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Lanigan M, Siers D, Schramski M, Shaffer A, John R, Knoper R, Huddleston S, Gunn-Sandell L, Kaizer A, Perry TE. The Adherence to an Intraoperative Blood Product Transfusion Algorithm Is Associated With Reduced Blood Product Transfusions in Cardiac Surgical Patients Undergoing Coronary Artery Bypass Grafts and Aortic and/or Valve Replacement Surgery: A Single-Center, Observational Study. J Cardiothorac Vasc Anesth 2024; 38:1135-1143. [PMID: 38413344 DOI: 10.1053/j.jvca.2024.01.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 01/02/2024] [Accepted: 01/24/2024] [Indexed: 02/29/2024]
Abstract
OBJECTIVE To demonstrate the value of a viscoelastic-based intraoperative transfusion algorithm to reduce non-RBC product administration in adult cardiac surgical patients. DESIGN A prospective observational study. SETTING At a quaternary academic teaching hospital. PARTICIPANTS Cardiac surgical patients. INTERVENTIONS Viscoelastic-based intraoperative transfusion algorithm. MEASUREMENTS AND MAIN RESULTS The study authors compared intraoperative blood product transfusion rates in 184 cardiac surgical patients to 236 historic controls after implementing a viscoelastic-based algorithm. The authors found a non-significant reduction in transfusion of 23.8% for fresh frozen plasma (FFP) units (0.84 ± 1.4 v 0.64 ± 1.38; p = ns), 33.4% for platelet units (0.90 ± 1.39 v 0.60 ± 131; p = ns), and 15.8% for cryoprecipitate units (0.19 ± 0.54 v 0.16 ± 0.50; p = ns). They found a 43.9% reduction in red blood cell (RBC) units transfused (1.98 ± 2.24 v 0.55 ± 1.36; p = 0.008). There were no statistically significant differences in time to extubation (8.0 hours (4.0-21.0) v 8.0 (4.0-22.3), reoperation for bleeding (15 [12.3%] v 10 [10.6%]), intensive care unit length of stay (ICU LOS) (51.0 hours [28.0-100.5] v 53.5 [33.3-99.0]) or hospital LOS (9.0 days [6.0-15.0] v 10.0 [7.0-17.0]). Deviation from algorithm adherence was 32.7% (48/147). Packed RBC, FFP, platelets, cryoprecipitate, and cell saver were significantly reduced in the Algorithm Compliant Cohort compared with historic controls, whereas times to extubation, ICU LOS, and hospital LOS did not reach significance. CONCLUSIONS After the implementation of a viscoelastic-based algorithm, patients received fewer packed RBC, FFP, platelets, cryoprecipitate, and cell saver. Algorithm-compliant patients received fewer transfusions; however, reductions in times to extubation, ICU LOS, and hospital LOS were not statistically significant compared with historic controls.
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Affiliation(s)
- Megan Lanigan
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN.
| | - Daniel Siers
- University of Minnesota Medical School, Minneapolis, MN
| | | | - Andrew Shaffer
- Department of Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN
| | - Ranjit John
- Department of Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN
| | - Ryan Knoper
- Department of Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN
| | - Stephen Huddleston
- Department of Cardiothoracic Surgery, University of Minnesota, Minneapolis, MN
| | - Lauren Gunn-Sandell
- University of Colorado Anschutz Medical Campus, Department of Biostatistics and Informatics, Aurora, CO
| | - Alexander Kaizer
- University of Colorado Anschutz Medical Campus, Department of Biostatistics and Informatics, Aurora, CO
| | - Tjorvi E Perry
- Department of Anesthesiology, University of Minnesota, Minneapolis, MN
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Kertai MD, Makkad B, Bollen BA, Grocott HP, Kachulis B, Boisen ML, Raphael J, Perry TE, Liu H, Grant MC, Gutsche J, Popescu WM, Hensley NB, Mazzeffi MA, Sniecinski RM, Teeter E, Pal N, Ngai JY, Mittnacht A, Augoustides YGT, Ibekwe SO, Martin AK, Rhee AJ, Walden RL, Glas K, Shaw AD, Shore-Lesserson L. Development and Publication of Clinical Practice Parameters, Reviews, and Meta-analyses: A Report From the Society of Cardiovascular Anesthesiologists Presidential Task Force. Anesth Analg 2024; 138:878-892. [PMID: 37788388 DOI: 10.1213/ane.0000000000006619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/05/2023]
Abstract
The Society of Cardiovascular Anesthesiologists (SCA) is committed to improving the quality, safety, and value that cardiothoracic anesthesiologists bring to patient care. To fulfill this mission, the SCA supports the creation of peer-reviewed manuscripts that establish standards, produce guidelines, critically analyze the literature, interpret preexisting guidelines, and allow experts to engage in consensus opinion. The aim of this report, commissioned by the SCA President, is to summarize the distinctions among these publications and describe a novel SCA-supported framework that provides guidance to SCA members for the creation of these publications. The ultimate goal is that through a standardized and transparent process, the SCA will facilitate up-to-date education and implementation of best practices by cardiovascular and thoracic anesthesiologists to improve patient safety, quality of care, and outcomes.
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Affiliation(s)
- Miklos D Kertai
- From the Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Benu Makkad
- Department of Anesthesiology, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | - Hilary P Grocott
- Department of Anesthesiology, Pharmacology and Therapeutics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Bessie Kachulis
- Department of Anesthesiology, Columbia University Medical Center, New York, New York
| | - Michael L Boisen
- Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jacob Raphael
- Department of Anesthesiology, Thomas Jefferson University Hospitals, Philadelphia, Pennsylvania
| | - Tjorvi E Perry
- Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota
| | - Hong Liu
- Department of Anesthesiology, University of California Davis Health, Sacramento, California
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | - Jacob Gutsche
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Wanda M Popescu
- Department of Anesthesiology, Yale School of Medicine, Hartford, Connecticut
| | - Nadia B Hensley
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medicine, Baltimore, Maryland
| | - Michael A Mazzeffi
- Department of Anesthesiology, University of Virginia, Charlottesville, Virginia
| | - Roman M Sniecinski
- Department of Anesthesiology, Emory University School of Medicine, Atlanta, Georgia
| | - Emily Teeter
- Department of Anesthesiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Nirvik Pal
- Department of Anesthesiology, Virginia Commonwealth University, Richmond, Virginia
| | - Jennie Y Ngai
- Department of Anesthesiology, Perioperative Care and Pain Medicine, NYU Langone Health, New York, New York
| | - Alexander Mittnacht
- Department of Anesthesiology, Westchester Medical Center, New York Medical College, Valhalla, New York
| | - Yianni G T Augoustides
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Stephanie O Ibekwe
- Department of Anesthesiology, Westchester Medical Center, New York Medical College, Valhalla, New York
| | | | - Amanda J Rhee
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Rachel L Walden
- Eskind Biomedical Library, Vanderbilt University, Nashville, Tennessee
| | - Kathryn Glas
- Department of Anesthesiology, College of Medicine Tucson, Tucson, Arizona
| | - Andrew D Shaw
- Department of Intensive Care and Resuscitation, Cleveland Clinic, Cleveland, Ohio
| | - Linda Shore-Lesserson
- Department of Anesthesiology, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
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Perry TE. Emerging principles and practices in enhanced recovery after thoracic surgery. Curr Opin Anaesthesiol 2024; 37:55-57. [PMID: 38111194 DOI: 10.1097/aco.0000000000001329] [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] [Subscribe] [Scholar Register] [Indexed: 12/20/2023]
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Solow M, Perry TE. Change Management and Health Care Culture. Anesthesiol Clin 2023; 41:693-705. [PMID: 37838377 DOI: 10.1016/j.anclin.2023.05.001] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2023]
Abstract
Change management in health care is the process of implementing new policies, procedures, and practices in order to improve the quality of patient care. It involves understanding the need for change, identifying the stakeholders involved, and developing a plan to implement and manage the change. Change management in health care requires a comprehensive and collaborative approach to ensure that changes are properly implemented, communicated, and monitored. It is essential for health care providers to be aware of the current trends in health care and to stay up to date with the latest technology in order to provide the best care possible.
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Affiliation(s)
- Maxamillian Solow
- Department of Anesthesiology, University of Minnesota, 420 Delaware Street, Southeast, Minneapolis, MN 55455, USA
| | - Tjorvi E Perry
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, University of Minnesota, 420 Delaware Street Southeast, MMC 294, Mayo Memorial Building, 8294A, Minneapolis, MN 55455, USA.
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Solow M, Perry TE. Multimodal prehabilitation program valuation for thoracic surgical patients. Curr Opin Anaesthesiol 2023; 36:61-67. [PMID: 36550606 DOI: 10.1097/aco.0000000000001212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
PURPOSE OF REVIEW Modifiable patient-related risk factors, such as physical, emotional, and cognitive frailty, poor nutritional status, sleep hygiene, anemia, alcohol abuse, and smoking reduce a patient's ability to effectively recover from the insult of surgery. Herein, we review the value of implementing a comprehensive prehabilitation program for patients undergoing thoracic surgery. RECENT FINDINGS Although prehabilitation is not a novel concept, recent evidence suggest that 4-6 weeks of prehabilitation prior to surgery is likely to increase a patient's preoperative functional status allowing patients to return to independence earlier after surgery. The value of a prehabilitation program can be determined using cost effectiveness analysis, cost-benefit analysis (CBA), cost-utility analysis (CUA), and cost-consequence analysis (CCA). SUMMARY It stands to reason that well designed prehabilitation programs can add value by improving quality metrics at a lower cost to our healthcare system. Definitive randomized trials are needed to confirm this notion.
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Affiliation(s)
- Maxamillian Solow
- Division of Cardiothoracic Anesthesia, Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota, USA
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Lanigan M, Siers D, Wilkey A, Barakat A, Shaffer A, John R, Knoper R, Huddleston S, Kaizer A, Perry TE. The use of a viscoelastic based transfusion algorithm significantly reduces non-red blood cell transfusion in patients undergoing left ventricular assist device placement or heart transplantation: A single-center observational study. J Cardiothorac Vasc Anesth 2022; 36:3038-3046. [DOI: 10.1053/j.jvca.2022.03.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/10/2022] [Accepted: 03/17/2022] [Indexed: 11/11/2022]
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Olejniczak M, Schwartz M, Webber E, Shaffer A, Perry TE. Viral Myocarditis-Incidence, Diagnosis and Management. J Cardiothorac Vasc Anesth 2020; 34:1591-1601. [PMID: 32127272 DOI: 10.1053/j.jvca.2019.12.052] [Citation(s) in RCA: 62] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 12/22/2019] [Accepted: 12/29/2019] [Indexed: 12/25/2022]
Abstract
Viral myocarditis has an incidence rate of 10 to 22 per 100,000 individuals. The presentation pattern of viral myocarditis can range from nonspecific symptoms of fatigue and shortness of breath to more aggressive symptoms that mimic acute coronary syndrome. After the initial acute phase presentation of viral myocarditis, the virus may be cleared, resulting in full clinical recovery; the viral infection may persist; or the viral infection may lead to a persistent autoimmune-mediated inflammatory process with continuing symptoms of heart failure. As a result of these 3 possibilities, the diagnosis, prognosis, and treatment of viral myocarditis can be extremely unpredictable and challenging for the clinician. Herein, the incidence, etiology, definition and classification, clinical manifestation, diagnosis, pathogenesis, prognosis, and treatment of viral myocarditis are reviewed, and how acute clinical care teams might differentiate between viral myocarditis and other acute cardiac conditions is discussed.
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Affiliation(s)
- Megan Olejniczak
- University of Minnesota, Department of Anesthesia, Minneapolis, MN
| | - Matthew Schwartz
- University of Minnesota, Department of Anesthesia, Minneapolis, MN
| | - Elizabeth Webber
- University of Minnesota, Department of Anesthesia, Minneapolis, MN
| | - Andrew Shaffer
- University of Minnesota, Department of Cardiothoracic Surgery, Minneapolis, MN
| | - Tjorvi E Perry
- University of Minnesota, Department of Anesthesia, Minneapolis, MN.
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Perry TE, Robbins J. REFRAMING AGING IN PLACE IN FLINT, MI: OLDER ADULTS’ UNDERSTANDINGS OF THEIR HOMES WITHIN COMMUNITY-WIDE TRAUMA. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.3101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- T E Perry
- Wayne State University School of Social Work, Detroit, Michigan, United States
| | - J Robbins
- Wayne State University, Detroit, MI, USA
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Perry TE, Sanford C, Millush G. UNDERSTANDING AND ADDRESSING DISPLACEMENT IN A CHANGING CITY: A COALITION’S WORK TO PRESERVE SENIOR HOUSING IN DETROIT, MI. Innov Aging 2018. [DOI: 10.1093/geroni/igy023.210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- T E Perry
- Wayne State University School of Social Work, Detroit, Michigan, United States
| | - C Sanford
- Tenant Organizer and Chair, Senior Housing Preservation-Detroit
| | - G Millush
- Chair, Strategic Planning, Senior Housing Preservation-Detroit and Chair, Board of Directors, Presbyterian Villages of Michigan
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Brown EKH, Harder KA, Apostolidou I, Wahr JA, Shook DC, Farivar RS, Perry TE, Konia MR. Identifying Variability in Mental Models Within and Between Disciplines Caring for the Cardiac Surgical Patient. Anesth Analg 2017; 125:29-37. [PMID: 28537973 DOI: 10.1213/ane.0000000000002087] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND The cardiac operating room is a complex environment requiring efficient and effective communication between multiple disciplines. The objectives of this study were to identify and rank critical time points during the perioperative care of cardiac surgical patients, and to assess variability in responses, as a correlate of a shared mental model, regarding the importance of these time points between and within disciplines. METHODS Using Delphi technique methodology, panelists from 3 institutions were tasked with developing a list of critical time points, which were subsequently assigned to pause point (PP) categories. Panelists then rated these PPs on a 100-point visual analog scale. Descriptive statistics were expressed as percentages, medians, and interquartile ranges (IQRs). We defined low response variability between panelists as an IQR ≤ 20, moderate response variability as an IQR > 20 and ≤ 40, and high response variability as an IQR > 40. RESULTS Panelists identified a total of 12 PPs. The PPs identified by the highest number of panelists were (1) before surgical incision, (2) before aortic cannulation, (3) before cardiopulmonary bypass (CPB) initiation, (4) before CPB separation, and (5) at time of transfer of care from operating room (OR) to intensive care unit (ICU) staff. There was low variability among panelists' ratings of the PP "before surgical incision," moderate response variability for the PPs "before separation from CPB," "before transfer from OR table to bed," and "at time of transfer of care from OR to ICU staff," and high response variability for the remaining 8 PPs. In addition, the perceived importance of each of these PPs varies between disciplines and between institutions. CONCLUSIONS Cardiac surgical providers recognize distinct critical time points during cardiac surgery. However, there is a high degree of variability within and between disciplines as to the importance of these times, suggesting an absence of a shared mental model among disciplines caring for cardiac surgical patients during the perioperative period. A lack of a shared mental model could be one of the factors contributing to preventable errors in cardiac operating rooms.
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Affiliation(s)
- Evans K H Brown
- From the *University of Minnesota Medical School, Minneapolis, Minnesota; †Center for Design in Health, College of Design and ‡Department of Anesthesiology, University of Minnesota, Minneapolis, Minnesota; §Department of Anesthesiology, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts; and ‖Department of Cardiac Surgery and ¶Department of Anesthesiology, Anesthesiology American Anesthesia of Minnesota, Minneapolis Heart Institute at Abbott Northwestern Hospital, Minneapolis, Minnesota
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Fox AA, Pretorius M, Liu KY, Collard CD, Perry TE, Shernan SK, De Jager PL, Hafler DA, Herman DS, DePalma SR, Roden DM, Muehlschlegel JD, Donahue BS, Darbar D, Seidman JG, Body SC, Seidman CE. Genome-wide assessment for genetic variants associated with ventricular dysfunction after primary coronary artery bypass graft surgery. PLoS One 2011; 6:e24593. [PMID: 21980348 PMCID: PMC3184087 DOI: 10.1371/journal.pone.0024593] [Citation(s) in RCA: 5] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 08/14/2011] [Indexed: 11/19/2022] Open
Abstract
Background Postoperative ventricular dysfunction (VnD) occurs in 9–20% of coronary artery bypass graft (CABG) surgical patients and is associated with increased postoperative morbidity and mortality. Understanding genetic causes of postoperative VnD should enhance patient risk stratification and improve treatment and prevention strategies. We aimed to determine if genetic variants associate with occurrence of in-hospital VnD after CABG surgery. Methods A genome-wide association study identified single nucleotide polymorphisms (SNPs) associated with postoperative VnD in male subjects of European ancestry undergoing isolated primary CABG surgery with cardiopulmonary bypass. VnD was defined as the need for ≥2 inotropes or mechanical ventricular support after CABG surgery. Validated SNPs were assessed further in two replication CABG cohorts and meta-analysis was performed. Results Over 100 SNPs were associated with VnD (P<10−4), with one SNP (rs17691914) encoded at 3p22.3 reaching genome-wide significance (Padditive model = 2.14×10−8). Meta-analysis of validation and replication study data for 17 SNPs identified three SNPs associated with increased risk for developing postoperative VnD after adjusting for clinical risk factors. These SNPs are located at 3p22.3 (rs17691914, ORadditive model = 2.01, P = 0.0002), 3p14.2 (rs17061085, ORadditive model = 1.70, P = 0.0001) and 11q23.2 (rs12279572, ORrecessive model = 2.19, P = 0.001). Conclusions No SNPs were consistently associated with strong risk (ORadditive model>2.1) of developing in-hospital VnD after CABG surgery. However, three genetic loci identified by meta-analysis were more modestly associated with development of postoperative VnD. Studies of larger cohorts to assess these loci as well as to define other genetic mechanisms and related biology that link genetic variants to postoperative ventricular dysfunction are warranted.
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Affiliation(s)
- Amanda A Fox
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, United States of America.
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Todoran TM, Sobieszczyk PS, Levy MS, Perry TE, Shook DC, Kinlay S, Davidson MJ, Eisenhauer AC. Percutaneous Extraction of Right Atrial Mass Using the AngioVac Aspiration System. J Vasc Interv Radiol 2011; 22:1345-7. [DOI: 10.1016/j.jvir.2011.04.004] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2010] [Revised: 04/01/2011] [Accepted: 04/06/2011] [Indexed: 10/17/2022] Open
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Abstract
Coronary artery bypass graft surgery is associated with several frequent postoperative adverse events. Outcome prediction is valued by patients and practitioners, because it provides some measure of balancing risks and benefits and provides expensive or higher-risk therapies to individuals at highest risk. Surgeons and anesthesiologists traditionally have relied on demographic, preoperative, and intraoperative risk factors to predict outcomes after cardiac surgery. Yet, such predictions often have poor positive and negative predictive value for the individual patient. Perioperative genetics attempts to determine the impact of an individual's genetic variation on the risk of developing adverse postoperative outcomes. In this article, the authors discuss emerging evidence that a patient's genetic makeup predisposes him or her to adverse outcomes following cardiac surgery and provide examples from perioperative bleeding, myocardial injury/infarction, and atrial fibrillation.
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Affiliation(s)
- Tjorvi E Perry
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115
| | - Jochen D Muehlschlegel
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115
| | - Simon C Body
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St., Boston, MA 02115
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Sutherland FWH, Perry TE, Yu Y, Sherwood MC, Rabkin E, Masuda Y, Garcia GA, McLellan DL, Engelmayr GC, Sacks MS, Schoen FJ, Mayer JE. From Stem Cells to Viable Autologous Semilunar Heart Valve. Circulation 2005; 111:2783-91. [PMID: 15927990 DOI: 10.1161/circulationaha.104.498378] [Citation(s) in RCA: 235] [Impact Index Per Article: 12.4] [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: 11/16/2022]
Abstract
BACKGROUND An estimated 275,000 patients undergo heart valve replacement each year. However, existing solutions for valve replacement are complicated by the morbidity associated with lifelong anticoagulation of mechanical valves and the limited durability of bioprostheses. Recent advances in tissue engineering and our understanding of stem cell biology may provide a lifelong solution to these problems. METHODS AND RESULTS Mesenchymal stem cells were isolated from ovine bone marrow and characterized by their morphology and antigen expression through immunocytochemistry, flow cytometry, and capacity to differentiate into multiple cell lineages. A biodegradable scaffold was developed and characterized by its tensile strength and stiffness as a function of time in cell-conditioned medium. Autologous semilunar heart valves were then created in vitro using mesenchymal stem cells and the biodegradable scaffold and were implanted into the pulmonary position of sheep on cardiopulmonary bypass. The valves were evaluated by echocardiography at implantation and after 4 months in vivo. Valves were explanted at 4 and 8 months and examined by histology and immunohistochemistry. Valves displayed a maximum instantaneous gradient of 17.2+/-1.33 mm Hg, a mean gradient of 9.7+/-1.3 mm Hg, an effective orifice area of 1.35+/-0.17 cm2, and trivial or mild regurgitation at implantation. Gradients changed little over 4 months of follow-up. Histology showed disposition of extracellular matrix and distribution of cell phenotypes in the engineered valves reminiscent of that in native pulmonary valves. CONCLUSIONS Stem-cell tissue-engineered heart valves can be created from mesenchymal stem cells in combination with a biodegradable scaffold and function satisfactorily in vivo for periods of >4 months. Furthermore, such valves undergo extensive remodeling in vivo to resemble native heart valves.
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Wu X, Rabkin-Aikawa E, Guleserian KJ, Perry TE, Masuda Y, Sutherland FWH, Schoen FJ, Mayer JE, Bischoff J. Tissue-engineered microvessels on three-dimensional biodegradable scaffolds using human endothelial progenitor cells. Am J Physiol Heart Circ Physiol 2004; 287:H480-7. [PMID: 15277191 DOI: 10.1152/ajpheart.01232.2003] [Citation(s) in RCA: 172] [Impact Index Per Article: 8.6] [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: 11/22/2022]
Abstract
Tissue engineering may offer patients new options when replacement or repair of an organ is needed. However, most tissues will require a microvascular network to supply oxygen and nutrients. One strategy for creating a microvascular network would be promotion of vasculogenesis in situ by seeding vascular progenitor cells within the biopolymeric construct. To pursue this strategy, we isolated CD34(+)/CD133(+) endothelial progenitor cells (EPC) from human umbilical cord blood and expanded the cells ex vivo as EPC-derived endothelial cells (EC). The EPC lost expression of the stem cell marker CD133 but continued to express the endothelial markers KDR/VEGF-R2, VE-cadherin, CD31, von Willebrand factor, and E-selectin. The cells were also shown to mediate calcium-dependent adhesion of HL-60 cells, a human promyelocytic leukemia cell line, providing evidence for a proinflammatory endothelial phenotype. The EPC-derived EC maintained this endothelial phenotype when expanded in roller bottles and subsequently seeded on polyglycolic acid-poly-l-lactic acid (PGA-PLLA) scaffolds, but microvessel formation was not observed. In contrast, EPC-derived EC seeded with human smooth muscle cells formed capillary-like structures throughout the scaffold (76.5 +/- 35 microvessels/mm(2)). These results indicate that 1) EPC-derived EC can be expanded in vitro and seeded on biodegradable scaffolds with preservation of endothelial phenotype and 2) EPC-derived EC seeded with human smooth muscle cells form microvessels on porous PGA-PLLA scaffolds. These properties indicate that EPC may be well suited for creating microvascular networks within tissue-engineered constructs.
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Affiliation(s)
- Xiao Wu
- Department of Surgery, Children's Hospital, Boston, MA 02115, USA
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Sutherland FWH, Perry TE, Nasseri BA, Wang J, Kaushal S, Guleserian KJ, Martin DP, Vacant JP, Mayer JE. Advances in the mechanisms of cell delivery to cardiovascular scaffolds: comparison of two rotating cell culture systems. ASAIO J 2002; 48:346-9. [PMID: 12141461 DOI: 10.1097/00002480-200207000-00003] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [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] [Indexed: 11/26/2022] Open
Abstract
Having a reliable method of delivering cells to polymer scaffolds in vitro is fundamental to the development of tissue engineered structures. This paper compares the efficacy of two rotating systems for this purpose. Ten conduits, measuring 40 mm by 10 mm, were fabricated from polyglycolic acid mesh and poly-4-hydrobutyrate. Five conduits were placed in a rotating wall vessel (RWV, Synthecon Inc., Houston, TX), developed by the National Aeronautics and Space Administration (NASA); five conduits were also placed in rotating individual sealed tubes (RISTs). Medium in the RWV was left unchanged for the duration of the experiment; medium in the RISTs required daily change. Samples of the discarded medium and samples from the RWV were analyzed for pH, pCO2, pO2, and lactate concentration. Constructs were assayed for DNA content as a surrogate for cell number. In the RWV, pH, pCO2, and pO2 remained stable, while the lactate concentration gradually increased. The measure of PO2 did not differ significantly between the RWV and the RISTs, but the pH was lower and the pCO2 and the lactate concentration measurements were higher in the RIST system at each time point (p = 0.001). After 6 days (p = 0.001), the total DNA per conduit was 226+/-7 microg for the conduits seeded in the RISTs and 396+/-18 microg for the conduits in the RWV, suggesting that the RWV is superior to the RIST system for delivering cells to polymer scaffolds.
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Affiliation(s)
- Fraser W H Sutherland
- Department of Cardiovascular Surgery, The Children's Hospital, Boston, Massachusetts 02115, USA
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Abstract
PURPOSE This study was aimed at determining whether fetal tissue constructs can be engineered from cells normally found in the amniotic fluid. METHODS A subpopulation of morphologically distinct cells was isolated mechanically from the amniotic fluid of pregnant ewes (n = 5) and expanded selectively. Its lineage was determined by immunofluorescent staining against multiple intermediate filaments and surface antigens. Proliferation rates were determined by both oxidation and total DNA assays and compared with immunocytochemically identical adult and fetal sheep cells. Statistical analysis was by analysis of variance for repeated measures (ANOVA). After expansion, the amniocytes were seeded onto a polyglycolic acid polymer/poly-4-hydroxybutyrate scaffold. The resulting construct was analyzed by both optical and scanning electron microscopy. RESULTS The immunocytochemical profile of expanded amniocytes was consistent with a mesenchymal, fibroblast/myofibroblast cell lineage. These cells proliferated significantly faster than comparable fetal and adult cells in culture. Amniocyte construct analysis showed dense, confluent layers of cells firmly attached to the scaffold, with no evidence of cell death. CONCLUSIONS (1) Subpopulations of fetal mesenchymal cells can be isolated consistently from the amniotic fluid. (2) Mesenchymal amniocytes proliferate more rapidly in vitro than comparable fetal and adult cells. (3) Mesenchymal amniocytes attach firmly to polyglycolic acid polymer. The amniotic fluid can be a reliable and practical source of cells for the engineering of select fetal tissue constructs.
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Affiliation(s)
- A Kaviani
- Children's Hospital, 300 Longwood Ave, Fegan 3, Boston, MA 02115, USA
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