1
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Ganta S, Haley J, El-Said H, Lane B, Haldeman S, Karamlou T, Moore J, Rao R, Nigro JJ. Stage 1 and 2 Palliation: Comparing Ductal Stenting and Aorto-Pulmonary Shunts in Single Ventricles with Duct-Dependent Pulmonary Blood Flow. Pediatr Cardiol 2024; 45:471-482. [PMID: 38265483 PMCID: PMC10891206 DOI: 10.1007/s00246-023-03386-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2023] [Accepted: 12/18/2023] [Indexed: 01/25/2024]
Abstract
Patent ductus arteriosus stenting (PDAS) for ductal-dependent pulmonary blood flow (DDPBF) provides a new paradigm for managing neonates with single ventricles (SV). Currently, sparse data exist regarding outcomes for subsequent palliation. We describe our experience with inter-stage care and stage 2 (S2P) conversion with PDAS in comparison to a prior era of patients who received surgical aorto-pulmonary shunts (APS). Retrospective review of 18 consecutive DDPBF SV patients treated with PDAS between 2016 and 2021 was done and compared with 9 who underwent APS from 2010 to 2016. Patient outcomes and pulmonary artery (PA) growth were analyzed. S2P was completed in all 18 with PDAS with no cardiac arrests and one post-S2P mortality. In the 9 APS patients, there was one cardiac arrest requiring ECMO and one mortality inter-stage. Off cardiopulmonary bypass strategy was utilized in 10/18 in the PDAS and 1/9 in the APS group (p = 0.005) at S2P. Shorter ventilation time, earlier PO feeding, and shorter hospital stay were noted in the PDAS group (p = 0.01, p = 0.006, p = 0.03) (S2P). Median Nakata index increase inter-stage was not significant between the PDAS and APS at 94.1 mm2/m2 versus 71.7 mm2/m2 (p = 0.94). Median change in pulmonary artery symmetry (PAS) was - 0.02 and - 0.24, respectively, which was statistically significant (p = 0.008). Neurodevelopmental outcomes were better in the PDAS group compared to the APS group (p = 0.02). PDAS provides excellent PA growth, inter-stage survival, progression along multistage single-ventricle palliation, and potentially improved neurodevelopmental outcomes. Most patients can be transitioned through 2 stages of palliation without CPB.
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Affiliation(s)
- Srujan Ganta
- Cardiothoracic Surgery, Rady Children's Hospital + University of California San Diego, 3020 Children's Way, MC5004, San Diego, CA, 92123, USA.
| | - Jessica Haley
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - Howaida El-Said
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - Brian Lane
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - Shylah Haldeman
- Cardiothoracic Surgery, Rady Children's Hospital + University of California San Diego, 3020 Children's Way, MC5004, San Diego, CA, 92123, USA
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - John Moore
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - Rohit Rao
- Pediatrics, Division of Cardiology, University of California San Diego, San Diego, CA, USA
| | - John J Nigro
- Cardiothoracic Surgery, Rady Children's Hospital + University of California San Diego, 3020 Children's Way, MC5004, San Diego, CA, 92123, USA
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2
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Bock MJ, Vaughn GR, Chau P, Berumen JA, Nigro JJ, Ingulli EG. Organ transplantation using COVID-19-positive deceased donors. Am J Transplant 2022; 22:2203-2216. [PMID: 35822320 PMCID: PMC9349433 DOI: 10.1111/ajt.17145] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [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] [Received: 03/20/2022] [Revised: 07/08/2022] [Accepted: 07/09/2022] [Indexed: 01/25/2023]
Abstract
The COVID-19 pandemic has influenced organ transplantation decision making. Opinions regarding the utilization of coronavirus disease-2019 (COVID-19) donors are mixed. We hypothesize that COVID-19 infection of deceased solid organ transplant donors does not affect recipient survival. All deceased solid organ transplant donors with COVID-19 testing results from March 15, 2020 to September 30, 2021 were identified in the OPTN database. Donors were matched to recipients and stratified by the COVID-19 test result. Outcomes were assessed between groups. COVID-19 test results were available for 17 694 donors; 150 were positive. A total of 269 organs were transplanted from these donors, including 187 kidneys, 57 livers, 18 hearts, 5 kidney-pancreases, and 2 lungs. The median time from COVID-19 testing to organ recovery was 4 days for positive and 3 days for negative donors. Of these, there were 8 graft failures (3.0%) and 5 deaths (1.9%). Survival of patients receiving grafts from COVID-19-positive donors is equivalent to those receiving grafts from COVID-19-negative donors (30-day patient survival = 99.2% COVID-19 positive; 98.6% COVID-19 negative). Solid organ transplantation using deceased donors with positive COVID-19 results does not negatively affect early patient survival, though little information regarding donor COVID-19 organ involvement is known. While transplantation is feasible, more information regarding COVID-19-positive donor selection is needed.
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Affiliation(s)
- Matthew J. Bock
- Division of Pediatric Cardiology, Department of PediatricsUniversity of California at San DiegoSan DiegoCaliforniaUSA
| | - Gabrielle R. Vaughn
- Division of Pediatric Cardiology, Department of PediatricsUniversity of California at San DiegoSan DiegoCaliforniaUSA
| | - Peter Chau
- Division of Pediatric Cardiology, Department of PediatricsUniversity of California at San DiegoSan DiegoCaliforniaUSA
| | - Jennifer A. Berumen
- Division of Transplant and Hepatobiliary Surgery, Department of SurgeryUniversity of California at San DiegoSan DiegoCaliforniaUSA
| | - John J. Nigro
- Division of Pediatric Cardiovascular and Thoracic Surgery, Department of SurgeryUniversity of California at San DiegoSan DiegoCaliforniaUSA
| | - Elizabeth G. Ingulli
- Division of Pediatric Nephrology, Department of PediatricsUniversity of California at San DiegoSan DiegoCaliforniaUSA
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3
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Ganta S, Artrip J, Schuchardt EL, Lai W, Ryan J, Nigro JJ. Repair of Anomalous Single Coronary Artery From the Pulmonary Artery (ASCAPA). World J Pediatr Congenit Heart Surg 2021; 13:511-514. [PMID: 34928744 DOI: 10.1177/21501351211064157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
We describe the management of an infant presenting with severe heart failure at 6 weeks of age found to have an anomalous single coronary artery originating from the main pulmonary artery (MPA). This patient was transferred to our hospital and ultimately had their coronary artery translocated to the ascending aorta successfully. Preoperative severe left ventricular (LV) dysfunction and moderate/severe mitral regurgitation (MR) improved to normal function and mild-to-moderate MR 6 weeks postrepair. Three-dimensional CT reconstructions proved valuable and allowed for accurate preoperative planning leading to successful coronary transfer.
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Affiliation(s)
- Srujan Ganta
- 14444Division of Cardiothoracic Surgery, Rady Children's Hospital, San Diego, CA, USA
| | - John Artrip
- 14444Division of Cardiothoracic Surgery, Rady Children's Hospital, San Diego, CA, USA.,12220Division of Cardiovascular and Thoracic Surgery, University of San Diego (UCSD), School of Medicine, San Diego, CA, USA
| | - Eleanor L Schuchardt
- 12220Department of Pediatrics, University of California San Diego (UCSD), School of Medicine, San Diego, CA, USA
| | - Wyman Lai
- 20209Children's Hospital of Orange County (CHOC), Orange County, CA, USA
| | - Justin Ryan
- 14444Webster Foundation 3DI Lab, Rady Children's Hospital, San Diego, CA, USA
| | - John J Nigro
- 14444Division of Cardiothoracic Surgery, Rady Children's Hospital, San Diego, CA, USA.,12220Division of Cardiovascular and Thoracic Surgery, University of San Diego (UCSD), School of Medicine, San Diego, CA, USA
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4
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Sweeney NM, Nahas SA, Chowdhury S, Batalov S, Clark M, Caylor S, Cakici J, Nigro JJ, Ding Y, Veeraraghavan N, Hobbs C, Dimmock D, Kingsmore SF. Author Correction: Rapid whole genome sequencing impacts care and resource utilization in infants with congenital heart disease. NPJ Genom Med 2021; 6:38. [PMID: 34039997 PMCID: PMC8155217 DOI: 10.1038/s41525-021-00205-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Affiliation(s)
- Nathaly M Sweeney
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA. .,Rady Children's Hospital, San Diego, CA, USA. .,Department of Pediatrics, University of California San Diego, La Jolla, CA, USA.
| | - Shareef A Nahas
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | - Shimul Chowdhury
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | - Sergey Batalov
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | - Michelle Clark
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | - Sara Caylor
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | - Julie Cakici
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA.,Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
| | - John J Nigro
- Rady Children's Hospital, San Diego, CA, USA.,Department of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Yan Ding
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | | | - Charlotte Hobbs
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | - David Dimmock
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
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5
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Aljohani OA, Mackie D, Fletcher EA, Shayan K, Vaughn GR, Singh RK, Nigro JJ. Heart Transplantation of a Preterm Infant With HLHS. World J Pediatr Congenit Heart Surg 2021; 12:675-677. [PMID: 33956540 DOI: 10.1177/2150135120979847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A 33-week gestation, 1.75-kg female infant with mitral stenosis/aortic atresia variant of hypoplastic left heart syndrome and severe ventriculo-coronary connections underwent surgical septectomy and bilateral pulmonary artery banding at five weeks of age (2.10 kg). After separation from bypass, she developed hemodynamic instability requiring venoarterial extracorporeal membrane oxygenation support. She was listed for heart transplantation and transplanted after three days of support with an oversized heart (4.7:1 donor-recipient weight ratio).
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Affiliation(s)
- Othman A Aljohani
- Division of Pediatric Cardiology, Rady Children's Hospital, University of California, San Diego, CA, USA
| | - Duncan Mackie
- University of California San Diego School of Medicine, San Diego, CA, USA
| | - Emily A Fletcher
- Division of Pediatric Cardiology, Rady Children's Hospital, University of California, San Diego, CA, USA
| | - Katayoon Shayan
- Department of Pathology, Rady Children's Hospital, University of California, San Diego, CA, USA
| | - Gabrielle R Vaughn
- Division of Pediatric Cardiology, Rady Children's Hospital, University of California, San Diego, CA, USA
| | - Rakesh K Singh
- Division of Pediatric Cardiology, Rady Children's Hospital, University of California, San Diego, CA, USA
| | - John J Nigro
- Department of Cardiovascular Surgery, Rady Children's Hospital, University of California, San Diego, CA, USA
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6
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Sweeney NM, Nahas SA, Chowdhury S, Batalov S, Clark M, Caylor S, Cakici J, Nigro JJ, Ding Y, Veeraraghavan N, Hobbs C, Dimmock D, Kingsmore SF. Rapid whole genome sequencing impacts care and resource utilization in infants with congenital heart disease. NPJ Genom Med 2021; 6:29. [PMID: 33888711 PMCID: PMC8062477 DOI: 10.1038/s41525-021-00192-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 03/19/2021] [Indexed: 11/09/2022] Open
Abstract
Congenital heart disease (CHD) is the most common congenital anomaly and a major cause of infant morbidity and mortality. While morbidity and mortality are highest in infants with underlying genetic conditions, molecular diagnoses are ascertained in only ~20% of cases using widely adopted genetic tests. Furthermore, cost of care for children and adults with CHD has increased dramatically. Rapid whole genome sequencing (rWGS) of newborns in intensive care units with suspected genetic diseases has been associated with increased rate of diagnosis and a net reduction in cost of care. In this study, we explored whether the clinical utility of rWGS extends to critically ill infants with structural CHD through a retrospective review of rWGS study data obtained from inpatient infants < 1 year with structural CHD at a regional children's hospital. rWGS diagnosed genetic disease in 46% of the enrolled infants. Moreover, genetic disease was identified five times more frequently with rWGS than microarray ± gene panel testing in 21 of these infants (rWGS diagnosed 43% versus 10% with microarray ± gene panels, p = 0.02). Molecular diagnoses ranged from syndromes affecting multiple organ systems to disorders limited to the cardiovascular system. The average daily hospital spending was lower in the time period post blood collection for rWGS compared to prior (p = 0.003) and further decreased after rWGS results (p = 0.000). The cost was not prohibitive to rWGS implementation in the care of this cohort of infants. rWGS provided timely actionable information that impacted care and there was evidence of decreased hospital spending around rWGS implementation.
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Affiliation(s)
- Nathaly M Sweeney
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA.
- Rady Children's Hospital, San Diego, CA, USA.
- Department of Pediatrics, University of California San Diego, La Jolla, CA, USA.
| | - Shareef A Nahas
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | - Shimul Chowdhury
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | - Sergey Batalov
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | - Michelle Clark
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | - Sara Caylor
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | - Julie Cakici
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
- Department of Family Medicine and Public Health, University of California San Diego, La Jolla, CA, USA
| | - John J Nigro
- Rady Children's Hospital, San Diego, CA, USA
- Department of Surgery, University of California San Diego, La Jolla, CA, USA
| | - Yan Ding
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | | | - Charlotte Hobbs
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
| | - David Dimmock
- Rady Children's Institute for Genomic Medicine, San Diego, CA, USA
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7
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Ganta S, Duster N, El-Said H, Artrip J, Rao R, Golding I, Dummer K, Nigro JJ. Staged Repair of Van Praagh Truncus Type A3. World J Pediatr Congenit Heart Surg 2021; 12:286-290. [PMID: 33684014 DOI: 10.1177/2150135121990387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Van Praagh (VP) A3 variant of truncus arteriosus (or common arterial trunk) is defined by only one pulmonary artery (usually the right) originating from the common trunk, while the other lung is supplied either by collaterals or a pulmonary artery arising from the aortic arch. This report describes a staged approach to manage a VP-A3 variant truncus arteriosus with ductal origin of the left pulmonary artery (LPA), a hypoplastic right pulmonary artery, and cyanosis. Initially, the ductal portion of the proximal LPA was stented with a Resolute Onyx drug-eluting stent. The pulmonary arteries grew and at four months of age had an acceptable McGoon ratio and Nakata index. The patient then underwent repair which included unifocalization of the branch pulmonary arteries, closure of the ventricular septal defect, and placement of a right ventricle-to-pulmonary artery homograft conduit.
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Affiliation(s)
- Srujan Ganta
- Division of Cardiothoracic Surgery, 2345Rady Children's Hospital, San Diego, CA, USA
| | - Nicole Duster
- Department Pediatrics, 12220University of California San Diego (UCSD) School of Medicine, San Diego, CA, USA
| | - Howaida El-Said
- Division of Cardiothoracic Surgery, 2345Rady Children's Hospital, San Diego, CA, USA.,Department Pediatrics, 12220University of California San Diego (UCSD) School of Medicine, San Diego, CA, USA
| | - John Artrip
- Division of Cardiothoracic Surgery, 2345Rady Children's Hospital, San Diego, CA, USA.,Division Cardiovascular and Thoracic Surgery, 12220University of California San Diego (UCSD) School of Medicine, San Diego, CA, USA
| | - Rohit Rao
- Department Pediatrics, 12220University of California San Diego (UCSD) School of Medicine, San Diego, CA, USA
| | - Ian Golding
- Department Pediatrics, 12220University of California San Diego (UCSD) School of Medicine, San Diego, CA, USA
| | - Kirsten Dummer
- Department Pediatrics, 12220University of California San Diego (UCSD) School of Medicine, San Diego, CA, USA
| | - John J Nigro
- Division of Cardiothoracic Surgery, 2345Rady Children's Hospital, San Diego, CA, USA.,Division Cardiovascular and Thoracic Surgery, 12220University of California San Diego (UCSD) School of Medicine, San Diego, CA, USA
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8
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Ratnayaka K, Nageotte SJ, Moore JW, Guyon PW, Bhandari K, Weber RL, Lee JW, You H, Griffin DA, Rao RP, Nigro JJ, El-Said HG. Patent Ductus Arteriosus Stenting for All Ductal-Dependent Cyanotic Infants: Waning Use of Blalock-Taussig Shunts. Circ Cardiovasc Interv 2021; 14:e009520. [PMID: 33685211 DOI: 10.1161/circinterventions.120.009520] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Kanishka Ratnayaka
- Division of Pediatric Cardiology (K.R., J.W.M., P.W.G., K.B., R.L.W., D.A.G., R.P.R., H.G.E.-S.), Rady Children's Hospital and UC San Diego School of Medicine, CA
| | - Stephen J Nageotte
- Division of Pediatric Cardiology, Department of Pediatrics, St. Louis Children's Hospital, Washington University School of Medicine, MO (S.J.N.)
| | - John W Moore
- Division of Pediatric Cardiology (K.R., J.W.M., P.W.G., K.B., R.L.W., D.A.G., R.P.R., H.G.E.-S.), Rady Children's Hospital and UC San Diego School of Medicine, CA
| | - Peter W Guyon
- Division of Pediatric Cardiology (K.R., J.W.M., P.W.G., K.B., R.L.W., D.A.G., R.P.R., H.G.E.-S.), Rady Children's Hospital and UC San Diego School of Medicine, CA
| | - Krishna Bhandari
- Division of Pediatric Cardiology (K.R., J.W.M., P.W.G., K.B., R.L.W., D.A.G., R.P.R., H.G.E.-S.), Rady Children's Hospital and UC San Diego School of Medicine, CA
| | - Rachel L Weber
- Division of Pediatric Cardiology (K.R., J.W.M., P.W.G., K.B., R.L.W., D.A.G., R.P.R., H.G.E.-S.), Rady Children's Hospital and UC San Diego School of Medicine, CA
| | - Jesse W Lee
- Division of Pediatric Cardiology, Baylor College of Medicine, The Children's Hospital of San Antonio, TX (J.W.L.)
| | - Hyeri You
- Biostatistics Unit, Altman Clinical and Translational Research Institute, University of California San Diego, CA (H.Y.)
| | - Danica A Griffin
- Division of Pediatric Cardiology (K.R., J.W.M., P.W.G., K.B., R.L.W., D.A.G., R.P.R., H.G.E.-S.), Rady Children's Hospital and UC San Diego School of Medicine, CA
| | - Rohit P Rao
- Division of Pediatric Cardiology (K.R., J.W.M., P.W.G., K.B., R.L.W., D.A.G., R.P.R., H.G.E.-S.), Rady Children's Hospital and UC San Diego School of Medicine, CA
| | - John J Nigro
- Division of Cardiovascular Surgery (J.J.N.), Rady Children's Hospital and UC San Diego School of Medicine, CA
| | - Howaida G El-Said
- Division of Pediatric Cardiology (K.R., J.W.M., P.W.G., K.B., R.L.W., D.A.G., R.P.R., H.G.E.-S.), Rady Children's Hospital and UC San Diego School of Medicine, CA
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9
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Wei ZA, Ratnayaka K, Si B, Singh-Gryzbon S, Cetatoiu MA, Fogel MA, Slesnick T, Yoganathan AP, Nigro JJ. An Anterior Anastomosis for the Modified Fontan Connection: A Hemodynamic Analysis. Semin Thorac Cardiovasc Surg 2021; 33:816-823. [PMID: 33662555 DOI: 10.1053/j.semtcvs.2021.01.056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 01/05/2021] [Indexed: 12/25/2022]
Abstract
This hemodynamic feasibility study examined total cavopulmonary connection (TCPC) designs connecting the extracardiac conduit to the anterior surface of pulmonary arteries (PAs) or superior vena cava (SVC) rather than to the inferior PA surface (traditional TCPC). The study involved twenty-five consecutive Fontan patients meeting inclusion criteria from a single institution. A virtual surgical platform mimicked the completed traditional TCPC and generated three anterior anastomosis designs: Anterior-PA, Middle-SVC, and SVC-Inn (Inn: innominate vein). Hemodynamic performance of anterior anastomosis designs was compared with the traditional TCPC regarding indexed power loss (iPL) and hepatic flow distribution (HFD). Compared to the traditional TCPC, the Anterior-PA design produces a similar iPL. The Middle-SVC design is also similar, though the iPL difference is positively correlated with the anastomosing height. The SVC-Inn design had significantly more iPL. The three anterior anastomosis designs did not have a significant difference in HFD (from traditional TCPC). Pulmonary flow distribution (PFD) has a stronger correlation with HFD from the anterior anastomosis designs than the traditional TCPC. This hemodynamic feasibility study examined anterior anastomosis, extracardiac TCPC designs that may offer surgeons clinical dexterity. The Anterior-PA design may be equivalent to the traditional TCPC. Fontan extracardiac conduit anastomosis just superior to the PAs (Middle-SVC) also preserves hemodynamic performance and avoids direct PA anastomosis. These designs could simplify surgical Fontan completion, and may particularly benefit patients requiring surgical dissection, having atypical PA orientation, or after PA stent angioplasty.
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Affiliation(s)
- Zhenglun Alan Wei
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia; Department of Biomedical Engineering, University of Massachusetts Lowell, Lowell, Massachusetts
| | - Kanishka Ratnayaka
- Division of Pediatric Cardiology, Rady Children's Hospital and UC San Diego School of Medicine, San Diego, California
| | - Biao Si
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | - Shelly Singh-Gryzbon
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia
| | | | - Mark A Fogel
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Timothy Slesnick
- Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ajit P Yoganathan
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, Georgia.
| | - John J Nigro
- Division of Cardiovascular Surgery, Rady Children's Hospital and UC San Diego School of Medicine, San Diego, California
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10
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El-Sabrout HR, Ryan JR, Hegde SR, El-Said HG, Nigro JJ, Moore JW, Ratnayaka K. Purpose-built transcatheter cavopulmonary anastomosis device requirements: Multi-modality imaging evaluation. Cardiovasc Revasc Med 2021; 34:128-133. [PMID: 33526391 DOI: 10.1016/j.carrev.2021.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Revised: 01/11/2021] [Accepted: 01/19/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND/PURPOSE Patients with a functional single ventricle undergo multiple, palliative open-heart surgeries. This includes a superior cavopulmonary anastomosis or bidirectional Glenn shunt. A less-invasive transcatheter approach may reduce morbidity. METHODS/MATERIALS We analyzed pre-Glenn X-ray contrast angiography (XA), cardiac computed tomography (CT), and cardiac magnetic resonance (CMR) studies. RESULTS Over an eleven-year period (1/2007 - 6/2017), 139 Glenn surgeries were performed at our institution. The typical age range at surgery was 59 - 371 days (median = 163; IQR = 138 - 203). Eight-nine XA, ten CT, and ten CMR studies obtained from these patients were analyzed. Cephalad SVC measurements (millimeters) were 7.3 ± 1.7 (XA), 7.7 ± 1.6 (CT) and 6.9 ± 1.8 (CMR). RPA measurements were 7.3 ± 1.9 (XA), 7.4 ± 1.6 (CT) and 6.6 ± 1.9 (CMR). Potential device lengths were 10.9 ± 6 - 17.4 ± 6.4 (XA), 10.1 ± 2.1 - 17.7 ± 2.4 (CT) and 17.3 ± 4. - 23.7 ± 5.5 (CMR). SVC-RPA angle (degrees) was 132.9 ± 13.2 (CT) and 140 ± 10.2 (MRI). Image quality of all CT (100%), almost all XA (SVC 100%, RPA 99%), and most MRI (SVC 80%, RPA 90%) were deemed sufficient. Parametric modeling virtual fit device with 10 mm diameter and 20 - 25 mm length was ideal. CONCLUSIONS Ideal transcatheter cavopulmonary shunt device for the typical patient would be 10 mm in diameter and 20-25 mm in length.
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Affiliation(s)
- Hannah R El-Sabrout
- Division of Pediatric Cardiology, Rady Children's Hospital and UC San Diego School of Medicine, 3020 Children's Way, San Diego, CA, USA
| | - Justin R Ryan
- Division of Pediatric Cardiology, Rady Children's Hospital and UC San Diego School of Medicine, 3020 Children's Way, San Diego, CA, USA; Division of Cardiovascular Surgery, Rady Children's Hospital and UC San Diego School of Medicine, 3020 Children's Way, San Diego, CA, USA
| | - Sanjeet R Hegde
- Division of Pediatric Cardiology, Rady Children's Hospital and UC San Diego School of Medicine, 3020 Children's Way, San Diego, CA, USA
| | - Howaida G El-Said
- Division of Pediatric Cardiology, Rady Children's Hospital and UC San Diego School of Medicine, 3020 Children's Way, San Diego, CA, USA
| | - John J Nigro
- Division of Cardiovascular Surgery, Rady Children's Hospital and UC San Diego School of Medicine, 3020 Children's Way, San Diego, CA, USA
| | - John W Moore
- Division of Pediatric Cardiology, Rady Children's Hospital and UC San Diego School of Medicine, 3020 Children's Way, San Diego, CA, USA
| | - Kanishka Ratnayaka
- Division of Pediatric Cardiology, Rady Children's Hospital and UC San Diego School of Medicine, 3020 Children's Way, San Diego, CA, USA.
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11
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Aljohani OA, Singh RK, Nageotte SJ, Do T, Ratnayaka K, Nigro JJ, Werho DK. Aortic Root Thrombosis on ECMO-A Novel Management Strategy. World J Pediatr Congenit Heart Surg 2020; 11:643-645. [PMID: 32853069 DOI: 10.1177/2150135120924416] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
A 15-year-old presented in cardiogenic shock secondary to viral myocarditis requiring venoarterial extracorporeal membrane oxygenation (ECMO) support. He developed large thrombi of the left ventricle and aortic root. Anticoagulation was increased, and medications were initiated to decrease the likelihood of aortic valve opening. He underwent balloon atrial septostomy followed by placement of a left atrial vent. A pigtail catheter was placed in the ascending aorta for direct heparin infusion. Serial echocardiograms showed progressive resolution of the thrombi. He was successfully weaned from ECMO and discharged home without neurological deficits.
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Affiliation(s)
- Othman A Aljohani
- Division of Pediatric Cardiology, Department of Pediatrics, 14444Rady Children's Hospital, University of California, San Diego, CA, USA
| | - Rakesh K Singh
- Division of Pediatric Cardiology, Department of Pediatrics, 14444Rady Children's Hospital, University of California, San Diego, CA, USA
| | - Stephen J Nageotte
- Division of Pediatric Cardiology, Department of Pediatrics, 14444Rady Children's Hospital, University of California, San Diego, CA, USA
| | - Thomas Do
- Division of Pediatric Cardiology, Department of Pediatrics, 14444Rady Children's Hospital, University of California, San Diego, CA, USA
| | - Kanishka Ratnayaka
- Division of Pediatric Cardiology, Department of Pediatrics, 14444Rady Children's Hospital, University of California, San Diego, CA, USA
| | - John J Nigro
- Department of Cardiovascular Surgery, 14444Rady Children's Hospital, San Diego, CA, USA
| | - David K Werho
- Division of Pediatric Cardiology, Department of Pediatrics, 14444Rady Children's Hospital, University of California, San Diego, CA, USA
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12
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Karamlou T, Pettersson G, Nigro JJ. Commentary: A pediatric perspective on the Ozaki procedure. J Thorac Cardiovasc Surg 2020; 161:1582-1583. [PMID: 32448681 DOI: 10.1016/j.jtcvs.2020.02.128] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 02/27/2020] [Accepted: 02/27/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Tara Karamlou
- Division of Congenital Cardiac Surgery, Cleveland Clinic Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Gosta Pettersson
- Division of Congenital Cardiac Surgery, Cleveland Clinic Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - John J Nigro
- Division of Cardiothoracic Surgery, Rady Children's Hospital San Diego, University of California San Diego, San Diego, Calif.
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13
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Spigel ZA, Razzouk A, Nigro JJ, Karamlou TB, Kavarana MN, Roeser ME, Adachi I. Pulmonary Artery Banding for Children With Dilated Cardiomyopathy: US Experience. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2020; 23:69-76. [PMID: 32354550 DOI: 10.1053/j.pcsu.2020.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Received: 01/11/2020] [Revised: 02/25/2020] [Accepted: 03/05/2020] [Indexed: 06/11/2023]
Abstract
Pulmonary artery band placement is a recently described therapeutic strategy for dilated cardiomyopathy with preserved right ventricular function, originally reported from Germany.1 We present the results of the multicenter retrospective study of pulmonary artery band experience in the United States, with comparison to the German experience. Five centers contributed a total 14 patients (median age 5 months, interquartile range 3.5-10). Mechanical ventilation was required in 9/12 (75%) patients and inotropes were used in 13/14 (93%) patients preoperatively. Ultimately, 4 (29%) patients experienced cardiac recovery, 8 (57%) were bridged to cardiac transplantation (6 with ventricular assist device placement), and 2 (14%) died. Although both the US and Germany series demonstrated high prevalence of achieving patients' individual target (either cardiac recovery or transplant), the mode of success was different (recovery rate: <1/3 in the United States and >2/3 in Germany). Lower recovery rate may be a reflection of sicker preoperative status, and thereby a more advanced stage of heart failure (preoperative intubation: >2/3 in the United States vs <1/3 in Germany). Further studies would be warranted to gain more insight into patient selection as well as optimal timing for the intervention.
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Affiliation(s)
- Zachary A Spigel
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas
| | - Anees Razzouk
- Loma Linda University Health, Loma Linda, California
| | - John J Nigro
- Phoenix Children's Hospital, Phoenix, Arizona; Division of Cardiovascular Surgery, Heart Institute, Rady Children's Hospital, San Diego, CA, USA
| | - Tara B Karamlou
- Phoenix Children's Hospital, Phoenix, Arizona; Division of Pediatric Cardiac Surgery, Heart Vascular Institute, 9500 Euclid Ave, Cleveland, OH
| | - Minoo N Kavarana
- Medical University of South Carolina, Charleston, South Carolina
| | | | - Iki Adachi
- Baylor College of Medicine and Texas Children's Hospital, Houston, Texas.
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14
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Montesa C, Karamlou T, Ratnayaka K, Pophal SG, Ryan J, Nigro JJ. Hepatic Vein Incorporation Into the Azygos System in Heterotaxy and Interrupted Inferior Vena Cava. World J Pediatr Congenit Heart Surg 2019; 10:330-337. [DOI: 10.1177/2150135119842869] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Patients with heterotaxy, single ventricle and interrupted inferior vena cava are at risk of developing significant pulmonary arteriovenous malformations and cyanosis, and inequitable distribution of hepatic factor has been implicated in their development. We describe our experience with a technique for hepatic vein incorporation that reliably provides resolution of cyanosis and presumably equitable hepatic factor distribution. Methods: A retrospective review of a single-surgeon experience was conducted for patients who underwent this modified Fontan operation utilizing an extracardiac conduit from the hepatic veins to the dominant superior cavopulmonary connection. Preoperative characteristics and imaging, operative details, and postoperative course and imaging were abstracted. Results: Median age at operation was 5 years (2-10 years) and median weight was 19.6 kg (11.8-23 kg). Sixty percent (3/5) of patients had Fontan completion without cardiopulmonary bypass, and follow-up was complete at a median of 14 months (range 1-20 months). Systemic saturations increased significantly from 81% ± 1.9% preoperatively to 95% ± 3.5% postoperatively, P = .0008. Median length of stay was 10 days (range: 7-14 days). No deaths occurred. One patient required reoperation for bleeding and one was readmitted for pleural effusion. Postoperative imaging suggested distribution of hepatic factor to all lung segments with improved pulmonary arteriovenous malformation burden. Conclusions: Hepatic vein incorporation for patients with heterotaxy and interrupted inferior vena cava should optimally provide equitable pulmonary distribution of hepatic factor with resolution of cyanosis. The described technique is performed through a conventional approach, is facile, and improves cyanosis in these complex patients.
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Affiliation(s)
- Christine Montesa
- Division of Cardiovascular Surgery, Heart Institute, Rady Children’s Hospital, San Diego, CA, USA
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Kanishka Ratnayaka
- Division of Cardiology, Heart Institute, Rady Children’s Hospital, San Diego, CA, USA
| | - Stephen G. Pophal
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - Justin Ryan
- 3D Innovations Lab, Heart Institute, Rady Children’s Hospital, San Diego, CA, USA
| | - John J. Nigro
- Division of Cardiovascular Surgery, Heart Institute, Rady Children’s Hospital, San Diego, CA, USA
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15
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Karamlou T, Meza JM, Najm HK, Nigro JJ, Hill KD. Single-ventricle reconstruction 2.0: A closer look at our understanding of care for infants undergoing the Norwood procedure. J Thorac Cardiovasc Surg 2019; 158:837-842.e5. [PMID: 31101343 DOI: 10.1016/j.jtcvs.2018.12.121] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Revised: 12/06/2018] [Accepted: 12/13/2018] [Indexed: 10/27/2022]
Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery and the Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio.
| | - James M Meza
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Hani K Najm
- Division of Pediatric Cardiac Surgery and the Heart Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - John J Nigro
- Division of Pediatric Cardiac Surgery, Rady Children's Hospital and the University of California, San Diego, San Diego, Calif
| | - Kevin D Hill
- Division of Pediatric Cardiology, Duke University Medical Center and the Duke Clinical Research Institute, Durham, NC
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16
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Plasencia JD, Kamarianakis Y, Ryan JR, Karamlou T, Park SS, Nigro JJ, Frakes DH, Pophal SG, Lagerstrom CF, Velez DA, Zangwill SD. Alternative methods for virtual heart transplant-Size matching for pediatric heart transplantation with and without donor medical images available. Pediatr Transplant 2018; 22:e13290. [PMID: 30251298 DOI: 10.1111/petr.13290] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2018] [Revised: 08/07/2018] [Accepted: 08/13/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Listed pediatric heart transplant patients have the highest solid-organ waitlist mortality rate. The donor-recipient body weight (DRBW) ratio is the clinical standard for allograft size matching but may unnecessarily limit a patient's donor pool. To overcome DRBW ratio limitations, two methods of performing virtual heart transplant fit assessments were developed that account for patient-specific nuances. Method 1 uses an allograft total cardiac volume (TCV) prediction model informed by patient data wherein a matched allograft 3-D reconstruction is selected from a virtual library for assessment. Method 2 uses donor images for a direct virtual transplant assessment. METHODS Assessments were performed in medical image reconstruction software. The allograft model was developed using allometric/isometric scaling assumptions and cross-validation. RESULTS The final predictive model included gender, height, and weight. The 25th-, 50th-, and 75th-percentiles for TCV percentage errors were -13% (over-prediction), -1%, and 8% (under-prediction), respectively. Two examples illustrating the potential of virtual assessments are presented. CONCLUSION Transplant centers can apply these methods to perform their virtual assessments using existing technology. These techniques have potential to improve organ allocation. With additional experience and refinement, virtual transplants may become standard of care for determining suitability of donor organ size for an identified recipient.
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Affiliation(s)
- Jonathan D Plasencia
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, Arizona
| | - Yiannis Kamarianakis
- School of Mathematical and Statistical Sciences, Arizona State University, Tempe, Arizona.,Institute of Applied and Computational Mathematics, Foundation for Research and Technology - Hellas, Heraklion, Crete, Greece
| | - Justin R Ryan
- Division of Cardiology, Division of Cardiothoracic Surgery, Children's Heart Center, Phoenix Children's Hospital, Phoenix, Arizona
| | | | - Susan S Park
- Division of Cardiology, Division of Cardiothoracic Surgery, Children's Heart Center, Phoenix Children's Hospital, Phoenix, Arizona
| | - John J Nigro
- Department of Cardiovascular Surgery, Rady Children's Hospital, San Diego, California
| | - David H Frakes
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, Arizona.,School of Electrical, Computer, and Energy Engineering, Arizona State University, Tempe, Arizona
| | - Stephen G Pophal
- Division of Cardiology, Division of Cardiothoracic Surgery, Children's Heart Center, Phoenix Children's Hospital, Phoenix, Arizona
| | - Carl F Lagerstrom
- Division of Cardiology, Division of Cardiothoracic Surgery, Children's Heart Center, Phoenix Children's Hospital, Phoenix, Arizona
| | - Daniel A Velez
- Division of Cardiology, Division of Cardiothoracic Surgery, Children's Heart Center, Phoenix Children's Hospital, Phoenix, Arizona
| | - Steven D Zangwill
- Division of Cardiology, Division of Cardiothoracic Surgery, Children's Heart Center, Phoenix Children's Hospital, Phoenix, Arizona
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17
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Anton-Martin P, Willis BC, Nigro JJ, Budolfson K, Raz D, Jamshidi R. Complete traumatic aortic transection. Journal of Pediatric Surgery Case Reports 2018. [DOI: 10.1016/j.epsc.2018.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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18
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Karamlou T, Velez DA, Nigro JJ. Encrypted prediction: A hacker's perspective. J Thorac Cardiovasc Surg 2017; 154:2038-2040. [DOI: 10.1016/j.jtcvs.2017.08.112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2017] [Accepted: 08/30/2017] [Indexed: 11/26/2022]
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19
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Karamlou T, Velez D, Nigro JJ. Invited Commentary. Ann Thorac Surg 2017; 104:1629. [PMID: 29054213 DOI: 10.1016/j.athoracsur.2017.04.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 04/24/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Tara Karamlou
- Division of Pediatric Cardiac Surgery, Phoenix Children's Hospital, Heart Center, Main Bldg, 1919 E Thomas Rd, Phoenix, AZ 85016.
| | - Daniel Velez
- Division of Pediatric Cardiac Surgery, Phoenix Children's Hospital, Heart Center, Main Bldg, 1919 E Thomas Rd, Phoenix, AZ 85016
| | - John J Nigro
- Rady Children's Hospital, Division of Pediatric Cardiac Surgery, San Diego, California
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20
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Rao R, Nigro JJ, Karamlou T. An apology or absolution for cerebral near-infrared spectroscopy: Can we get on the same wavelength? J Thorac Cardiovasc Surg 2017; 154:1063-1064. [PMID: 28502619 DOI: 10.1016/j.jtcvs.2017.04.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Accepted: 04/12/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Rohit Rao
- Division of Pediatric Cardiology and Critical Care, Phoenix Children's Hospital, Phoenix, Ariz
| | - John J Nigro
- Division of Pediatric Cardiac Surgery, Rady Children's Hospital, San Diego, Calif
| | - Tara Karamlou
- Division of Pediatric Cardiac Surgery, Phoenix Children's Hospital, Phoenix, Ariz.
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21
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Ashfaq A, Seckeler M, Pophal S, Rhee E, Ryan J, Rao R, Klewer S, Nigro JJ. Integration of Hybrid and Single Ventricle Rehabilitation Techniques to Treat a Neonate After Iatrogenic Mitral Injury. World J Pediatr Congenit Heart Surg 2016; 7:498-501. [PMID: 26865067 DOI: 10.1177/2150135115604469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 08/05/2015] [Indexed: 11/16/2022]
Abstract
Neonatal critical aortic stenosis is life threatening and requires intervention shortly after birth. Early percutaneous aortic valvuloplasty is generally considered to be an effective way to obtain reliable prograde flow. We describe the integrated use of hybrid, open surgical, and single ventricle rehabilitation techniques to successfully treat a neonate with borderline left-sided cardiac structures, who sustained a complication from balloon aortic valvuloplasty.
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Affiliation(s)
- Awais Ashfaq
- General Surgery, Mayo Clinic Arizona, Phoenix, AZ, USA
| | - Michael Seckeler
- Department of Pediatrics (Cardiology), University of Arizona, Tucson, AZ, USA
| | - Stephen Pophal
- Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Edward Rhee
- Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Justin Ryan
- Cardiology, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Rohit Rao
- Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - Scott Klewer
- Department of Pediatrics (Cardiology), University of Arizona, Tucson, AZ, USA
| | - John J Nigro
- Cardiothoracic Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
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22
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Nigro JJ, Velez DA. Retrograde Cardioplegia for Myocardial Protection During Arterial Switch Operation. Ann Thorac Surg 2014; 97:2233-4. [DOI: 10.1016/j.athoracsur.2013.10.102] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2013] [Revised: 10/08/2013] [Accepted: 10/18/2013] [Indexed: 10/25/2022]
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23
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Sanders DB, Smith BP, Sowell SR, Nguyen DH, Derby C, Eshun F, Nigro JJ. Sickle cell disease and complex congenital cardiac surgery: a case report and review of the pathophysiology and perioperative management. Perfusion 2013; 29:153-8. [DOI: 10.1177/0267659113499599] [Citation(s) in RCA: 9] [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] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Sickle cell anemia and thalassemia are hemoglobinopathies rarely encountered in the United States. Compounded with congenital heart disease, patients with sickle cell disease (SCD) requiring cardiopulmonary bypass and open-heart surgery represent the proverbial “needle in the haystack”. As such, there is some trepidation on the part of clinicians when these patients present for complex cardiac surgery. SCD is an autosomal, recessive condition that results from a single nucleotide polymorphism in the β-globin gene. Hemoglobin SS molecules (HgbSS) with this point mutation can polymerize under the right conditions, stiffening the erythrocyte membrane and distorting the cellular structure to the characteristic sickle shape. This shape change alters cellular transit through the microvasculature. As a result, circumstances such as hypoxia, hypothermia, acidosis or diminished blood flow can lead to aggregation, vascular occlusion and thrombosis. Chronically, SCD can give rise to multiorgan damage secondary to hemolysis and vascular obstruction. This review and case study details an 11-year-old African-American male with known SCD who presented to the cardiothoracic surgical service with congenital heart disease consisting of an anomalous, intramural right coronary artery arising from the left coronary sinus for surgical consultation and subsequent surgical correction. This case report will include a review of the pathophysiology and current literature regarding preoperative, intraoperative and postoperative management of SCD patients.
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Affiliation(s)
- DB Sanders
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - BP Smith
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - SR Sowell
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - DH Nguyen
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - C Derby
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - F Eshun
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - JJ Nigro
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
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24
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Park SS, Sanders DB, Smith BP, Ryan J, Plasencia J, Osborn MB, Wellnitz CM, Southard RN, Pierce CN, Arabia FA, Lane J, Frakes D, Velez DA, Pophal SG, Nigro JJ. Total artificial heart in the pediatric patient with biventricular heart failure. Perfusion 2013; 29:82-8. [PMID: 23868320 DOI: 10.1177/0267659113496580] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Mechanical circulatory support emerged for the pediatric population in the late 1980s as a bridge to cardiac transplantation. The Total Artificial Heart (TAH-t) (SynCardia Systems Inc., Tuscon, AZ) has been approved for compassionate use by the Food and Drug Administration for patients with end-stage biventricular heart failure as a bridge to heart transplantation since 1985 and has had FDA approval since 2004. However, of the 1,061 patients placed on the TAH-t, only 21 (2%) were under the age 18. SynCardia Systems, Inc. recommends a minimum patient body surface area (BSA) of 1.7 m(2), thus, limiting pediatric application of this device. This unique case report shares this pediatric institution's first experience with the TAH-t. A 14-year-old male was admitted with dilated cardiomyopathy and severe biventricular heart failure. The patient rapidly decompensated, requiring extracorporeal life support. An echocardiogram revealed severe biventricular dysfunction and diffuse clot formation in the left ventricle and outflow tract. The decision was made to transition to biventricular assist device. The biventricular failure and clot formation helped guide the team to the TAH-t, in spite of a BSA (1.5 m(2)) below the recommendation of 1.7 m(2). A computed tomography (CT) scan of the thorax, in conjunction with a novel three-dimensional (3D) modeling system and team, assisted in determining appropriate fit. Chest CT and 3D modeling following implantation were utilized to determine all major vascular structures were unobstructed and the bronchi were open. The virtual 3D model confirmed appropriate device fit with no evidence of compression to the left pulmonary veins. The postoperative course was complicated by a left lung opacification. The left lung anomalies proved to be atelectasis and improved with aggressive recruitment maneuvers. The patient was supported for 11 days prior to transplantation. Chest CT and 3D modeling were crucial in assessing whether the device would fit, as well as postoperative complications in this smaller pediatric patient.
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Affiliation(s)
- S S Park
- 1Division of Cardiothoracic Surgery, Division of Cardiology, Division of Critical Care Medicine, Children's Heart Center, Division of Radiology, Phoenix Children's Hospital, Phoenix, AZ, USA
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Abstract
The Fontan procedure represents the final stage of the transition to single ventricle physiology. Conversion of very complex congenital heart anatomy, such as hypoplastic left heart syndrome, double-outlet right ventricle or double-inlet left ventricle, to a single ventricle has grown in popularity as morbidity and mortality have improved. As these patients grow, survivors are at risk for impaired ventricular dysfunction, plastic bronchitis, protein-losing enteropathy and late failure. Late failing Fontan patients represent a particularly vexing scenario for clinicians, as the only durable treatment option is cardiac transplantation. However, in the short-term, some of these patients require support beyond medical management, with mechanical circulatory support via extracorporeal life support or a ventricular assist device. We report the successful bridge of an adolescent female post-Fontan conversion with late severe cardiac failure. The patient was initially resuscitated with extracorporeal life support, transitioned to a single Berlin Heart EXCOR® ventricular assist device and, subsequently, underwent successful cardiac transplantation.
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Affiliation(s)
- DB Sanders
- Scott and Laura Eller Congenital Heart Center, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - SR Sowell
- Scott and Laura Eller Congenital Heart Center, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - SS Park
- Scott and Laura Eller Congenital Heart Center, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - C Derby
- Scott and Laura Eller Congenital Heart Center, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
- Cardon Children’s Hospital, Banner Desert Hospital, Mesa, AZ, USA
| | - BC Willis
- Scott and Laura Eller Congenital Heart Center, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - JE Lane
- Scott and Laura Eller Congenital Heart Center, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | | | | | - SG Pophal
- Scott and Laura Eller Congenital Heart Center, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
| | - JJ Nigro
- Scott and Laura Eller Congenital Heart Center, St. Joseph’s Hospital and Medical Center, Phoenix, AZ, USA
- Children’s Heart Center, Phoenix Children’s Hospital, Phoenix, AZ, USA
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26
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Sanders DB, Sowell SR, Willis B, Lane J, Pierce C, Pophal S, Arabia FA, Nigro JJ. The role of extracorporeal life support in acute myocarditis: a bridge to recovery? J Extra Corpor Technol 2012; 44:205-209. [PMID: 23441561 PMCID: PMC4557562] [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] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 10/18/2012] [Indexed: 06/01/2023]
Abstract
Acute myocardial failure associated with myocarditis is highly lethal. Left ventricular assist device support for these patients has been advocated to decompress the left ventricle and facilitate myocardial remodeling and recovery. Concerns exist regarding the ability of venoarterial (VA) extracorporeal life support (ECLS) to decompress the left ventricle and allow effective myocardial recovery. ECLS has several advantages, including availability, rapid deployment, and flexibility, as compared with contemporary ventricular assist devices. The objective of this study was to provide a brief review of acute myocarditis and present our series of patients. After Institutional Review Board approval, we conducted a retrospective data analysis of patients on ECLS experiencing rapidly progressive myocardial failure from a normal baseline. Patients with a history of intrinsic heart disease were excluded. All patients were thought to have myocarditis and had failed medical therapy requiring emergent ECLS support. Five patients demographics are detailed in Table 1. Patients experienced life-threatening intractable dysrhythmias or cardiac arrest and were refractory to medical therapy with severe acidosis and impending multisystem organ failure. All patients were stabilized with VA ECLS, and the left ventricle and atrium were decompressed in four of five patients. A left atrial vent was placed in one patient. Myocardial recovery with successful weaning from ECLS was obtained in four of five patients and to a normal ejection fraction in three of the five. One patient failed ECLS weaning and required biventricular VAD support secondary to severe myocardial necrosis from giant cell myocarditis and was transplanted, one died, all others are alive at follow-up. ECLS is safe and effective to treat acute myocardial failure and may be used to obtain myocardial recovery in certain subsets. We devised a decision algorithm for ECLS deployment in this patient cohort and routinely use ECLS.
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Affiliation(s)
- D Bradford Sanders
- Eller Congenital Heart Center, St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA.
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Nigro JJ, Choi S, Graziano J, Gandy KL, Guerrero-Tiro LM, Cleveland DC. Modified Superior Repair for Supracardiac Total Anomalous Pulmonary Venous Connection in the Adult. Ann Thorac Surg 2007; 84:312-3. [PMID: 17588451 DOI: 10.1016/j.athoracsur.2006.10.035] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Revised: 09/16/2006] [Accepted: 10/16/2006] [Indexed: 11/25/2022]
Abstract
Repair of total anomalous pulmonary venous connection has been well described and is associated with good long-term outcomes for neonates and infants. Although rare, some patients initially present at adolescence or during adulthood and repair is complicated by compensatory changes related to chronic volume overload. Transection of the superior vena cava facilitates both exposure of the venous confluence and repair in these patients.
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Affiliation(s)
- John J Nigro
- Heart & Lung Institute, Saint Joseph's Hospital and Medical Center, Phoenix, Arizona 85013, USA.
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Nigro JJ, Bart RD, Derby CD, Sklansky MS, Starnes VA. Proximal Conduit Obstruction After Sano Modified Norwood Procedure. Ann Thorac Surg 2005; 80:1924-8. [PMID: 16242490 DOI: 10.1016/j.athoracsur.2004.06.054] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [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] [Received: 04/26/2004] [Revised: 06/06/2004] [Accepted: 06/11/2004] [Indexed: 10/25/2022]
Abstract
Sano and colleagues recently described a modification of first stage palliation for hypoplastic left heart syndrome utilizing a right ventricle to pulmonary artery conduit. Preliminary results are favorable, but experience with this technique is limited. We report a case of sudden death due to obstruction of the proximal conduit by fibrointimal hyperplasia. This case of lethal conduit obstruction presented 3 months after initial palliation. Early cardiac catheterization and second stage palliation may be necessary to minimize the risk of such adverse events after the Sano modification.
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Affiliation(s)
- John J Nigro
- Department of Cardiothoracic Surgery, Childrens Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California 90027, USA.
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Khwaja S, Nigro JJ, Starnes VA. The Ross procedure is an ideal aortic valve replacement operation for the teen patient. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2005:173-5. [PMID: 15818374 DOI: 10.1053/j.pcsu.2005.01.012] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [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: 05/02/2023]
Abstract
The Ross procedure is an ideal aortic valve replacement for the teenage patient because the pulmonary autograft is durable, is nonthrombogenic, has excellent hemodynamics, and grows. Since 1992, our center has performed 194 Ross procedures, and 53 of these were in teenagers (10 to 21 years of age). In this group, there have been no perioperative deaths, hospital length of stay was 4 days, and re-operation for autograft failure was only 2% at mean follow-up of 69 months. All patients are in NYHA heart failure class I. Because of its proven efficacy, the Ross operation is our preferred aortic valve replacement for the teenage patient.
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Affiliation(s)
- Shamsuddin Khwaja
- Department of Cardiothoracic Surgery, University of Southern California, Childrens Hospital Los Angeles, 90027, USA
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Backhus LM, Sievers EM, Bart RD, Schenkel FA, Cohen RG, Barr ML, Nigro JJ, Starnes VA, Bremner RM. Pleural Space Problems Following Living Lobar Transplantation. Chest 2004. [DOI: 10.1378/chest.126.4_meetingabstracts.844s-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Abstract
The objective of this study was to assess the course over time of the Barrett's metaplasia-dysplasia-carcinoma sequence. The method used was a retrospective analysis of the medical records of a patient series with a median follow-up of 25 months. The study was undertaken in a university hospital foregut laboratory. The progress of seven patients was followed through the sequence of Barrett's esophagus, low-grade dysplasia and high-grade dysplasia to cancer. They all underwent subsequent esophagectomy and were found to have intramucosal adenocarcinoma. The main outcome measure was the time from the first diagnosis of intestinal metaplasia to the development of low-grade dysplasia, high-grade dysplasia and adenocarcinoma. Low-grade dysplasia developed in a median of 24 months, high-grade dysplasia after a median of 33 months and cancer after 36 months. All patients underwent esophagectomy with reconstruction and no patient has had a recurrence at a median follow-up of 25 months (range 10-204 months). Patients on Barrett's surveillance who develop early esophageal adenocarcinoma did so within approximately 3 years after the diagnosis of non-dysplastic Barrett's esophagus.
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Affiliation(s)
- J Theisen
- Department of Surgery, Klinikum re.d.Isar, Munich, Germany.
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34
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Affiliation(s)
- Craig J Baker
- Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California and Children's Hospital Los Angeles, Los Angeles, California, USA
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35
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Nigro JJ, Schwartz DS, Bart RD, Bart CW, Lopez BM, Cunningham MJ, Barr ML, Bremner RM, Haddy SM, Wells WJ, Starnes VA. Neochordal repair of the posterior mitral leaflet. J Thorac Cardiovasc Surg 2004; 127:440-7. [PMID: 14762353 DOI: 10.1016/j.jtcvs.2003.09.035] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Myxomatous mitral valve insufficiency is traditionally repaired by posterior leaflet quadrangular resection and reconstruction. A simplified repair technique without leaflet resection is described, and our initial experience is reviewed. METHODS Thirty-nine consecutive patients with significant mitral regurgitation underwent repair since January 2000 by placement of expanded polytetrafluoroethylene sutures between the leading (coapting) edge of the posterior leaflet and the corresponding papillary muscle. An annuloplasty ring was placed, and no leaflet tissue was resected. Patient medical records were obtained and retrospectively reviewed. RESULTS Twenty-five men and 14 women (median age, 61 years; range, 40-88 years) had their mitral valve repaired by a variety of surgical approaches, including robotic (18 patients), right thoracotomy (6 patients), and sternal (15 patients). Three patients have required valve replacement: 1 at the initial operation, 1 because of dehiscence of the annuloplasty ring, and 1 after subsequent rupture of a previously normal native chorda. At follow-up (median, 12 months), 92% (33/36) of the remaining patients had an intact mitral repair with no to mild regurgitation, 8.3% (3/36) of patients had moderate regurgitation, and 92% of all patients (36/39) were in New York Heart Association class I. There were no deaths. CONCLUSIONS Myxomatous mitral regurgitation due to posterior leaflet insufficiency can be repaired without leaflet resection by placement of neochordae. This repair technique is effective and is readily accomplished by traditional and minimally invasive surgical approaches.
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Affiliation(s)
- John J Nigro
- Department of Cardiothoracic Surgery, Keck School of Medicine of the University of Southern California, Los Angeles, USA.
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36
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Campos GMR, Oberg S, Gastal O, Theisen J, Nigro JJ, Hagen JA, Costantini M, Bremner CG, DeMeester TR, Crookes PF. Manometry of the lower esophageal sphincter: inter- and intraindividual variability of slow motorized pull-through versus station pull-through manometry. Dig Dis Sci 2003; 48:1057-61. [PMID: 12822862 DOI: 10.1023/a:1023700309299] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [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: 01/28/2023]
Abstract
The purpose of this study was to evaluate the interindividual and intraindividual variability of slow motorized pull-through lower esophageal sphincter (LES) manometry compared to standard station pull-through LES manometry to measure LES overall length, abdominal length, and pressure and to report normal values for the slow motorized pull-through method. The slow motorized pull-through had significantly smaller coefficient of variation, indicating closer agreement between different examiners in analyzing a given tracing. The correlation coefficients for each parameter in normal subjects and symptomatic patients was significantly higher when using slow motorized pull-through for both patients and normal subjects for all three parameters. The 5th percentile of normal values obtained from 41 volunteers for LES overall length, abdominal length, and pressure was 2.7 cm, 1.4 cm, 5.1 mm Hg, respectively. The results indicate that the slow motorized pull-through method is more reproducible than the standard station pull-through method both between different observers and when the same examiner measures the same tracing on two different occasions.
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Affiliation(s)
- Guilherme M R Campos
- Department of Surgery, University of Southern California Keck School of Medicine, Los Angeles, California 90033-4612, USA
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Abstract
Biliptysis is a dramatic physical finding which suggests the presence of a direct communication (fistula) between the biliary and bronchial tree. We report a bronchial biliary fistula resulting from penetrating thoracoabdominal trauma and the use of positive-pressure ventilation to obtain initial fistula control prior to definitive surgical repair.
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Affiliation(s)
- John J Nigro
- Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles County University of Southern California Medical Center, 90033, USA.
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Abstract
Perforating benign ulcer is a very rare complication of Barrett's esophagus. This report presents the management of a patient with a Barrett's ulcer that penetrated into the left mainstem bronchus resulting in a life-threatening bronchial esophageal fistula. This rare complication was successfully managed by using a staged surgical approach, which combined the principles used for treating benign esophagorespiratory fistulas and perforating Barrett's ulcers.
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Affiliation(s)
- John J Nigro
- Department of Cardiothoracic Surgery, University of Southern California Keck School of Medicine, Los Angeles 90033, USA.
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39
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Bremner RM, Woo MS, Arroyo H, Nigro JJ, Horn MV, Wells WJ, Barr M, Starnes VA. The Effect of Pleural Adhesions on Pediatric Cystic Fibrosis Patients Undergoing Lung Transplantation. Am Surg 2001. [DOI: 10.1177/000313480106701204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
The degree of pleural scarring complicating cystic fibrosis (CF) lung disease is thought to impact on the outcome of adult lung transplantation. This has not been previously studied in the pediatric population. We studied all patients undergoing lung transplantation at Children's Hospital Los Angeles from 1993 through 2000. Operative times, grade of pleural scarring, blood product transfusion requirements, and perioperative mortality were compared for patients with cystic fibrosis (35) versus those without this diagnosis (11). Patients with CF were slightly older (14.7 ± 3.8 vs 10.6 ± 5.6 years; P = 0.01) but had similar weights (34.8 ± 8.7 vs 34.4 ± 12.3 kg). The degree of pleural scarring was greater in the CF group but was only severe in four patients. Scarring did not impact on operative times (237 ± 46 vs 219 ± 39 minutes; P = 0.22) or cardiopulmonary bypass times (127 ± 40 vs 133 ± 49 minutes). Total perioperative blood requirements for the two groups were similar (35.6 ± 14.9 vs 42.8 ± 76.7 cm3/kg; P = 0.82). Pleural scarring in the pediatric CF patients undergoing lung transplantation is only severe in a minority of patients. It does not increase duration of operation nor blood transfusion requirements. CT scanning is consequently unnecessary in the preoperative workup of CF patients being evaluated for transplantation. CF patients undergoing transplantation have perioperative outcomes similar to those of noncystic patients.
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Affiliation(s)
- Ross M. Bremner
- Cardioihoracic Transplant Team, Department of Cardiothoracic Surgery
| | - Marilyn S. Woo
- Division of Pediatric Pulmonology, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Hector Arroyo
- Cardioihoracic Transplant Team, Department of Cardiothoracic Surgery
| | - John J. Nigro
- Cardioihoracic Transplant Team, Department of Cardiothoracic Surgery
| | - Monica V. Horn
- Cardioihoracic Transplant Team, Department of Cardiothoracic Surgery
| | - Winfield J. Wells
- Cardioihoracic Transplant Team, Department of Cardiothoracic Surgery
| | - Mark Barr
- Cardioihoracic Transplant Team, Department of Cardiothoracic Surgery
| | - Vaughn A. Starnes
- Cardioihoracic Transplant Team, Department of Cardiothoracic Surgery
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40
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Tsai PI, Bremner RM, Mason RJ, Nigro JJ, Chandrasoma P, Peters JH, Bremner CG, DeMeester TR. Laparoscopic ultrasonic epithelial ablation of the lower esophagus after nissen fundoplication in a porcine model: assessment of tissue damage and healing process. Am Surg 2001; 67:1178-80. [PMID: 11768825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
A substantial population of patients with Barrett's esophagus has undergone antireflux surgery but still requires annual surveillance endoscopy. These patients would benefit from a definitive ablation of the Barrett's mucosa, which would remove the malignant potential of this disease. This study evaluates the efficacy of applying ultrasonic energy to remove the epithelium of the lower esophagus in a porcine model with prior Nissen fundoplication. Four Yakutan minipigs underwent laparoscopic Nissen fundoplication. After 2 weeks they underwent transgastric Cavitron ultrasonic surgical aspirator (CUSA; Valleylab, Boulder, CO) ablation of the lower esophageal epithelium. Healing of the mucosa was assessed by endoscopy at 2 weeks and pathological examination at 4 weeks after ablation. All pigs underwent successful laparoscopic Nissen fundoplication. Complete lower esophageal epithelial ablation was accomplished through the fundoplication in three animals. One pig developed a bezoar that prohibited ablation. At 2 weeks endoscopy showed patchy squamous epithelial regeneration, which was confirmed histologically. Esophageal specimens at 4 weeks showed complete regeneration of squamous epithelium with a partially healed small ulcer in one animal. No stricture formation was seen. We conclude that the CUSA technique can completely ablate Barrett's mucosa in the setting of a prior antireflux procedure. Healing with squamous mucosal regeneration is rapid and complete.
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Affiliation(s)
- P I Tsai
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, USA
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41
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Tsai PI, Bremner RM, Mason RJ, Nigro JJ, Chandrasoma P, Peters JH, Bremner CG, Demeester TR. Laparoscopic Ultrasonic Epithelial Ablation of the Lower Esophagus after Nissen Fundoplication in a Porcine Model: Assessment of Tissue Damage and Healing Process. Am Surg 2001. [DOI: 10.1177/000313480106701213] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
A substantial population of patients with Barrett's esophagus has undergone antireflux surgery but still requires annual surveillance endoscopy. These patients would benefit from a definitive ablation of the Barrett's mucosa, which would remove the malignant potential of this disease. This study evaluates the efficacy of applying ultrasonic energy to remove the epithelium of the lower esophagus in a porcine model with prior Nissen fundoplication. Four Yakutan minipigs underwent laparoscopic Nissen fundoplication. After 2 weeks they underwent transgastric Cavitron ultrasonic surgical aspirator (CUSA; Valleylab, Boulder, CO) ablation of the lower esophageal epithelium. Healing of the mucosa was assessed by endoscopy at 2 weeks and pathological examination at 4 weeks after ablation. All pigs underwent successful laparoscopic Nissen fundoplication. Complete lower esophageal epithelial ablation was accomplished through the fundoplication in three animals. One pig developed a bezoar that prohibited ablation. At 2 weeks endoscopy showed patchy squamous epithelial regeneration, which was confirmed histologically. Esophageal specimens at 4 weeks showed complete regeneration of squamous epithelium with a partially healed small ulcer in one animal. No stricture formation was seen. We conclude that the CUSA technique can completely ablate Barrett's mucosa in the setting of a prior antireflux procedure. Healing with squamous mucosal regeneration is rapid and complete.
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Affiliation(s)
- Peter I. Tsai
- Departments of Surgery and Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ross M. Bremner
- Departments of Surgery and Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Rodney J. Mason
- Departments of Surgery and Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - John J. Nigro
- Departments of Surgery and Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Para Chandrasoma
- Departments of Surgery and Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jeff H. Peters
- Departments of Surgery and Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Cedric G. Bremner
- Departments of Surgery and Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Tom R. Demeester
- Departments of Surgery and Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
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42
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Bremner RM, Woo MS, Arroyo H, Nigro JJ, Horn MV, Wells WJ, Barr M, Starnes VA. The effect of pleural adhesions on pediatric cystic fibrosis patients undergoing lung transplantation. Am Surg 2001; 67:1136-9. [PMID: 11768816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
The degree of pleural scarring complicating cystic fibrosis (CF) lung disease is thought to impact on the outcome of adult lung transplantation. This has not been previously studied in the pediatric population. We studied all patients undergoing lung transplantation at Children's Hospital Los Angeles from 1993 through 2000. Operative times, grade of pleural scarring, blood product transfusion requirements, and perioperative mortality were compared for patients with cystic fibrosis (35) versus those without this diagnosis (11). Patients with CF were slightly older (14.7+/-3.8 vs 10.6+/-5.6 years; P = 0.01) but had similar weights (34.8+/-8.7 vs 34.4+/-12.3 kg). The degree of pleural scarring was greater in the CF group but was only severe in four patients. Scarring did not impact on operative times (237+/-46 vs 219+/-39 minutes; P = 0.22) or cardiopulmonary bypass times (127+/-40 vs 133+/-49 minutes). Total perioperative blood requirements for the two groups were similar (35.6+/-14.9 vs 42.8+/-76.7 cm3/kg; P = 0.82). Pleural scarring in the pediatric CF patients undergoing lung transplantation is only severe in a minority of patients. It does not increase duration of operation nor blood transfusion requirements. CT scanning is consequently unnecessary in the preoperative workup of CF patients being evaluated for transplantation. CF patients undergoing transplantation have perioperative outcomes similar to those of noncystic patients.
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Affiliation(s)
- R M Bremner
- Department of Cardiothoracic Surgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, USA
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43
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Nigro JJ, Hagen JA, DeMeester TR, DeMeester SR, Theisen J, Peters JH, Kiyabu M. Occult esophageal adenocarcinoma: extent of disease and implications for effective therapy. Ann Surg 1999; 230:433-8; discussion 438-40. [PMID: 10493489 PMCID: PMC1420887 DOI: 10.1097/00000658-199909000-00015] [Citation(s) in RCA: 153] [Impact Index Per Article: 6.1] [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: 12/17/2022]
Abstract
OBJECTIVE The need for esophagectomy in patients with Barrett's esophagus, with no endoscopically visible lesion, and a biopsy showing high-grade dysplasia or adenocarcinoma has been questioned. Recently, endoscopic techniques to ablate the neoplastic mucosa have been encouraged. The aim of this study was to determine the extent of disease present in patients with clinically occult esophageal adenocarcinoma to define the magnitude of therapy required to achieve cure. METHODS Thirty-three patients with high-grade dysplasia (23 patients) or adenocarcinoma (10 patients) and no endoscopically visible lesion underwent repeat endoscopy and systematic biopsy followed by esophagectomy. The surgical specimens were analyzed to determine the biopsy error rate in detecting occult adenocarcinoma. In those with cancer, the depth of wall penetration and the presence of lymph node metastases on conventional histology and immunohistochemistry staining was determined. The findings were compared with those in 12 patients (1 with high-grade dysplasia, 11 with adenocarcinoma) who had visible lesions on endoscopy. RESULTS The biopsy error rate for detecting occult adenocarcinoma was 43%. Of 25 patients with cancer and no visible lesion, the cancer was limited to the mucosa in 22 (88%) and to the submucosa in 3 (12%). After en bloc esophagectomy, one patient without a visible lesion had a single node metastasis on conventional histology. No additional node metastases were identified on immunohistochemistry. The 5-year survival rate after esophagectomy was 90%. Patients with endoscopically visible lesions were significantly more likely to have invasion beyond the mucosa (9/12 vs. 3/25, p = 0.01) and involvement of lymph nodes (5/9 vs. 1/10, p = 0.057). CONCLUSIONS Endoscopy with systematic biopsy cannot reliably exclude the presence of occult adenocarcinoma in Barrett's esophagus. The lack of an endoscopically visible lesion does not preclude cancer invasion beyond the muscularis mucosae, cautioning against the use of mucosal ablative procedures. The rarity of lymph node metastases in these patients encourages a more limited resection with greater emphasis on improved alimentary function (esophageal stripping with vagal nerve preservation) to provide a quality of life compatible with the excellent 5-year survival rate of 90%.
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Affiliation(s)
- J J Nigro
- Department of Surgery, University of Southern California, Los Angeles 90033-4612, USA
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44
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Oberg S, Peters JH, Nigro JJ, Theisen J, Hagen JA, DeMeester SR, Bremner CG, DeMeester TR. Helicobacter pylori is not associated with the manifestations of gastroesophageal reflux disease. Arch Surg 1999; 134:722-6. [PMID: 10401822 DOI: 10.1001/archsurg.134.7.722] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
HYPOTHESIS Helicobacter pylori is not associated with gastroesophageal reflux disease and its complications, including adenocarcinoma of the esophagus and the gastroesophageal junction (GEJ). DESIGN Retrospective analysis. SETTING University tertiary referral center. PATIENTS Two hundred twenty-nine patients with symptoms suggestive of foregut disease underwent esophageal manometry, 24-hour pH monitoring, and upper gastrointestinal tract endoscopy, with biopsy specimens obtained from the gastric antrum, the GEJ, and the distal esophagus. In these and in an additional 114 patients with adenocarcinoma of the esophagus and the GEJ, the presence of H. pylori was determined by Giemsa stain. The presence of gastroesophageal reflux disease, defined by abnormal esophageal acid exposure, and its manifestations (carditis, erosive esophagitis, intestinal metaplasia limited to the GEJ, Barrett esophagus, and adenocarcinoma of the esophagus and GEJ) were correlated with the presence of H. pylori. RESULTS Helicobacter pylori was found on the biopsy specimens of the gastric antrum in 14.0% (32/229) of the patients with benign disease. It was not related to the features of gastroesophageal reflux disease, including abnormal esophageal acid exposure, erosive esophagitis, or Barrett esophagus. The presence of inflamed cardiac mucosa at the GEJ or carditis was inversely related to H. pylori infection and strongly associated with increased esophageal acid exposure. There was no association between the presence of intestinal metaplasia and H. pylori infection. Helicobacter pylori was found in 22 (19.3%) of the 114 patients with esophageal adenocarcinoma, which was not different from the prevalence of H. pylori in patients with benign disease. CONCLUSION Helicobacter pylori plays no role in the pathogenesis of gastroesophageal reflux disease or its complications.
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Affiliation(s)
- S Oberg
- Department of Surgery, Lund University Hospital, Sweden
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45
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Nigro JJ, DeMeester SR, Hagen JA, DeMeester TR, Peters JH, Kiyabu M, Campos GM, Oberg S, Gastal O, Crookes PF, Bremner CG. Node status in transmural esophageal adenocarcinoma and outcome after en bloc esophagectomy. J Thorac Cardiovasc Surg 1999; 117:960-8. [PMID: 10220691 DOI: 10.1016/s0022-5223(99)70377-6] [Citation(s) in RCA: 121] [Impact Index Per Article: 4.8] [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: 12/25/2022]
Abstract
OBJECTIVE Adenocarcinoma has replaced squamous cell as the most common esophageal cancer in the United States. The purpose of this study was to determine the prevalence and location of lymph node metastases, the feasibility of performing an R0 resection, and disease recurrence and survival in patients with transmural adenocarcinoma of the lower esophagus and gastroesophageal junction. METHODS Forty-four patients with transmural adenocarcinoma underwent en bloc esophagectomy with systematic thoracic and abdominal lymphadenectomy. They were followed up for a median of 23 months. RESULTS Actuarial survival for the entire group was 26% at 5 years. The most important predictors of the likelihood of recurrent disease and 5-year survival were the presence and number of lymph node metastases and the ratio of involved to total removed nodes. Seven patients (16%) were found to have no lymph node metastases and had an 85% 5-year survival. In contrast, patients with more than 4 involved nodes or a node ratio greater than 0.1 had a high likelihood of recurrence and death. Location of involved lymph nodes did not predict the likelihood of recurrence or death. Despite all patients having transmural tumors, recurrence within the field of the en bloc resection occurred in only 1 patient (2%). CONCLUSIONS En bloc esophagectomy in patients with transmural esophageal adenocarcinoma is required to obtain the survival benefit of an R0 resection, to adequately assess lymphatic tumor burden, and to be able to predict the likelihood of recurrence and death and thereby guide the use of postoperative adjuvant therapy.
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Affiliation(s)
- J J Nigro
- University of Southern California, Departments of Surgery and Cardiothoracic Surgery, Los Angeles, CA, USA
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46
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Eton D, Terramani TT, Wang Y, Takahashi AM, Nigro JJ, Tang L, Yu H. Genetic engineering of stent grafts with a highly efficient pseudotyped retroviral vector. J Vasc Surg 1999; 29:863-73. [PMID: 10231638 DOI: 10.1016/s0741-5214(99)70214-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [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: 10/25/2022]
Abstract
PURPOSE The purpose of this study was first to compare the gene transfer efficiency of amphotrophic murine leukemia viral vector (ampho-MuLV) with the efficiency of MuLV pseudotyped with the vesicular stomatitis virus G glycoprotein (VSVG-MuLV) in tissue of vascular origin. The second purpose of this study was to determine cell retention after the implantation of genetically engineered stent grafts. METHODS Gene transfer efficiency was ascertained with the b-galactosidase assay. The target tissues included endothelial cells (ECs), smooth muscle cells (SMCs), and human saphenous veins (HSVs). Polyurethane stent grafts were suffused with lac Z-transduced ECs and SMCs that were harvested from porcine jugular vein. The grafts were implanted into the iliac artery of each pig whose jugular vein had been harvested. Cell retention was analyzed at 1 and 4 weeks with X-Gal staining. RESULTS VSVG-MuLV transduction efficiency exceeded that of ampho-MuLV in human ECs (VSVG-MuLV, n = 24, 89% +/- 6%; ampho-MuLV, n = 18, 14% +/- 6%; P <. 001), human SMCs (VSVG-MuLV, n = 5, 92% +/- 3%; ampho-MuLV, n = 4, 17% +/- 2%; P <.001), pig ECs (VSVG-MuLV, n = 4, 81% +/- 2%; ampho-MuLV, n = 4, 13% +/- 3%; P <.001), and pig SMCs (VSVG-MuLV, n = 5, 89% +/- 3%; ampho-MuLV, n = 4, 16% +/- 1%; P <.001). As much as a 10-fold higher transduction efficiency was observed with VSVG-MuLV in HSVs. After the stent graft implantation, the engineered cells were retained and proliferated on the stent membrane, with ingrowth into the underlying intima. CONCLUSION VSVG-MuLV significantly increased the gene transfer efficiency in vascular SMCs and ECs and in organ-cultured HSVs. The cells were retained and proliferated on stent grafts for the short term in the pig.
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Affiliation(s)
- D Eton
- Division of Vascular Surgery, Department of Surgery, University of Southern California, Los Angeles, USA
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Oberg S, DeMeester TR, Peters JH, Hagen JA, Nigro JJ, DeMeester SR, Theisen J, Campos GM, Crookes PF. The extent of Barrett's esophagus depends on the status of the lower esophageal sphincter and the degree of esophageal acid exposure. J Thorac Cardiovasc Surg 1999; 117:572-80. [PMID: 10047662 DOI: 10.1016/s0022-5223(99)70337-5] [Citation(s) in RCA: 97] [Impact Index Per Article: 3.9] [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: 12/14/2022]
Abstract
OBJECTIVE The purpose of this study was to assess whether the extent of intestinal metaplasia is related to the severity of the gastroesophageal reflux disease. METHODS A total of 556 consecutive patients with symptoms suggestive of foregut disease had upper gastrointestinal endoscopy with extensive biopsies from the gastroesophageal junction and the esophagus. All patients had esophageal motility and 24-hour pH monitoring. In 411 patients, cardiac-type mucosa was identified; in 147 patients, the cardiac-type mucosa showed intestinal metaplasia. They were divided into 3 groups based on the extent of intestinal metaplasia commonly seen clinically: long segments (>3 cm), short segments (<3 cm), and limited to the gastroesophageal junction. The duration of symptoms, the status of the lower esophageal sphincter, the degree of esophageal acid exposure, and the time to clear a reflux episode were assessed in each group. RESULTS The presence of intestinal metaplasia in cardiac-type mucosa was associated with the hallmarks of gastroesophageal reflux disease. The extent of intestinal metaplasia correlated strongly with the degree of esophageal acid exposure (r = 0.711; P <.001) and inversely with the lower esophageal sphincter pressure (r = 0.351; P <.001) and length (r = 0. 259; P =.002). Patients with a long segment of intestinal metaplasia (>3 cm) had longer duration of symptoms (16 years) than those patients with a segment of intestinal metaplasia less than 3 cm (10 years; P =.048) or those patients with intestinal metaplasia limited to the gastroesophageal junction (10 years; P =.01). CONCLUSION The extent of intestinal metaplasia, that is, Barrett's esophagus, is related to the status of the lower esophageal sphincter and the degree of esophageal acid exposure.
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Affiliation(s)
- S Oberg
- University of Southern California, Department of Surgery, Los Angeles, CA, USA
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Nigro JJ, Hagen JA, DeMeester TR, DeMeester SR, Peters JH, Oberg S, Theisen J, Kiyabu M, Crookes PF, Bremner CG. Prevalence and location of nodal metastases in distal esophageal adenocarcinoma confined to the wall: implications for therapy. J Thorac Cardiovasc Surg 1999; 117:16-23; discussion 23-5. [PMID: 9869753 DOI: 10.1016/s0022-5223(99)70464-2] [Citation(s) in RCA: 159] [Impact Index Per Article: 6.4] [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: 12/17/2022]
Abstract
OBJECTIVE The purpose of this study was to characterize the prevalence and location of regional lymph node metastases in adenocarcinoma confined to the esophagal wall, to determine the extent of dissection required, and to investigate the applicability of nonoperative therapy. METHODS Histologic evaluation of the resected specimens after en bloc esophagogastrectomy with mediastinal and abdominal lymphadenectomy was performed on 37 patients with adenocarcinoma confined to the esophageal wall. Follow-up was complete in all patients (median 24 months). RESULTS Fifteen patients (41%) had intramucosal tumors. Twelve (32%) had submucosal tumors and 10 (27%) had muscular invasion. The prevalence of regional lymph node metastases (15/37 patients, 41%) increased progressively with depth of tumor invasion, with involved nodes identified in 80% of patients with muscular invasion. Lymph node metastases were also more common at distant node stations in intramuscular tumors (5/10, 50%). Actuarial survival for the entire group was 63% at 5 years. Recurrence was identified in 6 of the 37 patients (16%), with the risk of recurrence correlating with tumor depth. CONCLUSIONS Tumor depth is a strong predictor of the probabilities of regional lymph node metastases, the likelihood of involvement of distant node groups, and the risk of recurrence. Patients with invasion of the muscular wall are at particularly high risk. En bloc esophagectomy with mediastinal and abdominal lymphadenectomy has the highest likelihood of achieving an R0 resection. The long-term survival and low recurrence rate achieved with an en bloc esophagectomy emphasizes the importance of an aggressive lymph node dissection to remove all potentially involved nodes.
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Affiliation(s)
- J J Nigro
- University of Southern California, Department of Surgery, Los Angeles, Calif.90033-4612, USA
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