30-day mortality. RESULTS The rate of intraDex use was 25.5% (n=13963), and its administration was associated with increased odds for POD (odds ratio [OR], 1.85; 95% CI, 1.60-2.13), a small higher average pain score on day 3 (difference in mean [MD], 0.08; 95% CI, 0.02 to 0.14), increased odds for postoperative intubation/reintubation (OR, 1.29; 95% CI, 1.12-1.48), and a small lower average pain score at discharge (MD, -0.31; 95% CI, -0.21 to -0.41). PostDex was associated with a small higher average pain score at discharge (MD, 0.27, 95% CI, 0.21 to 0.34), and higher odds for 30-day mortality (OR, 1.25, 95% CI, 1.07-1.46). CONCLUSIONS In this registry of cardiac surgical patients dexmedetomidine administration was associated with POD and adverse outcomes.
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Affiliation(s)
- Nirvik Pal
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, VA, USA
| | - James H Abernathy
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Mark A Taylor
- Cleveland Clinic Foundation/Anesthesiology Institute, Cleveland, OH, USA
| | | | | | - Xiaoke Feng
- Department of Biostatistics, Nashville, TN, USA
| | | | - Miklos D Kertai
- Department of Anesthesiology Vanderbilt University Medical Center, Nashville, TN, USA.
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Triana AJ, Vyas R, Shah AS, Tiwari V. Predicting Length of Stay of Coronary Artery Bypass Grafting Patients Using Machine Learning. J Surg Res 2021; 264:68-75. [PMID: 33784585 DOI: 10.1016/j.jss.2021.02.003] [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: 09/16/2020] [Revised: 01/19/2021] [Accepted: 02/17/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND There is a growing need to identify which bits of information are most valuable for healthcare providers. The aim of this study was to search for the highest impact variables in predicting postsurgery length of stay (LOS) for patients who undergo coronary artery bypass grafting (CABG). MATERIALS AND METHODS Using a single institution's Society of Thoracic Surgeons (STS) Registry data, 2121 patients with elective or urgent, isolated CABG were analyzed across 116 variables. Two machine learning techniques of random forest and artificial neural networks (ANNs) were used to search for the highest impact variables in predicting LOS, and results were compared against multiple linear regression. Out-of-sample validation of the models was performed on 105 patients. RESULTS Of the 10 highest impact variables identified in predicting LOS, four of the most impactful variables were duration intubated, last preoperative creatinine, age, and number of intraoperative packed red blood cell transfusions. The best performing model was an ANN using the ten highest impact variables (testing sample mean absolute error (MAE) = 1.685 d, R2 = 0.232), which performed consistently in the out-of-sample validation (MAE = 1.612 d, R2 = 0.150). CONCLUSION Using machine learning, this study identified several novel predictors of postsurgery LOS and reinforced certain known risk factors. Out of the entire STS database, only a few variables carry most of the predictive value for LOS in this population. With this knowledge, a simpler linear regression model has been shared and could be used elsewhere after further validation.
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Affiliation(s)
- Austin J Triana
- Vanderbilt University School of Medicine, Nashville, Tennessee.
| | - Rushikesh Vyas
- Vanderbilt University Medical Center, Department of Cardiac Surgery, Nashville, Tennessee; Vanderbilt University Medical Center, Department of Thoracic Surgery, Nashville, Tennessee
| | - Ashish S Shah
- Vanderbilt University Medical Center, Department of Cardiac Surgery, Nashville, Tennessee
| | - Vikram Tiwari
- Vanderbilt University Medical Center, Department of Anesthesiology, Nashville, Tennessee; Vanderbilt University Medical Center, Department of Biomedical Informatics, Nashville, Tennessee; Vanderbilt University Medical Center, Department of Biostatistics, Nashville, Tennessee; Vanderbilt University Medical Center Surgical Analytics, Nashville, Tennessee; Vanderbilt University Owen Graduate School of Management, Nashville, Tennessee
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Shah AS. Commentary: The waiting is the hardest part. JTCVS Tech 2021; 7:191. [PMID: 34318241 PMCID: PMC8311991 DOI: 10.1016/j.xjtc.2021.03.009] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 02/28/2021] [Accepted: 03/01/2021] [Indexed: 11/15/2022] Open
Affiliation(s)
- Ashish S. Shah
- Address for reprints: Ashish S. Shah, MD, Department of Cardiac Surgery, Vanderbilt University Medical Center, Vanderbilt Medical Center East, 1215 21st Ave, S, Suite 5025, Nashville, TN 37232.
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Diamant MJ, Fox AL, Modi VA, Joshi AA, Clark DE, Bichell DP, Cedars A, Fowler R, Frischhertz BP, Mazurek JA, Schlendorf KH, Shah AS, Zalawadiya SK, Lindenfeld J, Menachem JN. No survival benefit associated with waiting for non-lung donor heart transplants for adult recipients with congenital heart disease. Clin Transplant 2021; 35:e14266. [PMID: 33615562 DOI: 10.1111/ctr.14266] [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] [Received: 12/04/2020] [Revised: 01/30/2021] [Accepted: 02/13/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Adults with congenital heart disease (CHD) awaiting heart transplant (HT) have higher mortality and waitlist removal due to clinical deterioration than those without CHD. The selective use of non-lung donors (NLD) to recover donor pulmonary vasculature to assist in graft implantation may be a contributing factor and is supported by consensus statements despite the recent use of pericardium or graft material as an alternative in pulmonary vascular reconstruction. The impact of selecting NLD for CHD recipients on wait time and mortality has not been evaluated. METHODS/RESULTS In the United Network for Organ Sharing (UNOS) Registry, 1271 HT recipients age ≥ 18 with CHD were identified between 1987 and 2016, 68% of which had NLDs. Prior to HT, NLD recipients were significantly less likely to be listed UNOS Status 1A, require mechanical ventilation, or intra-aortic balloon pump support. There was no difference in mean waitlist time (254 vs. 278 days, p = .31), 1-year mortality (82% vs. 80%, p = .81; adjusted odds ratio 1.32, 95% confidence interval [CI] 0.96-1.83, p = .08), or overall mortality (adjusted hazard ratio 1.08, 95% CI 0.86-1.36, p = .48) between recipients from NLD and concomitant lung donors. CONCLUSIONS Adult CHD patients who are less critically ill or listed at a lower status are more likely to receive HT from NLD. There is no overall mortality benefit associated with this practice. While specific cases may necessitate waiting for NLD, programs need to re-evaluate whether this should remain a more widespread practice among CHD patients.
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Affiliation(s)
- Michael J Diamant
- Division of Cardiology, Royal Columbian Hospital, New Westminster, BC, Canada.,Division of Cardiology, University of British Columbia, Vancouver, Canada
| | - Arieh L Fox
- Mount Sinai Heart, Mount Sinai Medical Center, St Luke's Hospital, New York, NY, USA
| | - Vivek A Modi
- St. Luke's University Health Network, Bethlehem, PA, USA
| | - Aditya A Joshi
- Mount Sinai Heart, Mount Sinai St Luke's Hospital, New York, NY, USA
| | - Daniel E Clark
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - David P Bichell
- Division of Pediatric Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ari Cedars
- Division of Cardiology, The Johns Hopkins Hospital and Johns Hopkins Children Center, Baltimore, MD, USA
| | - Rachel Fowler
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | | | - Jeremy A Mazurek
- Advanced Heart Failure/Transplantation Program, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Kelly H Schlendorf
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ashish S Shah
- Division of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Sandip K Zalawadiya
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - JoAnn Lindenfeld
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan N Menachem
- Division of Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Shah AS, Wakelin SA, Moot DJ, Blond C, Laugraud A, Ridgway HJ. Trifolium repens and T. subterraneum modify their nodule microbiome in response to soil pH. J Appl Microbiol 2021; 131:1858-1869. [PMID: 33638901 DOI: 10.1111/jam.15050] [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: 11/11/2020] [Revised: 02/22/2021] [Accepted: 02/23/2021] [Indexed: 11/29/2022]
Abstract
AIMS The influence of soil edaphic factors on recruitment and composition of bacteria in the legume nodule is unknown. Typically, low (acidic) pH soils have a negative effect on the plant-rhizobia symbiosis and thereby reduce clover growth. However, the specific relationship between soil pH and the ecology of rhizobia is unknown, in either their free-living or nodule-inhabiting states. We used New Zealand pasture systems with soils of different pH, and white (WC) and subterranean (SC) clovers, to examine the relationship between soil pH and the diversity of bacteria that inhabit the nodules. METHODS AND RESULTS Amplicon sequencing (16S rRNA) assessed the bacterial community in 5299 nodules recovered from both legume species grown in 47 soils of different edaphic (including pH) properties. Fewer nodules were formed on both clovers at low soil pH. As expected, rhizobia comprised ∼ 92% of the total reads in both clovers, however 28 non-rhizobia genera were also present. Soil pH influenced the community structure of bacteria within the nodule, and this was more evident in non-Rhizobium taxa than Rhizobium. Host strongly influenced the diversity of bacteria in the nodules. The alpha diversity of nodule microbiome in SC nodules was higher than in WC nodules and SC nodules also harbored a higher relative abundance of non-Rhizobium bacteria than WC. Beta diversity of Rhizobium and non-Rhizobium bacteria was influenced more by clover species rather than edaphic factors. CONCLUSIONS The results indicate that these clover species modified their nodule biomes in response to pH-stress. SIGNIFICANCE AND IMPACT OF THE STUDY The non-Rhizobium bacteria may have some functional significance (such as improved clover persistence in low pH soils) in legume nodules.
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Affiliation(s)
- A S Shah
- Faculty of Agriculture and Life Sciences, Lincoln University, Christchurch, New Zealand.,The New Zealand Institute for Plant and Food Research Ltd, Lincoln, New Zealand
| | - S A Wakelin
- Scion Research Ltd, Christchurch, New Zealand
| | - D J Moot
- Faculty of Agriculture and Life Sciences, Lincoln University, Christchurch, New Zealand
| | - C Blond
- Faculty of Agriculture and Life Sciences, Lincoln University, Christchurch, New Zealand
| | - A Laugraud
- AgResearch Ltd, Christchurch, New Zealand
| | - H J Ridgway
- Faculty of Agriculture and Life Sciences, Lincoln University, Christchurch, New Zealand.,The New Zealand Institute for Plant and Food Research Ltd, Lincoln, New Zealand
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