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Gikandi A, Stock E, DeMatt E, Hirji S, Awtry J, Quin JA, Tolis G, Biswas K, Zenati MA. Performance of left internal thoracic artery-left anterior descending artery anastomosis by residents versus attendings and coronary artery bypass grafting outcomes. Eur J Cardiothorac Surg 2024:ezae155. [PMID: 38598201 DOI: 10.1093/ejcts/ezae155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Revised: 03/06/2024] [Accepted: 04/08/2024] [Indexed: 04/11/2024] Open
Abstract
OBJECTIVES Performance of a technically sound Left Internal Thoracic Artery to Left Anterior Descending Artery (LITA-LAD) anastomosis during coronary artery bypass grafting (CABG) is critically important. We investigated CABG outcomes according to whether a resident or attending surgeon performed the LITA-LAD anastomosis using prospectively collected data from the multicenter, randomized REGROUP (Randomized Endograft Vein Perspective) Trial. METHODS This was a posthoc subanalysis of the REGROUP trial, which randomized veterans undergoing isolated on-pump CABG to endoscopic versus open vein harvest between 2014-2017. The primary endpoint was major cardiac adverse events (MACE), defined as the composite of all-cause death, nonfatal myocardial infarction, or repeat revascularization. RESULTS Among 1,084 patients, 344 (31.8%) LITA-LAD anastomoses were performed by residents and 740 (68.2%) by attending surgeons. Residents (when compared to attendings) operated on fewer patients with high tercile SYNTAX scores (22.1% vs. 37.4%, p < 0.001), performed less multiarterial CABG (5.2% vs. 14.6%, p < 0.001), and performed more anastomoses to distal targets with diameters > 2.0 mm (19.0% vs. 10.9%, p < 0.001) and non-calcified landing zones (25.1% vs. 21.6%, p < 0.001). During a median observation time of 4.7 years (interquartile range 3.84-5.45), MACE occurred in 77 patients (22.4%) in the resident group and 169 patients (22.8%) in the attending group (unadjusted HR 1.00; 95% confidence interval, 0.76-1.33; p = 0.99). Outcomes persisted on adjusted analyses. CONCLUSIONS Based on this REGROUP trial subanalysis, under careful supervision and with appropriate patient selection, LITA-LAD anastomoses performed by residents yields similar clinical outcomes compared to attendings.
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Affiliation(s)
- Ajami Gikandi
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Eileen Stock
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, MD, USA
| | - Ellen DeMatt
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, MD, USA
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jake Awtry
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jacquelyn A Quin
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA
| | - George Tolis
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kousick Biswas
- VA Cooperative Studies Program Coordinating Center, Office of Research and Development, U.S. Department of Veterans Affairs, Perry Point, MD, USA
| | - Marco A Zenati
- Division of Cardiac Surgery, Veterans Affairs (VA) Boston Healthcare System and Harvard Medical School, Boston, MA, USA
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Hulsmans M, Schloss MJ, Lee IH, Bapat A, Iwamoto Y, Vinegoni C, Paccalet A, Yamazoe M, Grune J, Pabel S, Momin N, Seung H, Kumowski N, Pulous FE, Keller D, Bening C, Green U, Lennerz JK, Mitchell RN, Lewis A, Casadei B, Iborra-Egea O, Bayes-Genis A, Sossalla S, Ong CS, Pierson RN, Aster JC, Rohde D, Wojtkiewicz GR, Weissleder R, Swirski FK, Tellides G, Tolis G, Melnitchouk S, Milan DJ, Ellinor PT, Naxerova K, Nahrendorf M. Recruited macrophages elicit atrial fibrillation. Science 2023; 381:231-239. [PMID: 37440641 PMCID: PMC10448807 DOI: 10.1126/science.abq3061] [Citation(s) in RCA: 22] [Impact Index Per Article: 22.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 06/02/2023] [Indexed: 07/15/2023]
Abstract
Atrial fibrillation disrupts contraction of the atria, leading to stroke and heart failure. We deciphered how immune and stromal cells contribute to atrial fibrillation. Single-cell transcriptomes from human atria documented inflammatory monocyte and SPP1+ macrophage expansion in atrial fibrillation. Combining hypertension, obesity, and mitral valve regurgitation (HOMER) in mice elicited enlarged, fibrosed, and fibrillation-prone atria. Single-cell transcriptomes from HOMER mouse atria recapitulated cell composition and transcriptome changes observed in patients. Inhibiting monocyte migration reduced arrhythmia in Ccr2-∕- HOMER mice. Cell-cell interaction analysis identified SPP1 as a pleiotropic signal that promotes atrial fibrillation through cross-talk with local immune and stromal cells. Deleting Spp1 reduced atrial fibrillation in HOMER mice. These results identify SPP1+ macrophages as targets for immunotherapy in atrial fibrillation.
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Affiliation(s)
- Maarten Hulsmans
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Maximilian J. Schloss
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - I-Hsiu Lee
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Aneesh Bapat
- Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Yoshiko Iwamoto
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Claudio Vinegoni
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Alexandre Paccalet
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Masahiro Yamazoe
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jana Grune
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Steffen Pabel
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
| | - Noor Momin
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Hana Seung
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Nina Kumowski
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Fadi E. Pulous
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Daniel Keller
- Department of Thoracic and Cardiovascular Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Constanze Bening
- Department of Thoracic and Cardiovascular Surgery, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Ursula Green
- Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jochen K. Lennerz
- Department of Pathology, Center for Integrated Diagnostics, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Richard N. Mitchell
- Department of Pathology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Andrew Lewis
- Radcliffe Department of Medicine, NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
- British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Barbara Casadei
- Radcliffe Department of Medicine, NIHR Biomedical Research Centre, University of Oxford, Oxford, UK
- British Heart Foundation Centre of Research Excellence, University of Oxford, Oxford, UK
| | - Oriol Iborra-Egea
- Institut del Cor Germans Trias i Pujol, CIBERCV, Badalona, Barcelona, Spain
| | - Antoni Bayes-Genis
- Institut del Cor Germans Trias i Pujol, CIBERCV, Badalona, Barcelona, Spain
| | - Samuel Sossalla
- Department of Internal Medicine II, University Medical Center Regensburg, Regensburg, Germany
- Department of Cardiology and Angiology, University of Giessen/DZHK, Partner Site Rhein-Main, Germany
| | - Chin Siang Ong
- Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Richard N. Pierson
- Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Jon C. Aster
- Department of Pathology, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - David Rohde
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Gregory R. Wojtkiewicz
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Ralph Weissleder
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Filip K. Swirski
- Cardiovascular Research Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - George Tellides
- Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - George Tolis
- Department of Cardiac Surgery, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA, USA
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Patrick T. Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Cardiovascular Disease Initiative, The Broad Institute of MIT and Harvard University, Cambridge, MA, USA
| | - Kamila Naxerova
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Matthias Nahrendorf
- Center for Systems Biology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
- Department of Internal Medicine I, University Hospital Wuerzburg, Wuerzburg, Germany
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Tolis G, Piechura LM, Mohan N, Pomerantsev EV, Hirji SA, Bloom JP. Operative Teaching of Coronary Bypass and Need for Repeat Catheterization: Does it Matter Who is Sewing? J Surg Educ 2023; 80:826-832. [PMID: 37080797 DOI: 10.1016/j.jsurg.2023.04.001] [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] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 03/22/2023] [Accepted: 04/01/2023] [Indexed: 05/03/2023]
Abstract
OBJECTIVE There are no studies to date comparing the patency of coronary bypass grafts constructed by attending surgeons versus trainees and the potential consequences of any such disparities. We explored this issue by comparing the patency of individual anastomoses performed by residents versus the attending surgeon. DESIGN We reviewed 765 continuous cases performed by a single surgeon which involved at least 1 coronary bypass anastomosis, totaling 2,173 distal anastomoses. At a median follow-up time of 36 months (interquartile range 20.5-47.3), 83 (10.9%) patients had undergone 110 cardiac catheterization procedures after their original operation for various indications. This angiographic information provided the data for our comparison cohorts. SETTING Cardiac surgery practice within an academic setting PARTICIPANTS: Adult patient undergoing coronary bypass grafting RESULTS: Of the 83 patients that underwent repeat catheterization, 23 (27.7%) were resident cases, 25 (30.1%) were attending cases and 35 (42.2%) were mixed. There were 4/83 (4.8%) patients with angiographic evidence of internal mammary artery graft compromise of which 3/4 (75%) had been constructed by the attending surgeon. Angiographic evidence of saphenous vein graft compromise was appreciated in 16/83 (19.3%) patients of which 9/16 (56.3%) of the grafts were constructed by the attending surgeon. CONCLUSIONS Liberal involvement of surgical trainees as primary operators in coronary revascularization cases led to equivalent rates of postoperative ischemic complications between the attending and resident groups. The outcome equivalence was also maintained when evaluated at the individual anastomosis patency level between the 2 groups. We conclude that academic programs should continue providing trainees significant experience as primary operating surgeons without fear of clinical outcome compromise.
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Affiliation(s)
- George Tolis
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Laura M Piechura
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Navyatha Mohan
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Eugene V Pomerantsev
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Sameer A Hirji
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jordan P Bloom
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Goudot G, Yanamandala M, Mitchell R, Tolis G, Gerhard Herman MD. Severe triple vessel disease secondary to IgG4-related coronary periarteritis. J Card Surg 2022; 37:5468-5471. [PMID: 36378869 DOI: 10.1111/jocs.17187] [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: 10/06/2022] [Accepted: 10/29/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Immunoglobulin G4-related disease is a rare systemic inflammatory disease that can lead to vascular manifestations such as periarteritis. CASE PRESENTATION A 41-year-old man with stress angina was referred for coronary bypass surgery due to triple vessel coronary disease. CONCLUSIONS Operative findings revealed significant adhesions and dense peri-coronary and periaortic thickening, also involving the left internal mammary artery. The IgG4-associated disease was confirmed by aortic pathology. The stress angina subsequently improved with the initiation of treatment with prednisone and rituximab.
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Affiliation(s)
- Guillaume Goudot
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Mounica Yanamandala
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Richard Mitchell
- Department of Pathology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - George Tolis
- Cardiac surgery Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Marie-Denise Gerhard Herman
- Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
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Naar L, Dorken Gallastegi A, Kongkaewpaisan N, Kokoroskos N, Tolis G, Melnitchouk S, Villavicencio-Theoduloz M, Mendoza AE, Velmahos GC, Kaafarani HMA, Jassar AS. Risk factors for ischemic gastrointestinal complications in patients undergoing open cardiac surgical procedures: A single-center retrospective experience. J Card Surg 2022; 37:808-817. [PMID: 35137981 DOI: 10.1111/jocs.16294] [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: 09/05/2021] [Revised: 12/18/2021] [Accepted: 01/28/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Ischemic gastrointestinal complications (IGIC) following cardiac surgery are associated with high morbidity and mortality and remain difficult to predict. We evaluated perioperative risk factors for IGIC in patients undergoing open cardiac surgery. METHODS All patients that underwent an open cardiac surgical procedure at a tertiary academic center between 2011 and 2017 were included. The primary outcome was IGIC, defined as acute mesenteric ischemia necessitating a surgical intervention or postoperative gastrointestinal bleeding that was proven to be of ischemic etiology and necessitated blood product transfusion. A backward stepwise regression model was constructed to identify perioperative predictors of IGIC. RESULTS Of 6862 patients who underwent cardiac surgery during the study period, 52(0.8%) developed IGIC. The highest incidence of IGIC (1.9%) was noted in patients undergoing concomitant coronary artery, valvular, and aortic procedures. The multivariable regression identified hypertension (odds ratio [OR] = 5.74), preoperative renal failure requiring dialysis (OR = 3.62), immunocompromised status (OR = 2.64), chronic lung disease (OR = 2.61), and history of heart failure (OR = 2.03) as independent predictors for postoperative IGIC. Pre- or intraoperative utilization of intra-aortic balloon pump or catheter-based assist devices (OR = 4.54), intraoperative transfusion requirement of >4 RBC units(OR = 2.47), and cardiopulmonary bypass > 180 min (OR = 2.28) were also identified as independent predictors for the development of IGIC. CONCLUSIONS We identified preoperative and intraoperative risk factors that independently increase the risk of developing postoperative IGIC after cardiac surgery. A high index of suspicion must be maintained and any deviation from the expected recovery course in patients with the above-identified risk factors should trigger an immediate evaluation with the involvement of the acute care surgical team.
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Affiliation(s)
- Leon Naar
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ander Dorken Gallastegi
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Napaporn Kongkaewpaisan
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Nikolaos Kokoroskos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - George Tolis
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mauricio Villavicencio-Theoduloz
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - April E Mendoza
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - George C Velmahos
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Haytham M A Kaafarani
- Division of Trauma, Emergency Surgery, and Surgical Critical Care, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Arminder S Jassar
- Division of Cardiac Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Brovman EY, Tolis G, Hirji S, Axtell A, Fields K, Muehlschlegel JD, Urman RD, Deseda GAC, Kaneko T, Karamnov S. Association Between Early Extubation and Postoperative Reintubation After Elective Cardiac Surgery: A Bi-institutional Study. J Cardiothorac Vasc Anesth 2022; 36:1258-1264. [PMID: 34980525 DOI: 10.1053/j.jvca.2021.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE It is unknown if remaining intubated after cardiac surgery is associated with a decreased risk of postoperative reintubation. The primary objective of this study was to investigate whether there was an association between the timing of extubation and the risk of reintubation after cardiac surgery. DESIGN A retrospective, observational study. SETTING Two university-affiliated tertiary care centers. PARTICIPANTS A total of 9,517 patients undergoing either isolated coronary artery bypass grafting (CABG) or aortic valve replacement (AVR). INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 6,609 isolated CABGs and 2,908 isolated AVRs were performed during the study period. Reintubation occurred in 112 patients (1.64%) after CABG and 44 patients (1.5%) after AVR. After multivariate logistic regression analysis, early extubation (within the first 6 postoperative hours) was not associated with a risk of reintubation after CABG (odds ratio [OR] 0.53, 95% CI 0.26-1.06) and AVR (OR 0.52, 95% CI 0.22-1.22). Risk factors for reintubation included increased age in both the CABG (OR per 10-year increase, 1.63; 95% CI 1.28-2.08) and AVR (OR per 10-year increase, 1.50; 95% CI 1.12-2.01) cohorts. Total bypass time, race, and New York Heart Association (NYHA) functional class were not associated with reintubation risk. CONCLUSION Reintubation after CABGs and AVRs is a rare event, and advanced age is an independent risk factor. Risk is not increased with early extubation. This temporal association and low overall rate of reintubation suggest the strategies for extubation should be modified in this patient population.
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Affiliation(s)
- Ethan Y Brovman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - George Tolis
- Department of Cardiac Surgery, Massachusetts General Hospital, Boston, MA
| | - Sameer Hirji
- Department of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Andrea Axtell
- Department of Cardiac Surgery, Massachusetts General Hospital, Boston, MA
| | - Kara Fields
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - J Daniel Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Richard D Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA
| | - Gaston A Cudemis Deseda
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Tsuyoshi Kaneko
- Department of Cardiac Surgery, Brigham and Women's Hospital, Boston, MA
| | - Sergey Karamnov
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA.
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Hirji SA, Ghandour H, Tolis G. Commentary: Sternal wound complications and internal mammary harvesting technique: An unresolved debate. J Thorac Cardiovasc Surg 2021:S0022-5223(21)01697-4. [PMID: 34922748 DOI: 10.1016/j.jtcvs.2021.11.070] [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: 11/26/2021] [Revised: 11/26/2021] [Accepted: 11/30/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Sameer A Hirji
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass
| | - Hiba Ghandour
- Department of Thoracic and Cardiovascular Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - George Tolis
- Division of Thoracic and Cardiac Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Mass.
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Baldwin AC, Tolis G. Branched internal mammary conduit permits non-sequenced total arterial revascularization. Asian Cardiovasc Thorac Ann 2020; 29:552-554. [PMID: 33215934 DOI: 10.1177/0218492320975952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recent trends in cardiac surgery have encouraged total arterial coronary revascularization, citing advantages in long-term patency and overall mortality. Often relying on sequenced, composite, and free-graft strategies, total arterial coronary revascularization is limited by conduit availability and surgical complexity. We present the use of bilateral internal mammary artery grafts to achieve nonsequential 3-vessel total arterial coronary revascularization using the preserved distal bifurcation of the right internal mammary artery. Utilization of distal internal mammary artery branches should be considered a viable strategy in select patients and can broaden the opportunities for total arterial coronary revascularization in patients with multivessel coronary disease.
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Affiliation(s)
- Andrew Cw Baldwin
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
| | - George Tolis
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, USA.,Harvard Medical School, Boston, MA, USA
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Axtell AL, Moonsamy P, Melnitchouk S, Jassar AS, Villavicencio MA, D'Alessandro DA, Tolis G, Cameron DE, Sundt TM. Starting elective cardiac surgery after 3 pm does not impact patient morbidity, mortality, or hospital costs. J Thorac Cardiovasc Surg 2020; 159:2314-2321.e2. [DOI: 10.1016/j.jtcvs.2019.06.125] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 06/05/2019] [Accepted: 06/06/2019] [Indexed: 11/25/2022]
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Axtell AL, Moonsamy P, Melnitchouk S, Tolis G, Jassar AS, D'Alessandro DA, Villavicencio MA, Cameron DE, Sundt TM. Preoperative predictors of new-onset prolonged atrial fibrillation after surgical aortic valve replacement. J Thorac Cardiovasc Surg 2020; 159:1407-1414. [DOI: 10.1016/j.jtcvs.2019.04.077] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Revised: 04/01/2019] [Accepted: 04/02/2019] [Indexed: 10/26/2022]
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Moonsamy P, Bhatt AB, Mohan N, Funamoto M, Melnitchouk S, D'Alessandro DA, Tolis G, Sundt TM, Cameron DE, Jassar A. LONG TERM FOLLOW-UP OF PATIENTS WITH COARCTATION OF THE AORTA. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)31236-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Bloom JP, Moonsamy P, Gartland RM, O'Malley C, Tolis G, Villavicencio-Theoduloz MA, Burkhardt C, Dunn P, Sundt TM, D'Alessandro DA. Impact of staff turnover during cardiac surgical procedures. J Thorac Cardiovasc Surg 2019; 161:139-144. [PMID: 31928826 DOI: 10.1016/j.jtcvs.2019.11.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 11/16/2019] [Accepted: 11/24/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE The impact of staff turnover during cardiac procedures is unknown. Accurate inventory of sharps (needles/blades) requires attention by surgical teams, and sharp count errors result in delays, can lead to retained foreign objects, and may signify communication breakdown. We hypothesized that increased team turnover raises the likelihood of sharp count errors and may negatively affect patient outcomes. METHODS All cardiac operations performed at our institution from May 2011 to March 2016 were reviewed for sharp count errors from a prospectively maintained database. Univariate and multivariable analyses were performed. RESULTS Among 7264 consecutive cardiac operations, sharp count errors occurred in 723 cases (10%). There were no retained sharps detected by x-ray in our series. Sharp count errors were lower on first start cases (7.7% vs 10.7%, P < .001). Cases with sharp count errors were longer than those without (7 vs 5.7 hours, P < .001). In multivariable analysis, factors associated with an increase in sharp count errors were non-first start cases (odds ratio [OR], 1.3; P = .006), weekend cases (OR, 1.6; P < .004), more than 2 scrub personnel (3 scrubs: OR, 1.3; P = .032; 4 scrubs: OR, 2; P < .001; 5 scrubs: OR, 2.4; P = .004), and more than 1 circulating nurse (2 nurses: OR, 1.9; P < .001; 3 nurses: OR, 2; P < .001; 4 nurses: OR, 2.4; P < .001; 5 nurses: OR, 3.1; P < .001). Sharp count errors were associated with higher rates of in-hospital mortality (OR, 1.9; P = .038). CONCLUSIONS Sharp count errors are more prevalent with increased team turnover and during non-first start cases or weekends. Sharp count errors may be a surrogate marker for other errors and thus increased mortality. Reducing intraoperative team turnover or optimizing hand-offs may reduce sharp count errors.
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Affiliation(s)
- Jordan P Bloom
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass.
| | - Philicia Moonsamy
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass
| | - Rajshri M Gartland
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass
| | - Catherine O'Malley
- Perioperative Services Administration, Massachusetts General Hospital, Boston, Mass
| | - George Tolis
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass
| | | | - Carolyn Burkhardt
- Perioperative Services Administration, Massachusetts General Hospital, Boston, Mass
| | - Peter Dunn
- Perioperative Services Administration, Massachusetts General Hospital, Boston, Mass
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Mass
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Axtell AL, Moonsamy P, Melnitchouk S, Tolis G, D'Alessandro DA, Villavicencio MA. Increasing donor sequence number is not associated with inferior outcomes in lung transplantation. J Card Surg 2019; 35:286-293. [PMID: 31730742 DOI: 10.1111/jocs.14343] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Donor sequence number (DSN) represents the number of recipients to whom an organ has been offered. The impact of seeing numerous prior refusals may potentially influence the decision to accept an organ. We sought to determine if DSN was associated with inferior posttransplant outcomes. METHODS Using the United Network for Organ Sharing database, a retrospective analysis was performed on 22 361 patients who received a lung transplant between 2005 and 2017. Patients were grouped into low DSN (1-24, n = 16 860) and high DSN (>24, n = 5501) categories. Baseline characteristics and posttransplant outcomes were analyzed. An institutional subgroup was also analyzed to compare rates of primary graft dysfunction (PGD) posttransplant. RESULTS The DSN ranged from 1 to 1735 (median, 7; interquartile range, 2-24). A total of 18 507 recipients received an organ with at least one prior refusal. Recipients of donors with a higher DSN were older (58 vs 55 years; P < .01) but had lower lung allocation scores (43.5 vs 47.5; P < .01). On adjusted analysis, high DSN was not associated with increased mortality (hazard ratio, 0.99; 95% confidence interval, 0.94-1.04; P = .77). There was no difference in the incidence of graft failure (P = .37) or retransplantation (P = .24). Recipient subgroups who received donors with an increasing DSN >50 and >75 also demonstrated no difference in mortality when compared with a low DSN (P = .86 and P = .97). There was no difference in PGD for patients with a low vs a high DSN at any time posttransplant. CONCLUSIONS DSN is not associated with increased mortality in patients undergoing lung transplantation and should not negatively influence the decision to accept a lung for transplant.
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Affiliation(s)
- Andrea L Axtell
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts.,Minehan Outcomes Fellow, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts
| | - Philicia Moonsamy
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts.,Martignetti Outcomes Fellow, Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - George Tolis
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David A D'Alessandro
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
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Trahanas JM, Kwolek CJ, Tolis G. Open Tacking of a Migrated Thoracic Endovascular Aortic Graft. Ann Vasc Surg 2019; 63:461.e7-461.e9. [PMID: 31629854 DOI: 10.1016/j.avsg.2019.09.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/01/2019] [Accepted: 09/13/2019] [Indexed: 11/18/2022]
Abstract
Complications of thoracic endovascular aortic repair (TEVAR) are beginning to emerge as novel vascular issues. While endovascular solutions exist for most, some graft complications require a more traditional open solution. These operations are most commonly performed for endoleak or disease progression. Much less frequently observed is the migration of the endograft requiring open reintervention. Herein we present a case of a proximally migrated TEVAR graft, which required open fixation under deep hypothermic circulatory arrest (DHCA).
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Affiliation(s)
- John M Trahanas
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA.
| | - Christopher J Kwolek
- Division of Vascular and Endovascular Surgery, Massachusetts General Hospital, Boston, MA
| | - George Tolis
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA
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16
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Tolis G, Bloom JP, Kwon MH. Reply. Ann Thorac Surg 2019; 109:983-984. [PMID: 31472137 DOI: 10.1016/j.athoracsur.2019.07.019] [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: 07/02/2019] [Accepted: 07/04/2019] [Indexed: 11/18/2022]
Affiliation(s)
- George Tolis
- Department of Surgery, Massachusetts General Hospital, Cox 630, 55 Fruit St, Boston, MA 2114.
| | - Jordan P Bloom
- Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael H Kwon
- Department of Surgery, Boston Children's Hospital, Boston, Massachusetts
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17
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Bloom JP, Heng E, Auchincloss HG, Melnitchouk SI, D'Alessandro DA, Villavicencio MA, Sundt TM, Tolis G. Cardiac Surgery Trainees as "Skin-to-Skin" Operating Surgeons: Midterm Outcomes. Ann Thorac Surg 2019; 108:262-267. [PMID: 30880141 DOI: 10.1016/j.athoracsur.2019.02.008] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [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: 11/08/2018] [Revised: 12/22/2018] [Accepted: 02/04/2019] [Indexed: 11/16/2022]
Abstract
BACKGROUND We have previously demonstrated that cardiac surgery trainees can safely perform operations "skin-to-skin" with adequate attending surgeon supervision. METHODS We used 100 consecutive cases (82 coronary artery bypass grafts, 9 aortic valve replacements, 7 coronary artery bypass grafts plus aortic valve replacements, 2 others) performed by residents (group R) to match 1:1 by procedure to nonconsecutive cases done by a single attending surgeon (group A) from July 2014 to October 2016. Patients were stratified based on whether the attending surgeon or trainee performed every critical step of the operation skin-to-skin. Outcomes included death, major morbidity, and readmission. RESULTS Patients in the two groups were similar with respect to demographic characteristics and comorbidities. The median follow-up time for patients in this study was 28 months (interquartile range: 23 to 35 months). There were seven deaths (3.5%; four in group A, three in group R, p = 0.7). Of the 43 patients (21.5%) who were readmitted during the study term, 27 patients (13.5%) were readmitted for causes related to the operation (11 in group A, 16 in group R, p = 0.02). The most common reasons for readmissions related to the operation were chest pain (n = 11), pleural effusion that required drainage (n = 8), pneumonia (n = 4), and unstable angina that required percutaneous coronary intervention (n = 3). No statistically significant differences were found in reasons for readmission between group A and group R. CONCLUSIONS The equivalence of postoperative outcomes previously demonstrated at 30 days persists at midterm follow-up. Our data indicate that trainees can be educated in operative cardiac surgery under the current paradigm without sacrificing outcome quality. It is reasonable to expect academic programs to continue providing trainees with experience as primary operating surgeons.
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Affiliation(s)
- Jordan P Bloom
- Division of Cardiothoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Elbert Heng
- Warren Alpert Medical School, Brown University, Providence, Rhode Island
| | - Hugh G Auchincloss
- Division of Cardiothoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Serguei I Melnitchouk
- Division of Cardiothoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David A D'Alessandro
- Division of Cardiothoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Mauricio A Villavicencio
- Division of Cardiothoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Thoralf M Sundt
- Division of Cardiothoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - George Tolis
- Division of Cardiothoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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Axtell AL, Fiedler AG, Lewis G, Melnitchouk S, Tolis G, D’Alessandro DA, Villavicencio MA. Reoperative sternotomy is associated with increased early mortality after cardiac transplantation. Eur J Cardiothorac Surg 2019; 55:1136-1143. [DOI: 10.1093/ejcts/ezy443] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [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: 08/28/2018] [Revised: 11/20/2018] [Accepted: 11/24/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
- Andrea L Axtell
- Division of Cardiac Surgery and Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - Amy G Fiedler
- Division of Cardiac Surgery and Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - Gregory Lewis
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
| | - Serguei Melnitchouk
- Division of Cardiac Surgery and Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - George Tolis
- Division of Cardiac Surgery and Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - David A D’Alessandro
- Division of Cardiac Surgery and Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
| | - Mauricio A Villavicencio
- Division of Cardiac Surgery and Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, MA, USA
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Bloom JP, Kwon MH, Tolis G. Early Distal Migration of a Self-Expanding Aortic Valve Prosthesis Causing Myocardial Infarction. Ann Thorac Surg 2018; 108:e1-e3. [PMID: 30593781 DOI: 10.1016/j.athoracsur.2018.11.050] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/21/2018] [Indexed: 11/30/2022]
Abstract
Early distal migration after transcatheter aortic valve replacement is a rare but potentially catastrophic complication that presents unique technical challenges for subsequent surgical management. This report describes a case of early distal migration of a Medtronic CoreValve Evolut R bioprosthesis (Minneapolis, MN) causing myocardial infarction from coronary ostial obstruction and provides a practical technique for open surgical device explantation and aortic valve re-replacement. Snaring the stent of the device using standard instruments is a simple but effective method for transcatheter aortic valve replacement explant that allows for optimal positioning of a single aortotomy at the standard anatomic site to facilitate subsequent surgical aortic valve replacement.
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Affiliation(s)
- Jordan P Bloom
- Division of Cardiothoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Michael H Kwon
- Department of Cardiac Surgery, Seattle Children's Hospital, Seattle, Washington
| | - George Tolis
- Division of Cardiothoracic Surgery, Department of Surgery, Massachusetts General Hospital, Boston, Massachusetts.
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Axtell AL, Chang DC, Melnitchouk S, Jassar AS, Tolis G, Villavicencio MA, Sundt TM, D'Alessandro DA. Early structural valve deterioration and reoperation associated with the mitroflow aortic valve. J Card Surg 2018; 33:778-786. [DOI: 10.1111/jocs.13953] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Andrea L. Axtell
- Corrigan Minehan Heart Center and Division of Cardiac Surgery; Massachusetts General Hospital; Boston Massachusetts
- Minehan Outcomes Fellow; Minehan Heart Center; Boston Massachusetts
| | - David C. Chang
- Codman Center for Clinical Effectiveness; Department of Surgery; Massachusetts General Hospital; Boston Massachusetts
| | - Serguei Melnitchouk
- Corrigan Minehan Heart Center and Division of Cardiac Surgery; Massachusetts General Hospital; Boston Massachusetts
| | - Arminder S. Jassar
- Corrigan Minehan Heart Center and Division of Cardiac Surgery; Massachusetts General Hospital; Boston Massachusetts
| | - George Tolis
- Corrigan Minehan Heart Center and Division of Cardiac Surgery; Massachusetts General Hospital; Boston Massachusetts
| | - Mauricio A. Villavicencio
- Corrigan Minehan Heart Center and Division of Cardiac Surgery; Massachusetts General Hospital; Boston Massachusetts
| | - Thoralf M. Sundt
- Corrigan Minehan Heart Center and Division of Cardiac Surgery; Massachusetts General Hospital; Boston Massachusetts
| | - David A. D'Alessandro
- Corrigan Minehan Heart Center and Division of Cardiac Surgery; Massachusetts General Hospital; Boston Massachusetts
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21
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Axtell AL, Heng EE, Fiedler AG, Melnitchouk S, D'Alessandro DA, Tolis G, Astor T, Dalia AA, Cudemus G, Villavicencio MA. Pain management and safety profiles after preoperative vs postoperative thoracic epidural insertion for bilateral lung transplantation. Clin Transplant 2018; 32:e13445. [PMID: 30412311 DOI: 10.1111/ctr.13445] [Citation(s) in RCA: 3] [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: 08/15/2018] [Revised: 10/15/2018] [Accepted: 11/04/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Thoracic epidural analgesia provides effective pain control after lung transplantation; however, the optimal timing of placement is controversial. We sought to compare pain control and pulmonary and epidural morbidity between patients receiving preoperative vs postoperative epidurals. METHODS Institutional records were reviewed for patients undergoing a bilateral lung transplant via a bilateral anterior thoracotomy with transverse sternotomy incision between January 2014 and January 2017. Pain control was measured using visual analog scale pain scores (0-10). Pulmonary complications included a composite of pneumonia, prolonged intubation, and reintubation/tracheostomy. RESULTS Among 103 patients, 72 (70%) had an epidural placed preoperatively and 31 (30%) had an epidural placed within 72 hours posttransplant. There were no differences in the rates of cardiopulmonary bypass (3% vs 0%, P = 0.59); however, patients with a preoperative epidural were less likely to be placed on extracorporeal membrane oxygenation intraoperatively (25% vs 52%, P = 0.01). Pain control was similar at 24 hours (1.2 vs 1.7, P = 0.05); however, patients with a preoperative epidural reported lower pain scores at 48 (1.2 vs 2.1, P = 0.02) and 72 hours posttransplant (0.8 vs 1.7, P = 0.02). There were no differences in primary graft dysfunction (42% vs 56%, P = 0.28), length of mechanical ventilation (19.5 vs 24 hours, P = 0.18), or adverse pulmonary events (33% vs 52%, P = 0.12). No adverse events including epidural hematoma, paralysis, or infection resulted from epidural placement. CONCLUSION Preoperative thoracic epidural placement provides improved analgesia without increased morbidity following lung transplantation.
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Affiliation(s)
- Andrea L Axtell
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Elbert E Heng
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Amy G Fiedler
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - David A D'Alessandro
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - George Tolis
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts
| | - Todd Astor
- Division of Pulmonary and Critical Care Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Adam A Dalia
- Division of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | - Gaston Cudemus
- Division of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts
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Villavicencio MA, Axtell AL, Spencer PJ, Heng EE, Kilmarx S, Dalpozzal N, Funamoto M, Roy N, Osho A, Melnitchouk S, D’Alessandro DA, Tolis G, Astor T. Lung Transplantation From Donation After Circulatory Death: United States and Single-Center Experience. Ann Thorac Surg 2018; 106:1619-1627. [DOI: 10.1016/j.athoracsur.2018.07.024] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 06/06/2018] [Accepted: 07/09/2018] [Indexed: 11/25/2022]
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Affiliation(s)
- George Tolis
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Axtell AL, Fiedler AG, Chang DC, Heng EE, Melnitchouk S, Tolis G, D’Alessandro DA, Villavicencio MA, Cameron DE, Sundt TM. Preoperative Predictors of atrial Fibrillation Late After Surgical Aortic Valve Replacement. J Am Coll Surg 2018. [DOI: 10.1016/j.jamcollsurg.2018.08.264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Villavicencio MA, Axtell AL, Osho A, Astor T, Roy N, Melnitchouk S, D'Alessandro D, Tolis G, Raz Y, Neuringer I, Sundt TM. Single- Versus Double-Lung Transplantation in Pulmonary Fibrosis: Impact of Age and Pulmonary Hypertension. Ann Thorac Surg 2018; 106:856-863. [PMID: 29803692 DOI: 10.1016/j.athoracsur.2018.04.060] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/25/2018] [Accepted: 04/02/2018] [Indexed: 01/25/2023]
Abstract
BACKGROUND Double-lung transplantation (DLT) has better long-term outcomes compared with single-lung transplantation (SLT) in pulmonary fibrosis. However, controversy persists about whether older patients or patients with high lung allocation scores would benefit from DLT. Moreover, the degree of pulmonary hypertension in which SLT should be avoided is unknown. METHODS A retrospective analysis using the United Network for Organ Sharing database was performed in all recipients of lung transplants for pulmonary fibrosis. Kaplan-Meier survival for SLT versus DLT was compared and stratified by age, allocation score, and mean pulmonary artery pressure. Cox regression and propensity-matching analyses were performed. RESULTS Between 1987 and 2015; 9,191 of 29,779 lung transplants were performed in pulmonary fibrosis. Ten-year survival rates were 55% for DLT and 32% for SLT (p < 0.001). When stratified by age, DLT recipients had improved survival at all age cutoffs, except age ≥70 years. In addition, DLT recipients had improved survival across all lung allocation scores (<45, ≥45, ≥60, ≥75) and all pulmonary artery pressure categories (<25, ≥25, ≥30, ≥40 mm Hg). Among DLT recipients, pulmonary artery pressure and allocation score did not affect survival. Among SLT recipients, a pressure ≥25 mm Hg did not influence survival. Conversely, patients with a pressure ≥30 mm Hg and an allocation score ≥45 had decreased survival. On Cox regression and on propensity matching, DLT had improved survival compared with SLT. CONCLUSIONS In pulmonary fibrosis, DLT has improved survival compared with SLT and should be considered the procedure of choice in patients younger than 70 years of age. SLT in patients with mean pulmonary artery pressure ≥30 mm Hg and an allocation score ≥45 should be discouraged.
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Affiliation(s)
- Mauricio A Villavicencio
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Andrea L Axtell
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Asishana Osho
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Todd Astor
- Harvard Medical School, Boston, Massachusetts; Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Nathalie Roy
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - David D'Alessandro
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - George Tolis
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Yuval Raz
- Harvard Medical School, Boston, Massachusetts; Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Isabel Neuringer
- Harvard Medical School, Boston, Massachusetts; Division of Pulmonary and Critical Care, Massachusetts General Hospital, Boston, Massachusetts
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Fiedler AG, Bhambhani V, Laikhter E, Picard MH, Wasfy MM, Tolis G, Melnitchouk S, Sundt TM, Wasfy JH. Aortic valve replacement associated with survival in severe regurgitation and low ejection fraction. Heart 2018; 104:835-840. [PMID: 29092919 DOI: 10.1136/heartjnl-2017-312024] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 09/30/2017] [Accepted: 10/04/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Although guidelines support aortic valve replacement (AVR) in patients with severe aortic regurgitation (AR) and left ventricular ejection fraction (LVEF) <50%, severe left ventricular dysfunction (LVEF <35%) is thought to confer high surgical risk. We sought to determine if a survival benefit exists with AVR compared with medical management in this high-risk, relatively rare population. METHODS A large institutional echocardiography database was queried to identify patients with severe AR and LVEF <35%. Manual chart review was performed. Due to small sample size and population heterogeneity, corrected group prognosis method was applied, which calculates the adjusted survival curve for each individual using fitted Cox proportional hazard model. Average survival adjusted for comorbidities and age was then calculated using the weighted average of the individual survival curves. RESULTS Initially, 2 54 614 echocardiograms were considered, representing 1 45 785 unique patients, of which 40 patients met inclusion criteria. Of those, 18 (45.0%) underwent AVR and 22 (55.0%) were managed medically. Absolute mortality was 27.8% in the AVR group and 91.2% in the medical management group. After multivariate adjustment, end-stage renal disease (HR=17.633, p=0.0335) and peripheral arterial disease (HR=6.050, p=0.0180) were associated with higher mortality. AVR was associated with lower mortality (HR=0.143, p=0.0490). Mean follow-up time of the study cohort was 6.58 years, and mean survival for patients undergoing AVR was 6.31 years. CONCLUSIONS Even after adjustment for clinical characteristics and patient age, AVR is associated with higher survival for patients with low LVEF and severe AR. Although treatment selection bias cannot be completely eliminated by this analysis, these results provide some evidence that surgery may be associated with prolonged survival in this high-risk patient group.
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Affiliation(s)
- Amy G Fiedler
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Vijeta Bhambhani
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Elizabeth Laikhter
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael H Picard
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Meagan M Wasfy
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - George Tolis
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Serguei Melnitchouk
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Jason H Wasfy
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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Tolis G, Spencer PJ, Bloom JP, Melnitchouk S, D'Alessandro DA, Villavicencio MA, Sundt TM. Teaching operative cardiac surgery in the era of increasing patient complexity: Can it still be done? J Thorac Cardiovasc Surg 2018; 155:2058-2065. [DOI: 10.1016/j.jtcvs.2017.11.109] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2017] [Revised: 11/02/2017] [Accepted: 11/17/2017] [Indexed: 12/21/2022]
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Shelton KT, Qu J, Bilotta F, Brown EN, Cudemus G, D’Alessandro DA, Deng H, DiBiasio A, Gitlin JA, Hahm EY, Hobbs LE, Houle TT, Ibala R, Loggia M, Pavone KJ, Shaefi S, Tolis G, Westover MB, Akeju O. Minimizing ICU Neurological Dysfunction with Dexmedetomidine-induced Sleep (MINDDS): protocol for a randomised, double-blind, parallel-arm, placebo-controlled trial. BMJ Open 2018; 8:e020316. [PMID: 29678977 PMCID: PMC5914725 DOI: 10.1136/bmjopen-2017-020316] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Delirium, which is prevalent in postcardiac surgical patients, is an acute brain dysfunction characterised by disturbances in attention, awareness and cognition not explained by a pre-existing neurocognitive disorder. The pathophysiology of delirium remains poorly understood. However, basic science and clinical studies suggest that sleep disturbance may be a modifiable risk factor for the development of delirium. Dexmedetomidine is a α-2A adrenergic receptor agonist medication that patterns the activity of various arousal nuclei similar to sleep. A single night-time loading dose of dexmedetomidine promotes non-rapid eye movement sleep stages N2 and N3 sleep. This trial hypothesises dexmedetomidine-induced sleep as pre-emptive therapy for postoperative delirium. METHODS AND ANALYSIS The MINDDS (Minimizing ICU Neurological Dysfunction with Dexmedetomidine-induced Sleep) trial is a 370-patient block-randomised, placebo-controlled, double-blinded, single-site, parallel-arm superiority trial. Patients over 60 years old, undergoing cardiac surgery with planned cardiopulmonary bypass, will be randomised to receive a sleep-inducing dose of dexmedetomidine or placebo. The primary outcome is the incidence of delirium on postoperative day 1, assessed with the Confusion Assessment Method by staff blinded to the treatment assignment. To ensure that the study is appropriately powered for the primary outcome measure, patients will be recruited and randomised into the study until 370 patients receive the study intervention on postoperative day 0. Secondary outcomes will be evaluated by in-person assessments and medical record review for in-hospital end points, and by telephone interview for 30-day, 90-day and 180-day end points. All trial outcomes will be evaluated using an intention-to-treat analysis plan. Hypothesis testing will be performed using a two-sided significance level (type I error) of α=0.05. Sensitivity analyses using the actual treatment received will be performed and compared with the intention-to-treat analysis results. Additional sensitivity analyses will assess the potential impact of missing data due to loss of follow-up. ETHICS AND DISSEMINATION The Partners Human Research Committee approved the MINDDS trial. Recruitment began in March 2017. Dissemination plans include presentations at scientific conferences, scientific publications and popular media. TRIAL REGISTRATION NUMBER NCT02856594.
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Affiliation(s)
- Kenneth T Shelton
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jason Qu
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Federico Bilotta
- Department of Anaesthesia and Critical Care Medicine, Sapienza University of Rome, Rome, Italy
| | - Emery N Brown
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
- Institute for Medical Engineering and Sciences, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | - Gaston Cudemus
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David A D’Alessandro
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Hao Deng
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Alan DiBiasio
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jacob A Gitlin
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Eunice Y Hahm
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Lauren E Hobbs
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Timothy T Houle
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Reine Ibala
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Marco Loggia
- Athinoula A. Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kara J Pavone
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Shahzad Shaefi
- Department of Anesthesia and Critical Care, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - George Tolis
- Department of Surgery, Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - M. Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Oluwaseun Akeju
- Department of Anesthesiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Axtell A, Fiedler A, Heng E, Melnitchouk S, D'Alessandro D, Tolis G, Astor T, Raz Y, Neuringer I, Villavicencio M. Rates of Primary Graft Dysfunction and Overall Survival Are Not Affected by the Laterality of the First Implanted Lung in Bilateral Lung Transplantation. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.644] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Heng E, Axtell A, Fiedler A, Melnitchouk S, D'Alessandro D, Tolis G, Cudemus G, Astor T, Villavicencio M. Preoperative Epidural Placement Provides Effective Analgesia Without Added Morbidity in Lung Transplantation. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.645] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Fiedler A, Axtell A, Heng E, Osho A, Melnitchouk S, D'Alessandro D, Tolis G, Astor T, Raz Y, Neuringer I, Villavicencio M. Low Partial Pressures of Oxygen in Circulatory Death Donors is Associated with Decreased Survival in Lung Transplant Recipients. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Villavicencio M, Axtell A, Fiedler A, Heng E, Raz Y, Neuringer I, Melnitchouk S, Tolis G, D'Alessandro D, Astor T. Impact of Carbon Dioxide Tension on Survival After Lung Transplantation for Pulmonary Fibrosis. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022] Open
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Villavicencio M, Axtell A, Fiedler A, Heng E, Kilmarx S, Roy N, Funamoto M, Astor T, Melnitchouk S, D'Alessandro D, Tolis G, Sundt T. Modified Surgical Technique of Normothermic Ex-Vivo Perfusion Reduces Cold Ischemic Time in Lung Transplantation During the EXPAND Trial. J Heart Lung Transplant 2018. [DOI: 10.1016/j.healun.2018.01.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Fiedler AG, Tolis G. Surgical Treatment of Valvular Heart Disease: Overview of Mechanical and Tissue Prostheses, Advantages, Disadvantages, and Implications for Clinical Use. Curr Treat Options Cardio Med 2018; 20:7. [DOI: 10.1007/s11936-018-0601-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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Abstract
Primary cardiac tumors are rare, present in roughly 0.05% of the population. Cardiac papillary fibroelastoma (CPF) is the second most common, accounting for 10% of primary cardiac tumors.[1] Most cases of CPFs are discovered incidentally on autopsy; however, they may present clinically with systemic embolization or heart failure symptoms. The recommended treatment for symptomatic CPF patients is surgical resection.[1] Treatment in asymptomatic patients remains somewhat controversial with incidentally discovered tumors presenting a clinical dilemma. We present a case of an atypically located CPF that was discovered incidentally on intraoperative transesophageal echocardiography (TEE) during a routine coronary artery bypass graft operation. This case highlights several important points for cardiac anesthesiologists. The first is the importance of performing a comprehensive intraoperative TEE. Next, this case reinforces the broad utility of TEE for evaluation of intracardiac tumors. Finally, this case demonstrates the importance of precise localization of intracardiac tumors.
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Affiliation(s)
- Genevieve E Staudt
- Department of Anesthesia, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Amy G Fiedler
- Department of Cardiac Surgery, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - George Tolis
- Department of Cardiac Surgery, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - David M Dudzinski
- Department of Cardiology, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Scott C Streckenbach
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA, USA
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Tolis G, Vlahakes GJ. Do not throw that sternal saw away yet…. J Thorac Cardiovasc Surg 2017; 155:937. [PMID: 29129422 DOI: 10.1016/j.jtcvs.2017.10.005] [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: 09/28/2017] [Accepted: 10/09/2017] [Indexed: 11/19/2022]
Affiliation(s)
- George Tolis
- Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass
| | - Gus J Vlahakes
- Division of Cardiac Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, Mass.
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Fiedler AG, Sundt TM, Tolis G. Post-Myocardial Infarction Ventricular Septal Defect Six Months following Coronary Artery Bypass Grafting. Heart Surg Forum 2017; 20:E162-E163. [PMID: 28846531 DOI: 10.1532/hsf.1763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 07/13/2017] [Accepted: 07/14/2017] [Indexed: 11/20/2022]
Abstract
Mechanical complications following acute myocardial infarction are associated with high mortality. We present the first reported case of a new post myocardial infarction ventricular septal defect (VSD) within six months of coronary artery bypass grafting. The patient underwent successful surgical correction of the VSD with the assistance of mechanical circulatory support (MCS). This case highlights the importance of mechanical circulatory support in the management of cardiogenic shock associated with rare complications of myocardial infarction, even after surgical revascularization.
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Affiliation(s)
- Amy G Fiedler
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - George Tolis
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, Massachusetts, USA
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Affiliation(s)
- Evanthia Diamanti-Kandarakis
- 1st Department of Internal Medicine, University of Athens, Laiko Hospital, 34 Aroes Street, P. Faliro, Athens, 175-62, Greece
| | | | - Antoni J. Duleba
- 1st Department of Internal Medicine, University of Athens, Laiko Hospital, Athens, Greece; Department of Endocrinology, Hippokration Hospital, University of Athens, Athens, Greece; Department of Obstetrics and Gynecology, Yale University School of Medicine, New Haven, Connecticut
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Abstract
INTRODUCTION Acute Type A Dissection remains a surgical emergency with a relatively high operative mortality despite advances in cardiac surgical techniques and medical management over the past thirty years. AREAS COVERED In this presentation we will discuss the issues surrounding diagnosis, triage, surgical treatment and perioperative medical management as well as long term surveillance of patients suffering from Acute Type A Dissection and present the literature that supports our management strategies. Expert commentary: The ultimate goal of surgical intervention for patients with Type A Acute Aortic Dissection is an alive patient. A more complicated operation which addresses the root and arch and potentially reduces late complications should be approached with caution since it may increase the operative mortality of the procedure itself. With the recent evolution in endovascular techniques, there is hope that later complications can be reduced without increasing the risk of the primary operation. It remains to be seen whether the improved distal aortic remodeling afforded by a combined open/endovascular approach to Acute Type A Dissection will lead to decreased need for aortic reinterventions and overall long term complications of a residual descending thoracic chronic dissection.
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Affiliation(s)
- George Tolis
- a Division of Cardiac Surgery , Massachusetts General Hospital , Boston , MA , USA
| | - Thoralf M Sundt
- a Division of Cardiac Surgery , Massachusetts General Hospital , Boston , MA , USA
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Abstract
In contrast to mitral regurgitation (MR) caused by structural abnormality of the valve ("primary" MR), about which there is increasing consensus regarding treatment, there is increasing controversy around the management of functional or "secondary" MR, of which "ischemic mitral regurgitation" (IMR) is a common cause. While the trend in the management of primary MR is increasingly aggressive, with wide agreement on the preference for repair over replacement such that debate centers on earlier and earlier repair even among asymptomatic patients, the situation is reversed in the setting of secondary MR with uncertainly beyond the mode of management (repair or replacement) to the value of intervening at all. This is, in part, because the term IMR has been somewhat loosely applied by the medical and surgical communities to include regurgitation secondary to active myocardial ischemia, as well as that resulting from a completed myocardial infarct. As a result, there is considerable variability in reported outcomes of surgical interventions for IMR. In addition, the natural history of IMR is quite adverse-more so than that of many solid organ malignancies-and its surgical treatment has traditionally carried a higher operative mortality than many cardiac surgical procedures, including similar operations for primary MR and incidental coronary artery disease. Added to this, with recent advances in both the medical and surgical treatment of heart failure improving nonoperative outcomes and simultaneously reducing operative risk compared to reports from previous decades, the landscape has been quite dynamic. Here, we review the issues surrounding surgical treatment for IMR, along with available evidence supporting different approaches, to lend an informed perspective on the divergent opinions among experts in this field and guide the appropriate management of the individual patient.
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Affiliation(s)
- George Tolis
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA.
| | - Thoralf M Sundt
- Division of Cardiac Surgery, Massachusetts General Hospital, Boston, MA, 02114, USA.
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Xekouki P, Pacak K, Almeida M, Wassif CA, Rustin P, Nesterova M, de la Luz Sierra M, Matro J, Ball E, Azevedo M, Horvath A, Lyssikatos C, Quezado M, Patronas N, Ferrando B, Pasini B, Lytras A, Tolis G, Stratakis CA. Succinate dehydrogenase (SDH) D subunit (SDHD) inactivation in a growth-hormone-producing pituitary tumor: a new association for SDH? J Clin Endocrinol Metab 2012; 97:E357-66. [PMID: 22170724 PMCID: PMC3319210 DOI: 10.1210/jc.2011-1179] [Citation(s) in RCA: 117] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Mutations in the subunits B, C, and D of succinate dehydrogenase (SDH) mitochondrial complex II have been associated with the development of paragangliomas (PGL), gastrointestinal stromal tumors, papillary thyroid and renal carcinoma (SDHB), and testicular seminoma (SDHD). AIM Our aim was to examine the possible causative link between SDHD inactivation and somatotropinoma. PATIENTS AND METHODS A 37-yr-old male presented with acromegaly and hypertension. Other family members were found with PGL. Elevated plasma and urinary levels of catecholamines led to the identification of multiple PGL in the proband in the neck, thorax, and abdomen. Adrenalectomy was performed for bilateral pheochromocytomas (PHEO). A GH-secreting macroadenoma was also found and partially removed via transsphenoidal surgery (TTS). Genetic analysis revealed a novel SDHD mutation (c.298_301delACTC), leading to a frame shift and a premature stop codon at position 133 of the protein. Loss of heterozygosity for the SDHD genetic locus was shown in the GH-secreting adenoma. Down-regulation of SDHD protein in the GH-secreting adenoma by immunoblotting and immunohistochemistry was found. A literature search identified other cases of multiple PGL and/or PHEO in association with pituitary tumors. CONCLUSION We describe the first kindred with a germline SDHD pathogenic mutation, inherited PGL, and acromegaly due to a GH-producing pituitary adenoma. SDHD loss of heterozygosity, down-regulation of protein in the GH-secreting adenoma, and decreased SDH enzymatic activity supports SDHD's involvement in the pituitary tumor formation in this patient. Older cases of multiple PGL and PHEO and pituitary tumors in the literature support a possible association between SDH defects and pituitary tumorigenesis.
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Affiliation(s)
- Paraskevi Xekouki
- Section on Endocrinology and Genetics, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Institutes of Health (NIH), Building 10, CRC, Room 1-3330, 10 Center Drive, MSC1103, Bethesda, Maryland 20892, USA
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Skoura E, Rondogianni P, Alevizaki M, Tzanela M, Tsagarakis S, Piaditis G, Tolis G, Datseris IE. Role of [(18)F]FDG-PET/CT in the detection of occult recurrent medullary thyroid cancer. Nucl Med Commun 2010; 31:567-75. [PMID: 20335822 DOI: 10.1097/mnm.0b013e3283384587] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE Many patients with medullary thyroid carcinoma (MTC) have persistently elevated calcitonin levels after initial treatment, indicating disease recurrence. Conventional imaging is often negative or shows equivocal findings. In this study we report our experience with 2-deoxy-2-[(18)F]fluoro-D-glucose positron emission tomography/computed tomography ([(18)F]FDG-PET/CT) in the evaluation of this specific group. METHODS Between February 2007 and May 2009, 38 [(18)F]FDG-PET/CT scans were performed on 32 patients with MTC and elevated calcitonin levels for localization of recurrent disease. Six of these patients had a second [(18)F]FDG-PET/CT scan. RESULTS Among the 38 [(18)F]FDG-PET/CT scans there were 18 positive and 20 negative scans. Out of the 18 positive scans, 17 were true positive and one false positive. These findings suggest that [(18)F]FDG-PET/CT provides additional information in almost half of all cases (overall per patient sensitivity of 47.4%) but using a serum calcitonin cut-off of 1000 pg/ml this rate is increased to 80%. An interesting finding of the study was that none of the six patients with multiple endocrine neoplasia type IIA syndrome had a positive [(18)F]FDG-PET/CT scan for MTC. When these patients were excluded, the overall per patient sensitivity rose to 60% and in patients with calcitonin levels >1000 pg/ml this rate increased to 100%. The mean SUV(max) of all lesions showing [(18)F]FDG uptake was 3.96 + or - 1.61 (range, 2-7). CONCLUSION [(18)F]FDG-PET/CT seems to be valuable for the detection of recurrence in patients with highly elevated calcitonin levels and negative conventional imaging findings. In addition, it seems that the sensitivity of [(18)F]FDG-PET/CT may be higher in patients with sporadic or familial MTC than in patients with MTC as part of multiple endocrine neoplasia type IIA syndrome.
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Affiliation(s)
- Evangelia Skoura
- Department of Nuclear Medicine, Evangelismos Hospital, Athens, Greece.
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Abstract
In the context of multiple neuroendocrine tumor syndromes, reproductive abnormalities may occur via a number of different mechanisms, such as hyperprolactinemia, increased GH/IGF-1 levels, hypogonadotropic hypogonadism, hypercortisolism, hyperandrogenism, hyperthyroidism, gonadotropin hypersecretion, as well as, tumorigenesis or functional disturbances in gonads or other reproductive organs. Precocious puberty and/or male feminization is a feature of McCune-Albright syndrome (MAS), neurofibromatosis type 1 (NF1), Carney complex (CNC), and Peutz-Jeghers syndrome (PJS), while sperm maturation and ovulation defects have been described in MAS and CNC. Although tumorigenesis of reproductive organs due to a multiple neuroendocrine tumor syndrome is very rare, certain lesions are characteristic and very unusual in the general population. Awareness leading to their recognition is important especially when other endocrine abnormalities coexist, as occasionally they may even be the first manifestation of a syndrome. Lesions such as certain types of ovarian cysts (MAS, CNC), pseudogynecomastia due to neurofibromas of the nipple-areola area (NF1), breast disease (CNC and Cowden disease (CD)), cysts and 'hypernephroid' tumors of the epididymis or bilateral papillary cystadenomas (mesosalpinx cysts) and endometrioid cystadenomas of the broad ligament (von Hippel-Lindau disease), testicular Sertoli calcifying tumors (CNC, PJS) monolateral or bilateral macroochidism and microlithiasis (MAS) may offer diagnostic clues. In addition, multiple neuroendocrine tumor syndromes may be complicated by reproductive malignancies including ovarian cancer in CNC, breast and endometrial cancer in CD, breast malignancies in NF1, and malignant sex-cord stromal tumors in PJS.
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Affiliation(s)
- Aristides Lytras
- Division of Endocrinology and Metabolism, Hippocrateion General Hospital, Vas. Sofias 108, Athens, Greece.
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Kousta E, Hadjiathanasiou CG, Tolis G, Papathanasiou A. Pleiotropic genetic syndromes with developmental abnormalities associated with obesity. J Pediatr Endocrinol Metab 2009; 22:581-92. [PMID: 19774839 DOI: 10.1515/jpem.2009.22.7.581] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Childhood obesity is a common and complex problem that may persist in adulthood. It may present as a component of genetic syndromes associated with dysmorphic features, developmental abnormalities, mental retardation and/or learning disabilities and often neuroendocrine dysfunction. Although the chromosomal abnormalities of these rare syndromes are already known, the specific genetic and pathophysiological mechanisms leading to the distinct phenotypes and obesity still remain unclarified. New exciting genetic pathways contributing to syndrome phenotype and leading to obesity have recently been identified. Prader-Willi syndrome is caused by loss of expression of the C/D box HBII-84 cluster of snoRNAs. Dysfunction of the primary cilium, thought to have important signalling functions, may contribute to disease phenotype and obesity in Bardet-Biedl, Alstrom and Carpenter syndromes. In this mini-review current knowledge of clinical and genetic characteristics is summarized as well as the pathogenesis of these syndromes with special emphasis on the pathogenesis of obesity.
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Affiliation(s)
- Eleni Kousta
- Department of Endocrinology, P & A Kyriakou Children's Hospital, Athens, Greece.
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Olenchock SA, Lee PH, Yehoshua T, Murphy SA, Symes J, Tolis G. Impact of Aprotinin on Adverse Clinical Outcomes and Mortality up to 12 Years in a Registry of 3,337 Patients. Ann Thorac Surg 2008; 86:560-6; discussion 566-7. [DOI: 10.1016/j.athoracsur.2008.04.048] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2008] [Revised: 04/11/2008] [Accepted: 04/14/2008] [Indexed: 10/21/2022]
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Angelopoulos NG, Goula A, Katounda E, Rombopoulos G, Kaltzidou V, Kaltsas D, Konstandelou E, Tolis G. Markers of bone metabolism in eugonadal female patients with beta-thalassemia major. Pediatr Hematol Oncol 2007; 24:481-91. [PMID: 17786784 DOI: 10.1080/08880010701533611] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Osteoprotegerin (OPG) and receptor activator of NF-kappaB ligand (RANKL) have been recently implicated in the pathogenesis of various types of osteoporosis. The aim of this study was to investigate bone turnover in eugonadal female patients with this disease and characterize the possible role of the OPG/RANKL system in thalassemia-related bone loss. Markers of bone turnover and bone mineral density (BMD) were measured in 16 eugonadal young females with beta-thalassemia major and 18 age- and sex-matched healthy controls. Bone turnover was significantly increased in thalassemic patients compared to controls but OPG was significantly higher in healthy subjects. BMD values negatively correlated with urine markers of bone resorption but not with OPG/sRANKL system.
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Dourakis SP, Alexopoulou A, Georgousi KK, Delladetsima JK, Tolis G, Archimandritis AJ. Glucagonoma Syndrome: Survival 21 Years With Concurrent Liver Metastases. Am J Med Sci 2007; 334:225-7. [PMID: 17873541 DOI: 10.1097/maj.0b013e318141ff0b] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
A patient who survived for 21 years since initial discovery of glucagonoma with concurrent liver metastases is described. Psychiatric symptoms, weight loss, necrolytic migratory erythema, diarrhea, and diabetes mellitus developed gradually after diagnosis of the tumor. No specific treatment was administered. The longevity of this patient may be related to the slow tumor growth expressed histologically by ischemic necrosis of the malignant cells and in imaging by extensive tumor calcifications, a very rare finding in this type of the tumor.
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Affiliation(s)
- Spyros P Dourakis
- Second Department of Medicine, University of Athens Medical School, Hippokration General Hospital, Athens, Greece
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Abstract
PURPOSE OF REVIEW Bone loss and muscle wasting are associated with increased morbidity and mortality in the elderly, most frequently as a result of fractures associated with poor neuromuscular conditioning leading to accidental falls. This paper reviews data that link pathways of the immune and endocrine systems with bone and muscle pathophysiology, as well as data on the impact of nutrition and physical activity on these systems. RECENT FINDINGS The growth hormone-insulin-like growth factor I axis and deficiencies in sex steroid hormones in aging appear linked with changes in the hypothalamic-pituitary-adrenal axis and immune function, accompanied by increased activity of the tumour necrosis factor-alpha axis. This is associated with activation of the RANK/RANKL/osteoprotegerin pathway and insulin resistance, affecting muscle and bone physiology. Vitamin D deficiency contributes to bone loss and muscle wasting, whereas other nutritional defects such as zinc or magnesium deficiencies may further complicate these catabolic states. SUMMARY As nutritional deficiencies responsible for bone and muscle derangement are correctable factors, careful nutritional assessment, in addition to evaluation of endocrine and immune status, may provide clinically important information allowing successful management of elderly patients in danger of neuromuscular dysfunction, accidental falls and bone fractures.
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Affiliation(s)
- Aristides Lytras
- Department of Endocrinology and Metabolism, Hippokrateion General Hospital, Athens, Greece.
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Angelopoulos N, Papanikolaou G, Noutsou M, Rombopoulos G, Goula A, Tolis G. Glucose metabolism, insulin secretion and insulin sensitivity in juvenile hemochromatosis. A case report and review of the literature. Exp Clin Endocrinol Diabetes 2007; 115:192-7. [PMID: 17427110 DOI: 10.1055/s-2007-970426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Among specific diabetes subtypes secondary to pancreatopathies, hereditary hemochromatosis is an inherited disorder of iron metabolism resulting in excessive iron overload and tissue damage in various organs. We here report the case of a man with the young-onset form of the disease and describe his glycaemic status before and during venesection therapy. A 25-year old man visited our clinic in Athens, Greece, with hypogonadotropic hypogonadism due to hereditary hemochromatosis. Genetic analysis revealed that he was suffering from the juvenile aggressive form and treatment was initiated with frequent phlebotomies in conjunction with androgen substitution. Within 18 months of therapy ferritin level was normalized and hypogonadism was fully restored. Despite severe iron overload, glucose tolerance remained normal during the various stages of the disease, although alterations in both insulin secretion and sensitivity were detected. Present data indicate that in juvenile hemochromatosis, the efficacy of the chelation therapy and probably the chronic interval required to restore normal iron concentration both play important roles in the formation of glucose metabolism characteristics.
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Affiliation(s)
- N Angelopoulos
- Endocrine Department, Hippokrateion Hospital of Athens, Athens, Greece.
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