1
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Quintana EN, DeBose-Scarlett A, McLaren TA, Gondek SP, Smith MC, Alder MR, Baker MT, Shah AS, Absi TS. Acute cardiogenic shock secondary to blunt traumatic aortic valve injury. Trauma Case Rep 2024; 51:100995. [PMID: 38572422 PMCID: PMC10987328 DOI: 10.1016/j.tcr.2024.100995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 04/05/2024] Open
Abstract
Background Blunt cardiac injuries rarely result in aortic valve cusp rupture, leading to acute aortic insufficiency and cardiogenic shock. This rare clinical entity carries a high mortality rate if left undiagnosed and not managed surgically, with few patients surviving beyond 24 h. It presents a diagnostic challenge in the polytrauma patient in shock, with multiple possible and complementary etiologies. Case presentation We present a 56-year-old male with persistent hypotension, a wide pulse pressure, and elevated serum troponin levels suggesting blunt cardiac injury after a motor vehicle accident. Transthoracic and transesophageal echocardiography revealed normal biventricular function but severe aortic insufficiency due to prolapse of the left coronary cusp.He was taken emergently to surgery, where aortic valve exploration revealed complete left coronary cusp avulsion from the aortic annulus with a mid-cusp tear, requiring aortic valve replacement with a bioprosthetic valve. Postoperative echocardiography showed normal biventricular function with a well-seated bioprosthetic aortic valve with no insufficiency. Conclusions Traumatic aortic valve injury can lead to torn or prolapsed cusps causing acute aortic insufficiency leading to cardiogenic shock, but early recognition with appropriate and targeted diagnostic imaging is vital to prevent rapid patient deterioration and demise.
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Affiliation(s)
- Eric N. Quintana
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Alexandra DeBose-Scarlett
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Thomas A. McLaren
- Department of Radiology, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Stephen P. Gondek
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Michael C. Smith
- Division of Trauma and Surgical Critical Care, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Madeleine R. Alder
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Michael T. Baker
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Ashish S. Shah
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
| | - Tarek S. Absi
- Department of Thoracic Surgery, Vanderbilt University Medical Center, Nashville, TN, United States of America
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2
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Schroder JN, Patel CB, DeVore AD, Casalinova S, Koomalsingh KJ, Shah AS, Anyanwu AC, D'Alessandro DA, Mudy K, Sun B, Strueber M, Khaghani A, Shudo Y, Esmailian F, Liao K, Pagani FD, Silvestry S, Wang IW, Salerno CT, Absi TS, Madsen JC, Mancini D, Fiedler AG, Milano CA, Smith JW. Increasing Utilization of Extended Criteria Donor Hearts for Transplantation: The OCS Heart EXPAND Trial. JACC Heart Fail 2024; 12:438-447. [PMID: 38276933 DOI: 10.1016/j.jchf.2023.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 11/09/2023] [Accepted: 11/28/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Extended criteria donor (ECD) hearts available with donation after brain death (DBD) are underutilized for transplantation due to limitations of cold storage. OBJECTIVES This study evaluated use of an extracorporeal perfusion system on donor heart utilization and post-transplant outcomes in ECD DBD hearts. METHODS In this prospective, single-arm, multicenter study, adult heart transplant recipients received ECD hearts using an extracorporeal perfusion system if hearts met study criteria. The primary outcome was a composite of 30-day survival and absence of severe primary graft dysfunction (PGD). Secondary outcomes were donor heart utilization rate, 30-day survival, and incidence of severe PGD. The safety outcome was the mean number of heart graft-related serious adverse events within 30 days. Additional outcomes included survival through 2 years benchmarked to concurrent nonrandomized control subjects. RESULTS A total of 173 ECD DBD hearts were perfused; 150 (87%) were successfully transplanted; 23 (13%) did not meet study transplantation criteria. At 30 days, 92% of patients had survived and had no severe PGD. The 30-day survival was 97%, and the incidence of severe PGD was 6.7%. The mean number of heart graft-related serious adverse events within 30 days was 0.17 (95% CI: 0.11-0.23). Patient survival was 93%, 89%, and 86% at 6, 12, and 24 months, respectively, and was comparable with concurrent nonrandomized control subjects. CONCLUSIONS Use of an extracorporeal perfusion system resulted in successfully transplanting 87% of donor hearts with excellent patient survival to 2 years post-transplant and low rates of severe PGD. The ability to safely use ECD DBD hearts could substantially increase the number of heart transplants and expand access to patients in need. (International EXPAND Heart Pivotal Trial [EXPANDHeart]; NCT02323321; Heart EXPAND Continued Access Protocol; NCT03835754).
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Affiliation(s)
| | | | - Adam D DeVore
- Duke University Hospital, Durham, North Carolina, USA
| | | | | | - Ashish S Shah
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | | | - Karol Mudy
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | - Benjamin Sun
- Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota, USA
| | | | | | - Yasuhiro Shudo
- Stanford University Medical Center, Stanford, California, USA
| | | | | | | | | | - I-Wen Wang
- Memorial Healthcare System, Hollywood, Florida, USA
| | | | - Tarek S Absi
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Joren C Madsen
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Donna Mancini
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Amy G Fiedler
- University of California-San Francisco, San Francisco, California, USA
| | | | - Jason W Smith
- University of California-San Francisco, San Francisco, California, USA
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3
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Novitskaya T, Nishat S, Covarrubias R, Wheeler DG, Chepurko E, Bermeo-Blanco O, Xu Z, Baer B, He H, Moore SN, Dwyer KM, Cowan PJ, Su YR, Absi TS, Schoenecker J, Bellan LM, Koch WJ, Bansal S, Feoktistov I, Robson SC, Gao E, Gumina RJ. Ectonucleoside triphosphate diphosphohydrolase-1 (CD39) impacts TGF-β1 responses: insights into cardiac fibrosis and function following myocardial infarction. Am J Physiol Heart Circ Physiol 2022; 323:H1244-H1261. [PMID: 36240436 PMCID: PMC9722260 DOI: 10.1152/ajpheart.00138.2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 10/03/2022] [Accepted: 10/03/2022] [Indexed: 12/14/2022]
Abstract
Extracellular purine nucleotides and nucleosides released from activated or injured cells influence multiple aspects of cardiac physiology and pathophysiology. Ectonucleoside triphosphate diphosphohydrolase-1 (ENTPD1; CD39) hydrolyzes released nucleotides and thereby regulates the magnitude and duration of purinergic signaling. However, the impact of CD39 activity on post-myocardial infarction (MI) remodeling is incompletely understood. We measured the levels and activity of ectonucleotidases in human left ventricular samples from control and ischemic cardiomyopathy (ICM) hearts and examined the impact of ablation of Cd39 expression on post-myocardial infarction remodeling in mice. We found that human CD39 levels and activity are significantly decreased in ICM hearts (n = 5) compared with control hearts (n = 5). In mice null for Cd39, cardiac function and remodeling are significantly compromised in Cd39-/- mice following myocardial infarction. Fibrotic markers including plasminogen activator inhibitor-1 (PAI-1) expression, fibrin deposition, α-smooth muscle actin (αSMA), and collagen expression are increased in Cd39-/- hearts. Importantly, we found that transforming growth factor β1 (TGF-β1) stimulates ATP release and induces Cd39 expression and activity on cardiac fibroblasts, constituting an autocrine regulatory pathway not previously appreciated. Absence of CD39 activity on cardiac fibroblasts exacerbates TGF-β1 profibrotic responses. Treatment with exogenous ectonucleotidase rescues this profibrotic response in Cd39-/- fibroblasts. Together, these data demonstrate that CD39 has important interactions with TGF-β1-stimulated autocrine purinergic signaling in cardiac fibroblasts and dictates outcomes of cardiac remodeling following myocardial infarction. Our results reveal that ENTPD1 (CD39) regulates TGF-β1-mediated fibroblast activation and limits adverse cardiac remodeling following myocardial infarction.NEW & NOTEWORTHY We show that CD39 is a critical modulator of TGF-β1-mediated fibroblast activation and cardiac remodeling following myocardial infarction via modulation of nucleotide signaling. TGF-β1-induced CD39 expression generates a negative feedback loop that attenuates cardiac fibroblast activation. In the absence of CD39 activity, collagen deposition is increased, elastin expression is decreased, and diastolic dysfunction is worsened. Treatment with ecto-apyrase attenuates the TGF-β1-induced profibrotic cardiac fibroblast phenotype, revealing a novel approach to combat post-myocardial infarction cardiac fibrosis.
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Affiliation(s)
- Tatiana Novitskaya
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Shamama Nishat
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Roman Covarrubias
- Division of Cardiac Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Davis Heart and Lung Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Debra G Wheeler
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Elena Chepurko
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Oscar Bermeo-Blanco
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Zhaobin Xu
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Bradly Baer
- Department of Mechanical Engineering, Vanderbilt University School of Engineering, Nashville, Tennessee
| | - Heng He
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Stephanie N Moore
- Division of Orthopedic Surgery, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Karen M Dwyer
- Immunology Research Center, St. Vincent's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Peter J Cowan
- Immunology Research Center, St. Vincent's Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Yan Ru Su
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tarek S Absi
- Division of Cardiac Surgery, Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Schoenecker
- Division of Orthopedic Surgery, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Leon M Bellan
- Department of Mechanical Engineering, Vanderbilt University School of Engineering, Nashville, Tennessee
| | | | - Shyam Bansal
- Davis Heart and Lung Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Igor Feoktistov
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Simon C Robson
- Transplantation Biology Research Center, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Erhe Gao
- Temple University, Philadelphia, Pennsylvania
| | - Richard J Gumina
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Department of Physiology and Cell Biology, The Ohio State University Wexner Medical Center, Columbus, Ohio
- Davis Heart and Lung Institute, The Ohio State University Wexner Medical Center, Columbus, Ohio
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4
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Wanjalla CN, Mashayekhi M, Bailin S, Gabriel CL, Meenderink LM, Temu T, Fuller DT, Guo L, Kawai K, Virmani R, Jenkins C, Abana CO, Warren CM, Gangula R, Smith R, Madhur MS, Finn AV, Gelbard AH, Su YR, Tyska MJ, Kalams SA, Harrison DG, Mallal SA, Absi TS, Beckman JA, Koethe JR. Anticytomegalovirus CD4 + T Cells Are Associated With Subclinical Atherosclerosis in Persons With HIV. Arterioscler Thromb Vasc Biol 2021; 41:1459-1473. [PMID: 33567869 DOI: 10.1161/atvbaha.120.315786] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Celestine N Wanjalla
- Division of Infectious Diseases (C.N.W., S.B., L.M.M., C.M.W., R.G., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville.,Tennessee Center for AIDS Research (C.N.W., C.L.G., C.M.W., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville
| | - Mona Mashayekhi
- Division of Diabetes, Endocrinology and Metabolism (M.M.), Vanderbilt University Medical Center, Nashville
| | - Samuel Bailin
- Division of Infectious Diseases (C.N.W., S.B., L.M.M., C.M.W., R.G., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville
| | - Curtis L Gabriel
- Tennessee Center for AIDS Research (C.N.W., C.L.G., C.M.W., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville.,Division of Gastroenterology (C.L.G., ), Vanderbilt University Medical Center, Nashville
| | - Leslie M Meenderink
- Division of Infectious Diseases (C.N.W., S.B., L.M.M., C.M.W., R.G., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville.,Department of Cell and Developmental Biology, Vanderbilt University, Nashville, TN (L.M.M.).,Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN (L.M.M., J.R.K.)
| | - Tecla Temu
- Department of Global Health, University of Washington, Seattle (T.T.)
| | | | - Liang Guo
- CVPath Institute, Gaithersburg, MD (D.T.F., L.G., K.K., R.V.)
| | - Kenji Kawai
- CVPath Institute, Gaithersburg, MD (D.T.F., L.G., K.K., R.V.)
| | - Renu Virmani
- CVPath Institute, Gaithersburg, MD (D.T.F., L.G., K.K., R.V.)
| | - Cathy Jenkins
- Department of Biostatistics (C.J.), Vanderbilt University Medical Center, Nashville
| | - Chike O Abana
- Department of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston (C.O.A.)
| | - Christian M Warren
- Division of Infectious Diseases (C.N.W., S.B., L.M.M., C.M.W., R.G., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville.,Tennessee Center for AIDS Research (C.N.W., C.L.G., C.M.W., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville
| | - Rama Gangula
- Division of Infectious Diseases (C.N.W., S.B., L.M.M., C.M.W., R.G., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville
| | - Rita Smith
- Division of Infectious Diseases (C.N.W., S.B., L.M.M., C.M.W., R.G., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville
| | - Meena S Madhur
- Division of Clinical Pharmacology (M.S.M., D.G.H.), Vanderbilt University Medical Center, Nashville
| | | | - Alexander H Gelbard
- Department of Otolaryngology (A.H.G., S.A.M.), Vanderbilt University Medical Center, Nashville
| | - Yan Ru Su
- Division of Cardiovascular Medicine (Y.R.S., J.A.B.), Vanderbilt University Medical Center, Nashville
| | | | - Spyros A Kalams
- Division of Infectious Diseases (C.N.W., S.B., L.M.M., C.M.W., R.G., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville.,Tennessee Center for AIDS Research (C.N.W., C.L.G., C.M.W., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville.,Department of Otolaryngology (A.H.G., S.A.M.), Vanderbilt University Medical Center, Nashville.,Vanderbilt Technologies for Advanced Genomics (VANTAGE) (S.A.M.), Vanderbilt University Medical Center, Nashville
| | - David G Harrison
- Division of Clinical Pharmacology (M.S.M., D.G.H.), Vanderbilt University Medical Center, Nashville
| | - Simon A Mallal
- Division of Infectious Diseases (C.N.W., S.B., L.M.M., C.M.W., R.G., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville.,Tennessee Center for AIDS Research (C.N.W., C.L.G., C.M.W., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville
| | - Tarek S Absi
- Department of Cardiac Surgery (T.S.A.), Vanderbilt University Medical Center, Nashville
| | - Joshua A Beckman
- Division of Cardiovascular Medicine (Y.R.S., J.A.B.), Vanderbilt University Medical Center, Nashville
| | - John R Koethe
- Division of Infectious Diseases (C.N.W., S.B., L.M.M., C.M.W., R.G., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville.,Tennessee Center for AIDS Research (C.N.W., C.L.G., C.M.W., R.S., S.A.K., S.A.M., J.R.K.), Vanderbilt University Medical Center, Nashville.,Veterans Affairs Tennessee Valley Healthcare System, Nashville, TN (L.M.M., J.R.K.)
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5
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Ramakrishnan A, Fontes ML, Lombard FW, Abdelmalak M, Hong Y, Shi Y, Shotwell MS, Billings FT, Pretorius M, Wanderer JP, Vyas R, Absi TS, Shah AS, Kertai MD. Mean Platelet Volume and Cardiac Surgery-Associated Atrial Fibrillation. J Cardiothorac Vasc Anesth 2020; 35:2533-2536. [PMID: 33262036 DOI: 10.1053/j.jvca.2020.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2020] [Revised: 11/03/2020] [Accepted: 11/06/2020] [Indexed: 11/11/2022]
Affiliation(s)
| | | | - Frederic W Lombard
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | | | | | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN
| | - Frederic T Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Mias Pretorius
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN; Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN
| | - Rushikesh Vyas
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Tarek S Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
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6
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Ramakrishnan A, Zheng C, Fontes ML, Lombard FW, Woolard AA, Shi Y, Shotwell MS, Billings FT, Pretorius M, Wanderer JP, Vyas R, Absi TS, Shah AS, Kertai MD. In reply: Uncertainties in the relationship between high mean platelet volume and acute kidney injury after cardiac surgery. Can J Anaesth 2020; 68:163-164. [PMID: 33083925 DOI: 10.1007/s12630-020-01836-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/05/2020] [Accepted: 10/08/2020] [Indexed: 10/23/2022] Open
Affiliation(s)
| | - Cynthia Zheng
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | | | - Frederic W Lombard
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Austin A Woolard
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Yaping Shi
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew S Shotwell
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Frederic T Billings
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mias Pretorius
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.,Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Rushikesh Vyas
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tarek S Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
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7
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Ramakrishnan A, Zheng C, Fontes ML, Lombard FW, Woolard AA, Shi Y, Shotwell MS, Billings FT, Pretorius M, Wanderer JP, Vyas R, Absi TS, Shah AS, Kertai MD. Mean platelet volume and cardiac-surgery–associated acute kidney injury: a retrospective study. Can J Anaesth 2020; 67:1775-1788. [DOI: 10.1007/s12630-020-01811-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/26/2020] [Accepted: 07/01/2020] [Indexed: 12/12/2022] Open
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8
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Haddad DN, Shipe ME, Absi TS, Danter MR, Vyas R, Levack M, Shah AS, Grogan EL, Balsara KR. Preparing for Bundled Payments: Impact of Complications Post-Coronary Artery Bypass Grafting on Costs. Ann Thorac Surg 2020; 111:1258-1263. [PMID: 32896546 DOI: 10.1016/j.athoracsur.2020.06.105] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 05/25/2020] [Accepted: 06/23/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Bundled payments for coronary artery bypass grafting (CABG) provide a single reimbursement for care provided from admission through 90 days post-discharge. We aim to explore the impact of complications on total institutional costs, as well as the drivers of high costs for index hospitalization. METHODS We linked clinical and internal cost data for patients undergoing CABG from 2014 to 2017 at a single institution. We compared unadjusted average variable direct costs, reporting excess cost from an uncomplicated baseline. We stratified by The Society of Thoracic Surgeons preoperative risk and quality outcome measures as well as value-based outcomes (readmission, post-acute care utilization). We performed multivariable linear regression to evaluate drivers of high costs, adjusting for preoperative and intraoperative characteristics and postoperative complications. RESULTS We reviewed 1789 patients undergoing CABG with an average of 2.7 vessels (SD 0.89). A significant proportion of patients were diabetic (51.2%) and obese (mean body mass index 30.6, SD 6.1). Factors associated with increased adjusted costs were preoperative renal failure (P = .001), diabetes (P = .001) and body mass index (P = .05), and postoperative stroke (P < .001), prolonged ventilation (P < .001), rebleeding requiring reoperation (P < .001) and renal failure (P < .001) with varying magnitude. Preoperative ejection fraction and insurance status were not associated with increased adjusted costs. CONCLUSIONS Preoperative characteristics had less of an impact on costs post-CABG than postoperative complications. Postoperative complications vary in their impact on internal costs, with reoperation, stroke, and renal failure having the greatest impact. In preparation for bundled payments, hospitals should focus on understanding and preventing drivers of high cost.
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Affiliation(s)
- Diane N Haddad
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Maren E Shipe
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Tarek S Absi
- Department of Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew R Danter
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Rushikesh Vyas
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Melissa Levack
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eric L Grogan
- Division of Thoracic Surgery, Tennessee Valley Healthcare System, Nashville, Tennessee
| | - Keki R Balsara
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee.
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9
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Halliday SJ, Matthews DT, Talati MH, Austin ED, Su YR, Absi TS, Fortune NL, Gailani D, Matafonov A, West JD, Hemnes AR. A multifaceted investigation into molecular associations of chronic thromboembolic pulmonary hypertension pathogenesis. JRSM Cardiovasc Dis 2020; 9:2048004020906994. [PMID: 32110389 PMCID: PMC7019411 DOI: 10.1177/2048004020906994] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 12/03/2022] Open
Abstract
Purpose Chronic thromboembolic pulmonary hypertension is characterized by incomplete
thrombus resolution following acute pulmonary embolism, leading to pulmonary
hypertension and right ventricular dysfunction. Conditions such as
thrombophilias, dysfibrinogenemias, and inflammatory states have been
associated with chronic thromboembolic pulmonary hypertension, but molecular
mechanisms underlying this disease are poorly understood. We sought to
characterize the molecular and functional features associated with chronic
thromboembolic pulmonary hypertension using a multifaceted approach. Methods We utilized functional assays to compare clot lysis times between chronic
thromboembolic pulmonary hypertension patients and multiple controls. We
then performed immunohistochemical characterization of tissue from chronic
thromboembolic pulmonary hypertension, pulmonary arterial hypertension, and
healthy controls, and examined RNA expression patterns of cultured
lymphocytes and pulmonary arterial specimens. We then confirmed RNA
expression changes using immunohistochemistry, immunofluorescence, and
Western blotting in pulmonary arterial tissue. Results Clot lysis times in chronic thromboembolic pulmonary hypertension patients
are similar to multiple controls. Chronic thromboembolic pulmonary
hypertension endarterectomized tissue has reduced expression of both smooth
muscle and endothelial cell markers. RNA expression profiles in pulmonary
arteries and peripheral blood lymphocytes identified differences in RNA
transcript levels related to inflammation and growth factor signaling, which
we confirmed using immunohistochemistry. Gene expression data also suggested
significant alterations in metabolic pathways, and immunofluorescence and
Western blot experiments confirmed that unglycosylated CD36 and adiponectin
expression were increased in chronic thromboembolic pulmonary hypertension
versus controls. Conclusions Our data do not support impaired clot lysis underlying chronic thromboembolic
pulmonary hypertension, but did demonstrate distinct molecular patterns
present both in peripheral blood and in pathologic specimens of chronic
thromboembolic pulmonary hypertension patients suggesting that altered
metabolism may play a role in chronic thromboembolic pulmonary hypertension
pathogenesis.
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Affiliation(s)
- Stephen J Halliday
- Division of Allergy, Pulmonary and Critical Care Medicine, University of Wisconsin Madison, Madison, USA
| | - Daniel T Matthews
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Megha H Talati
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Eric D Austin
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Yan R Su
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Tarek S Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, USA
| | - Niki L Fortune
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - David Gailani
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, USA
| | - Anton Matafonov
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, USA
| | - James D West
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
| | - Anna R Hemnes
- Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, USA
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10
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Williams RD, Foley NM, Vyas R, Huang S, Kertai MD, Balsara KR, Petracek MR, Shah AS, Absi TS. Predictors of Stroke After Minimally Invasive Mitral Valve Surgery Without the Cross-Clamp. Semin Thorac Cardiovasc Surg 2020; 32:47-56. [DOI: 10.1053/j.semtcvs.2019.09.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 09/04/2019] [Indexed: 11/11/2022]
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11
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Dunham WC, Weinger MB, Slagle J, Pretorius M, Shah AS, Absi TS, Shotwell MS, Beller M, Thomas E, Vnencak-Jones CL, Freundlich RE, Wanderer JP, Sandberg WS, Kertai MD. CYP2D6 Genotype-guided Metoprolol Therapy in Cardiac Surgery Patients: Rationale and Design of the Pharmacogenetic-guided Metoprolol Management for Postoperative Atrial Fibrillation in Cardiac Surgery (PREEMPTIVE) Pilot Study. J Cardiothorac Vasc Anesth 2019; 34:20-28. [PMID: 31606278 DOI: 10.1053/j.jvca.2019.09.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Revised: 08/29/2019] [Accepted: 09/04/2019] [Indexed: 12/25/2022]
Abstract
OBJECTIVES The Preemptive Pharmacogenetic-guided Metoprolol Management for Atrial Fibrillation in Cardiac Surgery (PREEMPTIVE) pilot trial aims to use existing institutional resources to develop a process for integrating CYP2D6 pharmacogenetic test results into the patient electronic health record, to develop an evidence-based clinical decision support tool to facilitate CYP2D6 genotype-guided metoprolol administration in the cardiac surgery setting, and to determine the impact of implementing this CYP2D6 genotype-guided integrated approach on the incidence of postoperative atrial fibrillation (AF), provider, and cost outcomes. DESIGN One-arm Bayesian adaptive design clinical trial. SETTING Single center, university hospital. PARTICIPANTS The authors will screen (including CYP2D6 genotype) up to 600 (264 ± 144 expected under the adaptive design) cardiac surgery patients, and enroll up to 200 (88 ± 48 expected) poor, intermediate, and ultrarapid CYP2D6 metabolizers over a period of 2 years at a tertiary academic center. INTERVENTIONS All consented and enrolled patients will receive the intervention of CYP2D6 genotype-guided metoprolol management based on CYP2D6 phenotype classified as a poor, intermediate, extensive (normal), or ultrarapid metabolizer. MEASUREMENTS AND MAIN RESULTS The primary outcome will be the incidence of postoperative AF. Secondary outcomes relating to rates of CYP2D6 genotype-guided prescription changes, costs, lengths of stay, and implementation metrics also will be investigated. CONCLUSIONS The PREEMPTIVE pilot study is the first perioperative pilot trial to provide essential information for the design of a future, large-scale trial comparing CYP2D6 genotype-guided metoprolol management with a nontailored strategy in terms of managing AF. In addition, secondary outcomes regarding implementation, clinical benefit, safety, and cost-effectiveness in patients undergoing cardiac surgery will be examined.
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Affiliation(s)
- Wills C Dunham
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew B Weinger
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Research and Innovation in System Safety, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jason Slagle
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Center for Research and Innovation in System Safety, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Mias Pretorius
- Department of anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Tarek S Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Matthew S Shotwell
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marc Beller
- Center for Precision Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Erica Thomas
- Department of Pharmaceutical Services, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Cindy L Vnencak-Jones
- Department of Pathology, Microbiology and Immunology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Robert E Freundlich
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jonathan P Wanderer
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Warren S Sandberg
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Informatics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Miklos D Kertai
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA.
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12
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Absi TS, Sundt TM, Camillo C, Schuessler RB, Gutierrez FR. Penetrating Atherosclerotic Ulcers of the Descending Thoracic Aorta May Be Managed Expectantly. Vascular 2016; 12:307-11. [PMID: 15768479 DOI: 10.1258/rsmvasc.12.5.307] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The natural history of penetrating atherosclerotic ulcers (PAUs) of the descending thoracic aorta remains unclear. Between January 1996 and June 2000, PAU was diagnosed in 36 patients (16 men, 20 women; mean age 74.9 ± 1.5 years) at Washington University. Imaging studies and hospital records were reviewed. Late follow-up was by search of the Social Security Death Index and telephone interview. None of 16 asymptomatic patients underwent operation. At follow-up (median 457 days), 6 patients had died of unrelated and 2 of unknown causes. Among 20 symptomatic patients, 10 had associated intramural hematoma (5) or dissection (5), of whom 3 underwent operation. At median follow-up (448 days), the 7 unoperated patients remained alive without an aortic operation. Among the remaining 10 symptomatic patients, 3 had an aortic operation and 2 died of unknown causes during follow-up (median 586 days). These data suggest that, in selected cases, PAU may be managed expectantly with careful observation.
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Affiliation(s)
- Tarek S Absi
- Department of Surgery, Division of Cardiothoracic Surgery, Washington University School of Medicine, St. Louis, MO, USA
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13
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Su YR, Chiusa M, Brittain E, Hemnes AR, Absi TS, Lim CC, Di Salvo TG. Right ventricular protein expression profile in end-stage heart failure. Pulm Circ 2015; 5:481-97. [PMID: 26401249 DOI: 10.1086/682219] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 12/30/2014] [Indexed: 11/03/2022] Open
Abstract
Little is known about the right ventricular (RV) proteome in human heart failure (HF), including possible differences compared to the left ventricular (LV) proteome. We used 2-dimensional differential in-gel electrophoresis (pH: 4-7, 10-150 kDa), followed by liquid chromatography tandem mass spectrometry, to compare the RV and LV proteomes in 12 explanted human hearts. We used Western blotting and multiple-reaction monitoring for protein verification and RNA sequencing for messenger RNA and protein expression correlation. In all 12 hearts, the right ventricles (RVs) demonstrated differential expression of 11 proteins relative to the left ventricles (LVs), including lesser expression of CRYM, TPM1, CLU, TXNL1, and COQ9 and greater expression of TNNI3, SAAI, ERP29, ACTN2, HSPB2, and NDUFS3. Principal-components analysis did not suggest RV-versus-LV proteome partitioning. In the nonischemic RVs (n = 6), 7 proteins were differentially expressed relative to the ischemic RVs (n = 6), including increased expression of CRYM, B7Z964, desmin, ANXA5, and MIME and decreased expression of SERPINA1 and ANT3. Principal-components analysis demonstrated partitioning of the nonischemic and ischemic RV proteomes, and gene ontology analysis identified differences in hemostasis and atherosclerosis-associated networks. There were no proteomic differences between RVs with echocardiographic dysfunction (n = 8) and those with normal function (n = 4). Messenger RNA and protein expression did not correlate consistently, suggesting a major role for RV posttranscriptional protein expression regulation. Differences in contractile, cytoskeletal, metabolic, signaling, and survival pathways exist between the RV and the LV in HF and may be related to the underlying HF etiology and differential posttranscriptional regulation.
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Affiliation(s)
- Yan Ru Su
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Manuel Chiusa
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Evan Brittain
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Anna R Hemnes
- Division of Pulmonary Medicine and Critical Care, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Tarek S Absi
- Department of Surgical Science, Division of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Chee Chew Lim
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Thomas G Di Salvo
- Division of Cardiovascular Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA
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14
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Brittain EL, Goyal SK, Sample MA, Leacche M, Absi TS, Papa F, Churchwell KB, Ball S, Byrne JG, Maltais S, Petracek MR, Mendes L. Minimally invasive fibrillating mitral valve replacement for patients with advanced cardiomyopathy: a safe and effective approach to treat a complex problem. J Thorac Cardiovasc Surg 2013; 148:2045-2051.e1. [PMID: 24332110 DOI: 10.1016/j.jtcvs.2013.10.062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2013] [Revised: 09/26/2013] [Accepted: 10/25/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The optimal management of mitral regurgitation (MR) in patients with cardiomyopathy has been controversial. Minimally invasive fibrillating mitral valve replacement (mini-MVR) might limit postoperative morbidity and mortality by minimizing recurrent MR. We hypothesized that mini-MVR with complete chordal sparing would offer low mortality and halt left ventricular (LV) remodeling in patients with severe cardiomyopathy and severe MR. METHODS From January 2006 to August 2009, 65 patients with an LV ejection fraction (LVEF) of ≤35% underwent mini-MVR. The demographic, echocardiographic, and clinical outcomes were analyzed. RESULTS The operative mortality compared with the Society of Thoracic Surgeons-predicted mortality was 6.2% versus 6.6%. It was 5.6% versus 7.4% for patients with an LVEF of ≤20% and 8.3% versus 17.9% among patients with a Society of Thoracic Surgeons-predicted mortality of ≥10%. At a median follow-up of 17 months, no recurrent MR or change in the LV dimensions or LVEF had developed, but the right ventricular systolic pressure had decreased (P=.02). At the first postoperative visit and latest follow-up visit, the New York Heart Association class had decreased from 3.0±0.6 to 1.7±0.7 and 2.0±1.0, respectively (P<.0001 for both). Patients with an LVEF of ≤20% and LV end-diastolic diameter of ≥6.5 cm were more likely to meet a composite of death, transplantation, or LV assist device insertion (P=.046). CONCLUSIONS Our results have shown that mini-MVR is safe in patients with advanced cardiomyopathy and resulted in no recurrent MR, stabilization of the LVEF and LV dimensions, and a decrease in right ventricular systolic pressure. This mini-MVR technique can be used to address severe MR in patients with advanced cardiomyopathy.
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Affiliation(s)
- Evan L Brittain
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn.
| | - Sandeep K Goyal
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Matthew A Sample
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Marzia Leacche
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Tarek S Absi
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Frank Papa
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Keith B Churchwell
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
| | - Stephen Ball
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - John G Byrne
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Simon Maltais
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Michael R Petracek
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tenn
| | - Lisa Mendes
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
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15
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Umakanthan R, Petracek MR, Leacche M, Solenkova NV, Eagle SS, Thompson A, Ahmad RM, Greelish JP, Ball SK, Hoff SJ, Absi TS, Balaguer JM, Byrne JG. Minimally invasive right lateral thoracotomy without aortic cross-clamping: an attractive alternative to repeat sternotomy for reoperative mitral valve surgery. J Heart Valve Dis 2010; 19:236-243. [PMID: 20369510] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
BACKGROUND AND AIM OF THE STUDY The study aim was to determine the safety and benefits of minimally invasive mitral valve surgery without aortic cross-clamping for mitral valve surgery after previous cardiac surgery. METHODS Between January 2006 and August 2008, a total of 90 consecutive patients (38 females, 52 males; mean age 66 +/- 9 years) underwent minimally invasive mitral valve surgery after having undergone previous cardiac surgery. Of these patients, 80 (89%) underwent mitral valve replacement and 10 (11%) mitral valve repair utilizing a small (5 cm) right lateral thoracotomy along the 4th or 5th intercostal space under fibrillatory arrest (mean temperature 28 +/- 2 degrees C). The predicted mortality, calculated using the Society of Thoracic Surgeons (STS) algorithm, was compared to the observed mortality. RESULTS The mean ejection fraction was 45 +/- 13%, mean NYHA class 3 +/- 1, while 66 patients (73%) had previous coronary artery bypass grafting and 37 (41%) had previous valve surgery. Twenty-six patients (29%) underwent non-elective surgery. Cardiopulmonary bypass was instituted through axillary (n = 19), femoral (n = 70) or direct use aortic (n = 1) cannulation. Operative mortality was 2% (2/90), lower than the STS-predicted mortality of 7%. Three patients (3%) developed acute renal failure postoperatively, one patient (1%) required new-onset hemodialysis, and one (1%) developed postoperative stroke. No patients developed postoperative myocardial infarction. The mean postoperative packed red blood cell transfusion requirement at 48 h was 2 +/- 3 units. CONCLUSION Minimally invasive right thoracotomy without aortic cross-clamping is an excellent alternative to conventional redo-sternotomy for reoperative mitral valve surgery. The present study confirmed that this technique is safe and effective in reducing operative mortality in high-risk patients undergoing reoperative cardiac surgery.
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16
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Van Vickle-Chavez SJ, Tung WS, Absi TS, Ennis TL, Mao D, Cobb JP, Thompson RW. Temporal changes in mouse aortic wall gene expression during the development of elastase-induced abdominal aortic aneurysms. J Vasc Surg 2006; 43:1010-20. [PMID: 16678698 DOI: 10.1016/j.jvs.2006.01.004] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2005] [Accepted: 01/06/2006] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize temporal changes in mouse aortic wall gene expression associated with the development of experimental abdominal aortic aneurysms. METHODS C57BL/6 mice underwent transient perfusion of the abdominal aorta with either elastase (n = 61) or heat-inactivated elastase as a control (n = 68). Triplicate samples of radiolabeled aortic wall complementary DNA were prepared at intervals of 0, 3, 7, 10, and 14 days, followed by hybridization to nylon microarrays (1181 genes). Autoradiographic intensity data were normalized by conversion to z scores, and differences in gene expression were defined by two-tailed z tests at a significance threshold of P < .01. RESULTS Elastase perfusion caused a progressive increase in aortic diameter up to 14 days accompanied by transmural inflammation and destructive remodeling of the elastic media. No aneurysms occurred in the control group. Compared with healthy aorta, 336 genes exhibited significant alterations during at least 1 interval after elastase perfusion (135 at more than 1 interval and 14 at all intervals), with pronounced increases for interleukin 6, cyclin E2, interleukin 1beta, osteopontin, CD14/lipopolysaccharide receptor, P-selectin glycoprotein ligand 1, and gelatinase B/matrix metalloproteinase 9 (all >20-fold on day 3). Sixty-two genes exhibited synchronous alterations in the elastase and control groups, thus suggesting a nonspecific response. By direct comparisons between the elastase and control groups, there were 384 genes with significant differences in expression for at least 1 interval after aortic perfusion, including 234 with differential upregulation (eg, p44MAPK/ERK1, osteopontin, heat shock protein 84, hypoxia-inducible factor 1alpha, apolipoprotein E, monocyte chemotactic protein 3, MIG (monokine induced by gamma interferon), and interleukin 2 receptor gamma) and 163 with differential downregulation (eg, prothrombin, granzyme B, ataxia telangiectasia mutated, and interleukin-converting enzyme). CONCLUSIONS Development of elastase-induced abdominal aortic aneurysms in mice is accompanied by altered aortic wall expression of genes associated with acute and chronic inflammation, matrix degradation, and vascular tissue remodeling. Knowledge of these alterations will facilitate further studies on the functional molecular mechanisms that underlie aneurysmal degeneration.
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17
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Absi TS, Sundt TM, Camillo CJ, Schuessler RB, Gutierrez FR. Penetrating Atherosclerotic Ulcers of the Descending Thoracic Aorta May Be Managed Expectantly. Vascular 2004. [DOI: 10.2310/6670.2004.00041] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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18
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Absi TS, Sundt TM, Tung WS, Moon M, Lee JK, Damiano RR, Thompson RW. Altered patterns of gene expression distinguishing ascending aortic aneurysms from abdominal aortic aneurysms: complementary DNA expression profiling in the molecular characterization of aortic disease. J Thorac Cardiovasc Surg 2003; 126:344-57; discission 357. [PMID: 12928630 DOI: 10.1016/s0022-5223(02)73576-9] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.0] [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: 11/28/2022]
Abstract
OBJECTIVES The purpose of this study was to profile altered patterns of gene expression that characterize degenerative ascending thoracic aortic aneurysms and to compare these patterns with those observed for infrarenal abdominal aortic aneurysms. METHODS Full-thickness aortic wall tissues were obtained during surgical repair of degenerative thoracic aortic aneurysms and infrarenal abdominal aortic aneurysms (n = 4 each), with normal thoracic and abdominal aortas from organ transplant donors used as control preparations. Radiolabeled complementary DNA was prepared for each specimen and hybridized to complementary DNA microarrays, and differential levels of gene expression between aneurysmal and normal aortic tissues at each site were assessed by parametric statistics. RESULTS Of 1185 genes examined, 112 (9.5%) were differentially expressed (P <.05) between thoracic aortic aneurysms and normal thoracic aorta, with 105 increased and 7 decreased. There were 104 genes (8.8%) differentially expressed between infrarenal abdominal aortic aneurysms and normal abdominal aorta (65 increased and 39 decreased). Quantitative increases in expression for 97 genes were unique to thoracic aortic aneurysms, whereas increases for 61 genes were unique to infrarenal abdominal aortic aneurysms. Although 8 gene products were significantly altered in both thoracic and infrarenal abdominal aortic aneurysms, these changes were directionally concordant for only 4 (matrix metalloproteinase 9/gelatinase B, v-yes-1 oncogene, mitogen-activated protein kinase 9, and intercellular adhesion molecule 1/CD54). Results for 9 genes were independently confirmed by quantitative reverse transcriptase-polymerase chain reaction. CONCLUSIONS Thoracic aortic aneurysms and infrarenal abdominal aortic aneurysms exhibit distinct patterns of gene expression relative to normal aorta from the same sites, with most alterations being unique to each disease. Degenerative aneurysms arising in different locations are thus characterized by a high degree of molecular heterogeneity, reflecting different pathophysiologic mechanisms.
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MESH Headings
- Adolescent
- Adult
- Aged
- Aged, 80 and over
- Aortic Dissection/classification
- Aortic Dissection/genetics
- Aortic Dissection/pathology
- Aorta/pathology
- Aortic Aneurysm, Abdominal/classification
- Aortic Aneurysm, Abdominal/genetics
- Aortic Aneurysm, Abdominal/pathology
- Aortic Aneurysm, Thoracic/classification
- Aortic Aneurysm, Thoracic/genetics
- Aortic Aneurysm, Thoracic/pathology
- Aortic Diseases/classification
- Aortic Diseases/genetics
- Aortic Diseases/pathology
- Cell Adhesion Molecules/genetics
- Cell Adhesion Molecules/metabolism
- Cytokines/genetics
- Cytokines/metabolism
- DNA Fingerprinting
- DNA Glycosylases
- DNA, Complementary/genetics
- Extracellular Matrix/genetics
- Extracellular Matrix/metabolism
- Extracellular Matrix/pathology
- Female
- Gene Expression Profiling
- Gene Expression Regulation/genetics
- Humans
- Lymphotoxin-alpha/genetics
- Lymphotoxin-alpha/metabolism
- Lymphotoxin-beta
- Male
- Membrane Proteins/genetics
- Membrane Proteins/metabolism
- Middle Aged
- Myocytes, Smooth Muscle/metabolism
- Myocytes, Smooth Muscle/pathology
- N-Glycosyl Hydrolases/genetics
- N-Glycosyl Hydrolases/metabolism
- Oligonucleotide Array Sequence Analysis
- Protein Kinases/genetics
- Protein Kinases/metabolism
- Receptors, Tumor Necrosis Factor/genetics
- Receptors, Tumor Necrosis Factor/metabolism
- Reverse Transcriptase Polymerase Chain Reaction
- Statistics as Topic
- Transcription, Genetic/genetics
- Uracil-DNA Glycosidase
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Affiliation(s)
- Tarek S Absi
- Departments of Surgery, Sections of Cardiac and Vascular Surgery, Washington University School of Medicine, 9901 Wohl Hospital, 4960 Children's Place, St. Louis, MO 63110, USA
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Abstract
BACKGROUND We have used a variety of techniques to correct left ventricular outflow tract obstructions, including, in the past, placement of an apicoaortic valved conduit to bypass the outflow tract. Because the operation was technically difficult, it had fallen into disuse. Recently, we used a simplified transthoracic approach to implant apicoaortic conduits in 7 patients with complex lesions of the left ventricular outflow tract. METHODS The thoracic cavity was entered through the fifth intercostal space in all 7 patients. The distal end of the valve-containing conduit was attached to the aorta with continuous 3-0 or 4-0 polypropylene sutures after incising the pleura over the distal descending aorta. The pericardium was opened to expose the left ventricular apex, which was cored so that the proximal end of the conduit could be inserted into the left ventricular cavity. RESULTS Five of the patients recovered completely. The 2 patients who died had severe heart disease and multiple comorbidities. CONCLUSIONS The transthoracic approach gives direct access to the descending aorta and avoids a redo sternotomy. The technique, which is simple to perform, does not compromise major coronary arteries, the conduction system, or other valves; and may be useful in patients who are not good candidates for other, more conventional procedures.
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Affiliation(s)
- D A Cooley
- Texas Heart Institute at St. Luke's Episcopal Hospital, Houston 77225-0345, USA.
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