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Wagner CM, Fu W, Brescia AA, Woodford J, Green C, Likosky DS, Hawkins RB, Romano MA, Ailawadi G, Bolling SF. Sex-Based Differences in Concomitant Tricuspid Repair During Degenerative Mitral Surgery. Ann Thorac Surg 2024:S0003-4975(24)00263-7. [PMID: 38615976 DOI: 10.1016/j.athoracsur.2024.03.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 02/21/2024] [Accepted: 03/18/2024] [Indexed: 04/16/2024]
Abstract
BACKGROUND Women with mitral valve disease have higher rates of tricuspid regurgitation (TR) than men. Although tricuspid valve repair (TVr) decreases the progression of TR, we hypothesize that there may be sex-based differences in concomitant TVr at the time of mitral valve operations. METHODS Adults undergoing mitral valve operation for degenerative disease with moderate or worse preoperative TR at a high-volume center from 2014 to 2023 were identified. Patients with a previous tricuspid intervention were excluded. A multivariable logistic regression identified predictors of concomitant TVr. To evaluate the clinical impact of not performing TVr, a competing risk model compared development of severe TR or valve-related reoperation by sex among patients without TVr. RESULTS Most included patients were women (55% [n = 214 of 388]), and the median age was 73 years (quartile 1-quartile 3, 65-79 years). There was no difference in the rate of severe TR by sex (female, 28%; male, 26%; P = .63). The unadjusted rate of concomitant TVr was 57% for women and 73% for men (P < .001). Overall, women had 52% lower adjusted odds of TVr (adjusted odds ratio, 0.48; 95% CI, 0.29-0.81; P = .006), including a lower adjusted rate for moderate TR (47% [95% CI, 45%-49%] vs 66% [95% CI, 64%-69%]) and for severe TR (83% [95% CI, 81%-86] vs 92% [95% CI, 90%-93%]) Among those without TVr, 12% of women and 0% of men had severe TR or required a valve-related reoperation at 4 years (P < .001). CONCLUSIONS Women with moderate or severe TR undergoing mitral valve operation for degenerative disease were less likely to receive concomitant TVr, severe TR was more likely to develop, or they would more likely need a valve-related reoperation. Evaluation of sex-based treatment differences is imperative to improve outcomes for women.
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Affiliation(s)
- Catherine M Wagner
- National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan; Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
| | - Whitney Fu
- Department of Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - Jessica Woodford
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - China Green
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Donald S Likosky
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Robert B Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
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Gupte T, Al-Sadawi M, Luke T, Smith EK, Mehta N, Liang JJ, Chugh A, Morady F, Romano MA, Oral H, Ghannam M. Clinical outcomes of patients referred for left atrial appendage exclusion who did and did not undergo the procedure. Heart Rhythm 2024:S1547-5271(24)00216-9. [PMID: 38403234 DOI: 10.1016/j.hrthm.2024.02.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 02/18/2024] [Accepted: 02/21/2024] [Indexed: 02/27/2024]
Abstract
BACKGROUND Left atrial appendage exclusion (LAAE) is an effective alternative to long-term anticoagulation in patients with atrial fibrillation. Not all patients considered for LAAE undergo the procedure because of ineligibility, anatomic or medical constraints, and preference of the patient. OBJECTIVE The objective of this study was to report on the management strategies and long-term clinical outcomes of patients referred to a dedicated multidisciplinary LAAE clinic, including all who subsequently did and did not undergo LAAE. METHODS This was a retrospective analysis of prospectively acquired data from all patients referred to the comprehensive multidisciplinary LAAE clinic at the University of Michigan between 2016 and 2022. A consecutive 301 patients (age, 75 ± 8 years; 106 women) with atrial fibrillation were evaluated. LAAE was performed in 168 patients (56%) with use of the Watchman device in 146 (49%) and surgically in 22 (7%). LAAE was not performed in 133 patients (44%, no-LAAE group) because of ineligibility in 62 (21%), anatomic constraints in 23 (7%), and preference of the patient in 48 (36%). The CHA2DS2-VASc score (4.7 ± 1.5 vs 4.1 ± 1.6; P = .002) and HAS-BLED score (3.4 ± 1.0 vs 2.8 ± 1.1; P < .001) were higher in the LAAE groups. RESULTS Anticoagulant therapy was discontinued in 137 of 146 (94%) and 61 of 133 (61%) in the Watchman and no-LAAE groups, respectively (P < .001). During a median follow-up of 2.2 years (interquartile range, 1.2-4.0 years), in the LAAE (n = 168) and no-LAAE (n = 133) groups, respectively, 39 (23%) vs 29 (22%) deaths, 13 (8%) vs 5 (4%) thromboembolic events, and 24 (14%) vs 23 (17%) bleeding complications occurred. Continued long-term anticoagulation was not a predictor of clinical outcomes. CONCLUSION After a comprehensive evaluation in a multidisciplinary clinic, ∼50% of the patients referred for LAAE did not proceed with LAAE and resumed anticoagulation.
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Affiliation(s)
- Trisha Gupte
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Mohammed Al-Sadawi
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Tiffany Luke
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Eryn K Smith
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Nimita Mehta
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Jackson J Liang
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Aman Chugh
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Fred Morady
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Hakan Oral
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan
| | - Michael Ghannam
- Section of Electrophysiology, Division of Cardiology, University of Michigan, Ann Arbor, Michigan.
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Wagner CM, Brescia AA, Watt TMF, Bergquist C, Rosenbloom LM, Ceniza NN, Markey GE, Ailawadi G, Romano MA, Bolling SF. Surgical strategy and outcomes for atrial functional mitral regurgitation: All functional mitral regurgitation is not the same! J Thorac Cardiovasc Surg 2024; 167:647-655. [PMID: 35618531 DOI: 10.1016/j.jtcvs.2022.02.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 01/10/2022] [Accepted: 02/23/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Functional mitral regurgitation (FMR) is a cardiac pathology that causes the mitral valve to malfunction, leading to mitral regurgitation (MR). The optimal strategy for FMR remains unclear, and FMR outcomes are poor. All etiologies of FMR might not be the same, and subdividing patients with FMR caused by atrial (AFMR) versus ventricular FMR pathology might be important. Herein, we present outcomes of patients with AFMR to define this "new" population. METHODS Data of patients who underwent mitral valve repair for MR from 2000 to 2020 were reviewed. Patients with degenerative/myxomatous disease, ejection fraction <50% (ventricular FMR), and miscellaneous etiologies including endocarditis and rheumatic disease were excluded to isolate a population of "pure" AFMR patients. Descriptive characteristics and outcomes data were analyzed. RESULTS Among 123 total AFMR patients, mean preoperative left atrial dimensions were enlarged to 4.9 (95% CI, 4.7-5.0) cm, whereas mean preoperative left ventricular diastolic dimensions remained near normal at 5.0 (95% CI, 4.9-5.2) cm. Preoperative atrial fibrillation was noted in 61% (74/123). Echocardiogram was performed in 58% (71/123) of patients at a median of 569 (interquartile range, 75-1782) days after surgery. Of those, 72% (51/71) had trivial or no MR, 22% (16/71) mild, and only 6% (4/71) moderate or greater MR. Only 1.6% (2/123) required redo mitral valve reoperation. Estimated 5-year survival was 74%. CONCLUSIONS Patients with AFMR do well after mitral valve repair using an annuloplasty ring, with low rates of reoperation, mortality, and recurrence of MR. Mitral annuloplasty should be considered the surgical therapy of choice for AFMR.
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Affiliation(s)
| | | | - Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Curtis Bergquist
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Liza M Rosenbloom
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Nicolas N Ceniza
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Grace E Markey
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
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Wagner CM, Fu WW, Brescia AA, Hawkins RB, Romano MA, Ailawadi G, Bolling SF. Repeat crossclamp after failed initial degenerative mitral valve repair is safe and successful. JTCVS Open 2023; 16:209-217. [PMID: 38204717 PMCID: PMC10775030 DOI: 10.1016/j.xjon.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 07/31/2023] [Accepted: 08/14/2023] [Indexed: 01/12/2024]
Abstract
Objective Surgical risk and long-term outcomes when re-crossclamp is required during degenerative mitral valve repair are unknown. We examined the outcomes of patients who required re-crossclamp for mitral valve reintervention. Methods Adults undergoing mitral valve repair for degenerative mitral valve disease at a single center from 2007 to 2021 who required more than 1 crossclamp for mitral valve reintervention were included. Outcomes including major morbidity and 30-day mortality were collected. Kaplan-Meier analysis characterized survival and freedom from recurrent mitral regurgitation. Results A total of 69 patients required re-crossclamp for mitral valve reintervention. Of those, 72% (n = 50) underwent successful re-repair and the remaining underwent mitral valve replacement (28%, n = 19). Major morbidity occurred in 23% (n = 16). There was no 30-day mortality, and median long-term survival was 10.9 years for those undergoing re-repair and 7.2 years for those undergoing replacement (P = .79). Midterm echocardiography follow-up was available for 67% (33/50) of patients who were successfully re-repaired with a median follow-up of 20 (interquartile range, 7-37) months. At late follow-up, 90% of patients had mild or less mitral regurgitation. Of those re-repaired, 2 patients later required mitral valve reintervention. Conclusions Patients requiring re-crossclamp for residual mitral regurgitation had low perioperative morbidity and no mortality. Most patients underwent successful re-repair (vs mitral valve replacement) with excellent valve function and long-term survival. In the event of unsatisfactory repair at the time of mitral valve repair, attempt at re-repair is safe and successful with the appropriate valvar anatomy.
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Affiliation(s)
- Catherine M. Wagner
- Department of Cardiac Surgery, University of Michigan Medicine, Ann Arbor, Mich
| | - Whitney W. Fu
- Department of General Surgery, University of Michigan Medicine, Ann Arbor, Mich
| | | | - Robert B. Hawkins
- Department of Cardiac Surgery, University of Michigan Medicine, Ann Arbor, Mich
| | - Matthew A. Romano
- Department of Cardiac Surgery, University of Michigan Medicine, Ann Arbor, Mich
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan Medicine, Ann Arbor, Mich
| | - Steven F. Bolling
- Department of Cardiac Surgery, University of Michigan Medicine, Ann Arbor, Mich
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Wagner CM, Fu W, Hawkins RB, Romano MA, Ailawadi G, Bolling SF. Alfieri versus conventional repair for bileaflet mitral valve prolapse. JTCVS Open 2023; 16:242-249. [PMID: 38204703 PMCID: PMC10775110 DOI: 10.1016/j.xjon.2023.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 09/12/2023] [Accepted: 10/03/2023] [Indexed: 01/12/2024]
Abstract
Objective Mitral valve repair for bileaflet prolapse can be complex, involving multiple chords or resection. The Alfieri technique for bileaflet disease is simple but may be associated with mitral stenosis or recurrent mitral regurgitation. Outcomes of patients with bileaflet prolapse undergoing mitral valve repair using the Alfieri versus conventional chord/resection techniques were compared. Methods Adults undergoing mitral valve repair for bileaflet prolapse for degenerative disease from 2017 to 2023 were stratified by repair technique. Outcomes including operative mortality and echocardiogram data were compared. Time to event analysis was used to characterize freedom from recurrent mitral regurgitation (moderate or greater mitral regurgitation). Results Among 188 patients with bileaflet prolapse, 37% (70) were repaired with the Alfieri and the remaining patients were repaired with chords/resection. Compared with chords/resection, patients undergoing the Alfieri had shorter cardiopulmonary bypass and crossclamp times. Operative mortality (0% [0/70] vs 2% [2/118], P = .27) was similar between both techniques. The mean mitral gradient was low and similar for the Alfieri versus chords/resection (3 vs 3, P = .34). Development of recurrent mitral regurgitation at 2 years, incorporating the competing risk of death and mitral reintervention, was 4.3% (95% CI, 1.5%-9.3%) for the Alfieri technique and 5.8% (95% CI, 2.2%-11.8%) for chord/resection (P = .83). Conclusions Both the Alfieri and chord/resection techniques had low rates of recurrent mitral regurgitation at 2 years. The mitral valve gradient was low and similar regardless of technique; thus, those who received the Alfieri technique did not have an increased rate of mitral stenosis. The Alfieri may be an underused technique for bileaflet prolapse.
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Affiliation(s)
- Catherine M. Wagner
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
- National Clinician Scholar's Program, Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Mich
| | - Whitney Fu
- Department of Surgery, University of Michigan, Ann Arbor, Mich
| | - Robert B. Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Matthew A. Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Steven F. Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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6
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Wagner CM, Schultz ML, Brescia AA, Wang Y, Fu W, Hawkins RB, Romano MA, Ailawadi G, Bolling SF. Surgical outcomes of patients at prohibitive risk who are reconsidered for surgery. JTCVS Open 2023; 16:234-241. [PMID: 38204727 PMCID: PMC10775058 DOI: 10.1016/j.xjon.2023.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 08/07/2023] [Accepted: 08/28/2023] [Indexed: 01/12/2024]
Abstract
Objectives Transcatheter treatment of advanced mitral and tricuspid valve disease is largely limited to patients at prohibitive surgical risk, although many are not candidates for transcatheter treatment. Here, we describe surgical outcomes of patients at prohibitive risk who were ineligible for transcatheter therapies to guide surgeons in management of this unique population. Methods Patients at prohibitive risk, defined per surgeon or cardiologist discretion, who were initially referred for a transcatheter mitral or tricuspid intervention in a multidisciplinary atrioventricular valve clinic, were identified from 2019 to 2022. Preoperative risk, operative outcomes, and long-term mortality were evaluated. Results A total of 337 patients at prohibitive risk were referred for evaluation in a multidisciplinary atrioventricular valve clinic. Of those, 161 underwent transcatheter therapy, 130 patients underwent continued medical management, and 45 were reevaluated and had high-risk surgery. Among surgical patients, 51% were women with a median age of 76 years (quartile 1-quartile 3, 65-81 years). Most patients presented in heart failure (83%; n = 37 out of 45), and 73% were in New York Heart Association functional class III or IV. Most patients (94%; n = 43) had a mitral valve intervention, of whom 56% (24 out of 43) had a mitral valve replacement. The 30-day mortality rate was 4% (2 out of 45) and major morbidity occurred in 33% (15 out of 45). By Kaplan-Meier analysis, 1-year survival was 86% ± 9%. Conclusions Select patients at prohibitive risk who were ineligible for transcatheter mitral or tricuspid valve intervention underwent surgery with overall low operative mortality and excellent 1-year survival. Patients a prohibitive risk whose anatomy is not amenable to transcatheter devices should be reconsidered for surgery.
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Affiliation(s)
| | - Megan L. Schultz
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | | | - Yoyo Wang
- University of Michigan Medical School, Ann Arbor, Mich
| | - Whitney Fu
- Department of General Surgery, University of Michigan, Ann Arbor, Mich
| | - Robert B. Hawkins
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Matthew A. Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Steven F. Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Michigan Mitral Research Group
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
- University of Michigan Medical School, Ann Arbor, Mich
- Department of General Surgery, University of Michigan, Ann Arbor, Mich
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Deshmukh A, Romano MA, Oral H. Hybrid ventricular tachycardia ablation: Choosing the right tool for the job. Heart Rhythm 2023; 20:1718-1719. [PMID: 37774775 DOI: 10.1016/j.hrthm.2023.09.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 09/25/2023] [Indexed: 10/01/2023]
Affiliation(s)
- Amrish Deshmukh
- Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, Michigan
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Hakan Oral
- Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, Michigan.
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8
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Watt TMF, Brescia AA, Murray SL, Rosenbloom LM, Wisnielwski A, Burn D, Romano MA, Bolling SF. Does Sustained Reduction of Functional Mitral Regurgitation Impact Survival? Semin Thorac Cardiovasc Surg 2023; 36:37-46. [PMID: 37633624 DOI: 10.1053/j.semtcvs.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/17/2023] [Indexed: 08/28/2023]
Abstract
Functional mitral regurgitation (FMR) is associated with increased mortality and has been considered a marker for advanced heart disease, yet the value of mitral valve repair (MVr) in this population remains unclear. This study aims to evaluate the impact of reducing FMR burden through surgical MVr on survival. Patients with severe FMR who underwent MVr with an undersized, complete, rigid, annuloplasty between 2004 and 2017 were assessed (n = 201). Patients were categorized based on grade of recurrent FMR (0-4). Time-to-event Kaplan-Meier estimations of freedom from death or reoperation were performed using the log-rank test. Cox proportional hazards models evaluated all-cause mortality and reported in hazards ratios (HR) and 95% confidence intervals (CI). Patients were categorized by postoperative recurrent FMR: 45% (91/201) of patients had grade 0, 29% (58/201) grade 1, 20% (40/201) grade 2, 2% (4/201) grade 3%, and 4% (8/201) grade 4. The cumulative incidence of reoperation with death as a competing risk was higher in patients with grades ≥3 recurrent FMR compared to grades ≤2 (44.6% vs 14.6%, subhazard ratio 3.69 [95% CI, 1.17-11.6]; P = 0.026). Overall freedom from death or reoperation was superior for recurrent FMR grades ≤2 compared to grades ≥3 (log-rank P < 0.001). Increasing recurrent FMR grade was independently associated with mortality (HR 1.30 [95% CI, 1.07-1.59] P = 0.009). Reduced postoperative FMR grade resulted in an incrementally lower risk of death or reoperation after MVr. These results suggest that achieving a durable reduction in FMR burden improves long-term survival.
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Affiliation(s)
| | | | | | | | | | - David Burn
- Department of Mathematics, Quinnipiac University
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9
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Pienta MJ, Romano MA. Secondary Mitral Regurgitation and Transcatheter Mitral Valve Therapies: Do They Have a Role in Advanced Heart Failure with Reduced Ejection Fraction? Cardiol Clin 2023; 41:575-582. [PMID: 37743079 DOI: 10.1016/j.ccl.2023.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Transcatheter mitral valve repair should be considered for patients with severe secondary mitral regurgitation with symptomatic heart failure with reduced ejection fraction for symptom improvement and survival benefit. Patients with a higher severity of secondary mitral regurgitation relative to the degree of left ventricular dilation are more likely to benefit from transcatheter mitral valve repair. A multidisciplinary Heart Team should participate in patient selection for transcatheter mitral valve therapy.
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Affiliation(s)
- Michael J Pienta
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Matthew A Romano
- Department of Cardiac Surgery, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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10
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Pienta MJ, Theurer P, He C, Clark M, Haft J, Bolling SF, Willekes C, Nemeh H, Prager RL, Romano MA, Ailawadi G. Contemporary Management of Ischemic Mitral Regurgitation at Coronary Artery Bypass Grafting. Ann Thorac Surg 2023; 115:88-95. [PMID: 36150477 DOI: 10.1016/j.athoracsur.2022.08.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 07/09/2022] [Accepted: 09/12/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND Recent guidelines for the treatment of moderate or severe ischemic mitral regurgitation (IMR) in patients undergoing coronary artery bypass grafting (CABG) have changed. This study assessed the real-world impact of changing guidelines on the management of IMR during CABG over time. We hypothesized that the utilization of mitral valve repair for IMR would decrease over time, whereas mitral valve replacement for severe IMR would increase. METHODS Patients undergoing CABG in a statewide collaborative database (2011-2020) were stratified by severity of IMR. Trends in mitral valve repair or replacement were evaluated. To account for differences of the patients, propensity score-matched analyses were used to compare patients with and without mitral intervention. RESULTS A total of 11,676 patients met inclusion criteria, including 1355 (11.6%) with moderate IMR and 390 (3.3%) with severe IMR. The proportion of patients undergoing mitral intervention for moderate IMR decreased over time (2011, 17.7%; 2020, 7.5%; Ptrend = .001), whereas mitral replacement for severe IMR remained stable (2011, 11.1%; 2020, 13.3%; Ptrend = .14). Major morbidity was higher for patients with moderate IMR who underwent mitral intervention (29.1% vs 19.9%; P = .005). In a propensity analysis of 249 well-matched pairs, there was no difference in major morbidity (29.3% with mitral intervention vs 23.7% without; P = .16) or operative mortality (1.2% vs 2.4%; P = .5). CONCLUSIONS Consistent with recent guideline updates, patients with moderate IMR were less likely to undergo mitral repair. However, the rate of replacement for severe IMR did not change. Mitral intervention during CABG did not increase operative mortality or morbidity.
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Affiliation(s)
- Michael J Pienta
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Patty Theurer
- Michigan Society of Thoracic and Cardiovascular Surgery Quality Collaborative, Ann Arbor, Michigan
| | - Chang He
- Michigan Society of Thoracic and Cardiovascular Surgery Quality Collaborative, Ann Arbor, Michigan
| | - Melissa Clark
- Michigan Society of Thoracic and Cardiovascular Surgery Quality Collaborative, Ann Arbor, Michigan
| | - Jonathan Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | | | | | - Richard L Prager
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
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11
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Park TJ, Hansen R, Gillard P, Shah D, Ferguson WG, Piccini J, Romano MA, Devine B. Healthcare resource utilization and costs for patients with postoperative atrial fibrillation in the United States. J Med Econ 2023; 26:1417-1423. [PMID: 37801391 DOI: 10.1080/13696998.2023.2267390] [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: 07/20/2023] [Accepted: 10/03/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Postoperative atrial fibrillation (POAF) is one of the most common complications following cardiac surgery. POAF is associated with increased hospitalization costs, but its long-term economic burden is not well defined. OBJECTIVE To assess 30-day and 1-year incremental healthcare resource utilization (HRU) and costs associated with POAF in the United States (US). METHODS This retrospective cohort study used claims data from the IBM Watson MarketScan database. A cohort of US adults aged 55--90 years who underwent open-heart surgery between 1 January 2017 and 31 December 2018 was used to compare patients who experienced POAF versus patients who did not (controls). The outcomes of interest were incremental HRU and costs, which were assessed during the index hospitalization and 30-day and 1-year postdischarge time periods. Inverse probability weighting was used to adjust for differences in baseline characteristics. RESULTS A total of 8,020 patients met the study inclusion criteria with 5,765 patients in the control cohort (mean age, 63.4 years) and 2,255 patients in the POAF cohort (mean age, 65.8 years). After adjustment, patients with POAF had an index hospitalization that was 1.9 days longer (99% CI, 1.3-2.4 days; p < 0.001) and cost $13,919 more (99% CI, $2,828-$25,011; p < 0.001) than for patients without POAF. POAF patients also had significantly higher HRU at 30 days and 1-year postdischarge with incremental costs of $4,649 (99% CI, $1,479-$7,819; p < 0.001) and $10,671 (99% CI, $2,407-$18,935; p < 0.001), respectively. CONCLUSION POAF following open-heart surgery poses a significant economic burden up to 1 year postdischarge.
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Affiliation(s)
- Tae Jin Park
- Allergan, an AbbVie Company, Irvine, CA, USA
- University of Washington, Seattle, WA, USA
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12
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Pienta MJ, Theurer P, He C, Zehr K, Drake D, Murphy E, Bolling SF, Romano MA, Prager R, Thompson MP, Ailawadi G, Martin D, George K, Batra S, Liakonis C, Dabir R, Shannon F, Robinson P, Delucia A, Kaakeh B, Zehr K, Mandal K, Simonetti V, Nemeh H, Alnajjar R, Holmes R, Batra S, Gandhi D, Minanov K, Talbott J, Martin J, Downey R, Collar A, Lall S, Pridjian A, Fanning J, Baghelai K, Pruitt A, Schwartz C, Kim K, Blakeman B. Racial Disparities in Mitral Valve Surgery: A Statewide Analysis. J Thorac Cardiovasc Surg 2022; 165:1815-1823.e8. [PMID: 35414409 DOI: 10.1016/j.jtcvs.2021.11.096] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 11/01/2021] [Accepted: 11/04/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Racial disparities in health care have come to the forefront. We hypothesized that Black race was associated with worse preoperative risk, lower repair rates, and worse outcomes among patients who underwent mitral valve surgery. METHODS All patients who underwent mitral valve repair or replacement with or without coronary artery bypass grafting from 2011 to 2020 in a statewide collaborative database were stratified into 3 racial groups, White, Black, and other. Preoperative characteristics, procedure type, and outcomes were evaluated. RESULTS A total of 9074 mitral valve operations were performed at 33 centers (Black 1009 [11.1%], White 7862 [86.6%]). Preoperative combined Society of Thoracic Surgeons morbidity and mortality was higher for Black patients (Black 32%, White 22%, other 23%, [P < .001]) because of a greater proportion of diabetes, hypertension, and chronic lung disease. White patients were more likely to undergo mitral repair (White 66%, Black 53.3%, other 57%; P < .001). Operative mortality was similar across racial groups (White 3.7%, Black 4.6%, other 4.5%; P = .36). After adjusting for preoperative factors, mitral etiology, and hospitals, race was not associated with mitral valve repair, complications, or mortality, but Black patients had higher odds of extended care facility utilization and readmission. CONCLUSIONS Contrary to our hypothesis, there was no difference in the odds of repair or operative mortality across races after accounting for risk and etiology. However, Black patients were more likely to be readmitted after discharge. These findings support a greater focus on reducing disparities in mitral valve surgery.
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13
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Brescia AA, Watt TMF, Murray SL, Rosenbloom LM, Kleeman KC, Allgeyer H, Eid J, Romano MA, Bolling SF. Rheumatic mitral valve repair or replacement in the valve-in-valve era. J Thorac Cardiovasc Surg 2022; 163:591-602.e1. [PMID: 32620398 PMCID: PMC7655552 DOI: 10.1016/j.jtcvs.2020.04.118] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2019] [Revised: 03/31/2020] [Accepted: 04/15/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE For degenerative mitral disease, repair is superior to replacement; however, the best operative strategy for rheumatic mitral disease remains unclear. We evaluated the association between decision-making in choosing repair versus replacement and outcomes across 2 decades of rheumatic mitral surgery. METHODS Patients undergoing isolated, first-time rheumatic mitral surgery were identified. Era 1 (1997-2008) and Era 2 (2009-2018) were distinguished by intraoperative assessment of anterior leaflet mobility/calcification (Era 2) in deciding between mitral repair versus replacement. Primary outcome was a composite of death, reoperation, and severe valve dysfunction. RESULTS Among 180 patients, age was 59 ± 14 years, and ejection fraction was 58% ± 10%. A higher proportion in Era 1 (n = 56) compared with Era 2 (n = 124) had preoperative atrial fibrillation (68% vs 46%; P = .006); the groups were otherwise similar. Primary indication was mitral stenosis in 69% (124 out of 180; pure = 35, mixed = 89) and did not differ by era (P = .67). During Era 1, 70% (39 out of 56) underwent repair, compared with 33% (41 out of 124) during Era 2 (P < .001). Freedom from death, reoperation, or severe valve dysfunction at 5 years was higher in Era 2 (72% ± 9%) than Era 1 (54% ± 13%; P = .04). Five-year survival was higher in Era 2 than Era 1, but did not differ between repair versus replacement. Five-year cumulative incidence of reoperation with death as a competing risk did not differ by era, but was higher after repair than replacement. CONCLUSIONS Careful assessment of anterior leaflet mobility/calcification to determine mitral repair or replacement was associated with improved outcomes. This decision-making strategy may alter the threshold for rheumatic mitral replacement in the current valve-in-valve era.
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Affiliation(s)
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- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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14
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Romano MA. Commentary: Cut to the chase: It's a matter of principle. JTCVS Tech 2021; 10:53-54. [PMID: 34984360 PMCID: PMC8691919 DOI: 10.1016/j.xjtc.2021.10.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2021] [Revised: 10/16/2021] [Accepted: 10/19/2021] [Indexed: 11/05/2022] Open
Affiliation(s)
- Matthew A. Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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15
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Lau WC, Shannon FL, Bolling SF, Romano MA, Sakwa MP, Trescot A, Shi L, Johnson RL, Starnes VA, Grehan JF. Intercostal Cryo Nerve Block in Minimally Invasive Cardiac Surgery: The Prospective Randomized FROST Trial. Pain Ther 2021; 10:1579-1592. [PMID: 34545530 PMCID: PMC8586406 DOI: 10.1007/s40122-021-00318-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 09/02/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Intercostal cryo nerve block has been shown to enhance pulmonary function recovery and pain management in post-thoracotomy procedures. However, its benefit have never been demonstrated in minimal invasive thoracotomy heart valve surgery (Mini-HVS). The purpose of the study was to determine whether intraoperative intercostal cryo nerve block in conjunction with standard of care (collectively referred to hereafter as CryoNB) provided superior analgesic efficacy in patients undergoing Mini-HVS compared to standard-of-care (SOC). METHODS FROST was a prospective, 3:1 randomized (CryoNB vs. SOC), multicenter trial in patients undergoing Mini-HVS. The primary endpoint was the 48-h postoperative forced expiratory volume in 1 s (FEV1) result. Secondary endpoints were visual analog scale (VAS) scores for pain at the surgical site and general pain, intensive care unit and hospital length-of-stay, total opioid consumption, and allodynia at 6 months postoperatively. RESULTS A total of 84 patients were randomized to the two arms of the trial CryoNB (n = 65) and SOC (n = 19). Baseline Society of Thoracic Surgeons Predictive Risk of Mortality (STS PROM) score, ejection fraction, and FEV1 were similar between cohorts. A higher 48-h postoperative FEV1 result was demonstrated in the CryoNB cohort versus the SOC cohort (1.20 ± 0.46 vs. 0.93 ± 0.43 L; P = 0.02, one-sided two-sample t test). Surgical site VAS scores were similar between the CryoNB and SOC cohorts at all postoperative timepoints evaluated, but VAS scores not related to the surgical site were lower in the SOC group at 72, 94, and 120 h postoperatively. The SOC cohort had a 13% higher opioid consumption than the CryoNB cohort. One of 64 CryoNB patients reported allodynia that did not require pain medication at 10 months. CONCLUSIONS The results of FROST demonstrated that intercostal CryoNB provided enhanced FEV1 score at 48 h postoperatively with optimized analgesic effectiveness versus SOC. Future larger prospective randomized trials are warranted to determine whether intercostal CryoNB has an opioid-sparing effect in patients undergoing Mini-HVS. TRIAL REGISTRATION Clinicaltrials.gov identifier: NCT02922153.
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Affiliation(s)
- Wei C. Lau
- William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48703 USA
| | - Francis L. Shannon
- William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48703 USA
| | | | | | - Marc P. Sakwa
- Memorial Care Heart and Vascular Institute, Long Beach, CA USA
| | | | | | - Robert L. Johnson
- William Beaumont Hospital, 3601 West 13 Mile Road, Royal Oak, MI 48703 USA
| | | | - John F. Grehan
- United Heart and Vascular Institute—Allina, Saint Paul, MN USA
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16
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Romano MA. Commentary: Is it a long run for a short slide? JTCVS Tech 2021; 10:300-301. [PMID: 34977743 PMCID: PMC8691223 DOI: 10.1016/j.xjtc.2021.08.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Revised: 08/04/2021] [Accepted: 08/11/2021] [Indexed: 11/19/2022] Open
Affiliation(s)
- Matthew A. Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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17
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Brescia AA, Watt TMF, Rosenbloom LM, Murray SL, Wu X, Romano MA, Bolling SF. Anterior versus posterior leaflet mitral valve repair: A propensity-matched analysis. J Thorac Cardiovasc Surg 2021; 162:1087-1096.e3. [PMID: 32305185 PMCID: PMC7483316 DOI: 10.1016/j.jtcvs.2019.11.148] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 10/09/2019] [Accepted: 11/23/2019] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Mitral valve repair is superior to replacement for degenerative disease, but long-term outcomes of anterior versus posterior leaflet repair remain poorly defined. We propensity matched anterior and posterior repairs to compare long-term outcomes. METHODS Patients undergoing first-time degenerative mitral repair between 1992 and 2018 were identified. Primary outcome was overall survival. Secondary outcomes were postprocedural residual mitral regurgitation and reoperation. From 1025 patients, 1:1 propensity score matching was performed, yielding 309 anterior (isolated anterior = 85, bileaflet = 224) and 309 isolated posterior repairs. RESULTS Age was 58 ± 15 years, ejection fraction was 57% ± 10%, and matched groups were well balanced. Anterior repairs had longer bypass (122 ± 53 vs 109 ± 43 minutes, P = .001) and crossclamp (94 ± 44 vs 85 ± 62 minutes, P = .033) times. Mean residual mitral regurgitation grade was 0.44 (95% confidence interval, 0.24-0.65) for anterior repair and 0.30 (95% confidence interval, 0.13-0.47) for posterior repair (P = .31). Overall, 92% (569/618) of matched patients had no residual mitral regurgitation, with no differences in mitral regurgitation grade between groups (P = .77). Survival did not differ between anterior (10 years: 72% ± 7%; 15 years: 63% ± 7%) and posterior (10 years: 74% ± 7%; 15 years: 60% ± 8%) groups (log-rank P = .93). Linearized incidence of reoperation was 0.62% per patient-year, including 0.74% for anterior and 0.48% for posterior repairs. Cumulative incidence of reoperation at 15 years was 7.5% after anterior repair and 4.9% after posterior repair (Gray's test P = .26). CONCLUSIONS No long-term survival or reoperation difference was found between posterior and anterior repair. On the basis of these findings, surgeons at centers of excellence should aim for repair of both anterior and posterior leaflet pathology with the same decision-making threshold over valve replacement for degenerative mitral disease.
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Affiliation(s)
| | - Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Liza M Rosenbloom
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Shannon L Murray
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Xiaoting Wu
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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18
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Tang PC, Duggal NM, Haft JW, Romano MA, Bolling SF, Abou El Ela A, Wu X, Colvin MM, Aaronson KD, Pagani FD. Left Ventricular Assist Device Implantation in Patients with Preoperative Severe Mitral Regurgitation. ASAIO J 2021; 67:1139-1147. [PMID: 34570728 DOI: 10.1097/mat.0000000000001379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We examined cardiac features associated with residual mitral regurgitation (MR) following continuous-flow left ventricular assist device (cfLVAD) implant. From 2003 to 2017, 134 patients with severe MR underwent cfVLAD implant without mitral valve (MV) intervention. Echocardiographic (echo) assessment occurred pre-cfLVAD, early post-cfLVAD, and at last available echo. Ventricular and atrial volumes were calculated from established formulas and normalized to be predicted. Cluster analysis based on preoperative normalized left ventricular and atrial volumes, and MV height identified grades 1, 2, and 3 with progressively larger cardiac chamber sizes. Median early echo follow-up was 0.92 (0.55, 1.45) months and the last follow-up was 15.12 (5.28, 38.28) months. Mitral regurgitation improved early after cfLVAD by 2.10 ± 1.16 grades (p < 0.01). Mitral regurgitation severity at the last echocardiogram positively correlated with the preoperative left ventricular volume (p = 0.014, R = 0.212), left atrial volume (p = 0.007, R = 0.233), MV anteroposterior height (p = 0.032, R = 0.185), and MV mediolateral diameter (p = 0.043, R = 0.175). Morphologically, smaller grade 1 hearts were correlated with MR resolution at the late follow-up (p = 0.023). Late right ventricular failure (RVF) at the last clinical follow-up was less in grade 1 (4/48 [8.3%]) compared with grades 2 and 3 (26/86 [30.2%]), p = 0.004). Grade 1 cardiac dimensions correlates with improvement in severe MR and had less late RVF.
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Affiliation(s)
| | | | | | | | | | | | | | - Monica M Colvin
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Keith D Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
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19
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Tang PC, Lei I, Chen YE, Wang Z, Ailawadi G, Romano MA, Salvi S, Aaronson KD, Si MS, Pagani FD, Haft JW. Risk factors for heart transplant survival with greater than 5 h of donor heart ischemic time. J Card Surg 2021; 36:2677-2684. [PMID: 34018246 DOI: 10.1111/jocs.15621] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/01/2021] [Accepted: 03/09/2021] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Implantation of donor hearts with prolonged ischemic times is associated with worse survival. We sought to identify risk factors that modulate the effects of prolonged preservation. METHODS Retrospective review of the United Network for Organ Sharing database (2000-2018) to identify transplants with >5 (n = 1526) or ≤5 h (n = 35,733) of donor heart preservation. In transplanted hearts preserved for >5 h, Cox-proportional hazards identify modifiers for survival. RESULTS Compared to ≤5 h, transplanted patients with >5 h of preservation spent less time in status 1B (76 ± 160 vs. 85 ± 173 days, p = .027), more commonly had ischemic cardiomyopathy (42.3% vs. 38.3%, p = .002), and less commonly received a blood type O heart (45.4% vs. 50.8%, p < .001). Longer heart preservation time was associated with a higher incidence of postoperative stroke (4.5% vs. 2.5%, p < .001), and dialysis (16.4% vs. 10.6%, p < .001). Prolonged preservation was associated with a greater likelihood of death from primary graft dysfunction (2.8% vs. 1.5%, p < .001) but there was no difference in death from acute (2.0% vs. 1.7%, p = .402) or chronic rejection (2.0% vs. 1.9%, p = .618). In transplanted patients with >5 h of heart preservation, multivariable analysis identified greater mortality with ischemic cardiomyopathy etiology (hazard ratio [HR] = 1.36, p < 0.01), pre-transplant dialysis (HR = 1.84, p < .01), pre-transplant extracorporeal membrane oxygenation (ECMO, HR = 2.36, p = .09), and O blood type donor hearts (HR = 1.35, p < .01). CONCLUSION Preservation time >5 h is associated with worse survival. This mortality risk is further amplified by preoperative dialysis and ECMO, ischemic cardiomyopathy etiology, and use of O blood type donor hearts.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Ienglam Lei
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Y E Chen
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Zhong Wang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Shachi Salvi
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Keith D Aaronson
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Ming-Sing Si
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan, USA
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20
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Brescia AA, Watt TMF, Rosenbloom LM, Williams AM, Bolling SF, Romano MA. Patient and Surgeon Predictors of Mitral and Tricuspid Valve Repair for Infective Endocarditis. Semin Thorac Cardiovasc Surg 2021; 34:67-77. [PMID: 33865973 DOI: 10.1053/j.semtcvs.2021.03.017] [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: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 11/11/2022]
Abstract
Mitral repair (MVr) is superior to replacement for degenerative disease; however, its benefit is less established for endocarditis. We report outcomes of repair or replacement for mitral/tricuspid endocarditis and identify predictors of MVr. Patients undergoing first-time surgery for mitral (n = 260) or tricuspid (n = 71) endocarditis between 1992 to 2018 were identified. Patients with aortic endocarditis were excluded. Primary outcome was all-cause mortality and secondary outcome was MVr. Patients were stratified into active and treated endocarditis separately for mitral and tricuspid groups. Predictors of MVr were assessed through multivariable logistic regression and adjusted likelihood of MVr through marginal effects estimates. A mitral specialist was defined by performing ≥25 annual degenerative MVr. Among 331 patients, 70% (181/260) of those with mitral valve endocarditis and 52% (37/71) of those with tricuspid endocarditis underwent repair. The MVr group compared with replacement had a higher proportion of elective acuity and less diabetes, hypertension, active endocarditis, cardiogenic shock, and dialysis. Estimated 5-year survival did not differ between repair versus replacement for active mitral (68 ± 14% vs 60 ± 14%, P = 0.34) or tricuspid endocarditis (60 ± 17% vs 61 ± 19%, P = 0.67), but was superior after repair for treated mitral endocarditis (86 ± 7% vs 51 ± 24%, P = 0.014). Independent predictors of mortality included dialysis for active and treated mitral endocarditis, and mitral replacement (vs MVr) for treated mitral endocarditis. The likelihood of MVr was 82 ± 5% for mitral specialists and 47 ± 9% for non-specialists (P < 0.001). MVr for endocarditis should be pursued, if feasible. Importantly, achieving MVr was driven not only by patient factors, but also surgeon experience.
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Affiliation(s)
| | - Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Liza M Rosenbloom
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Aaron M Williams
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
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21
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Abstract
BACKGROUND This qualitative research explored the lived experiences of patients who experienced postponement of elective cardiac and vascular surgery due to coronavirus disease 2019 (COVID-19). We know very little about patients during the novel coronavirus pandemic. Understanding the patient voice may play an important role in prioritization of postponed cases and triage moving forward. METHODS Utilizing a hermeneutical phenomenological qualitative design, we interviewed 47 individuals who experienced a postponement of cardiac or vascular surgery due to the COVID-19 pandemic. Data were analyzed and informed by phenomenological research methods. RESULTS Patients in our study described 3 key issues around their postponement of elective surgery. Patients described robust narratives about the meanings of their elective surgeries as the chance to "return to normal" and alleviate symptoms that impacted everyday life. Second, because of the meanings most of our patients ascribed to their surgeries, postponement often took a toll on how patients managed physical health and emotional well-being. Finally, paradoxically, many patients in our study were demonstrative that they would "rather die from a heart attack" than be exposed to the coronavirus. CONCLUSIONS We identified several components of the patient experience, encompassing quality of life and other desired benefits of surgery, the risks of COVID, and difficulty reconciling the 2. Our study provides significant qualitative evidence to inform providers of important considerations when rescheduling the backlog of patients. The emotional and psychological distress that patients experienced due to postponement may also require additional considerations in postoperative recovery.
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Affiliation(s)
- Mary E. Byrnes
- Center for Healthcare Outcomes and Policy
- Department of Surgery
| | - Craig S. Brown
- Center for Healthcare Outcomes and Policy
- Department of Surgery
| | - Ana C. De Roo
- Center for Healthcare Outcomes and Policy
- Department of Surgery
| | - Matthew A. Corriere
- Center for Healthcare Outcomes and Policy
- Department of Vascular Surgery, Frankel Cardiovascular Center
| | - Matthew A. Romano
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan Medicine, Ann Arbor, MI
| | - Shinichi Fukuhara
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan Medicine, Ann Arbor, MI
| | - Karen M. Kim
- Department of Cardiac Surgery, Frankel Cardiovascular Center, University of Michigan Medicine, Ann Arbor, MI
| | - Nicholas H. Osborne
- Center for Healthcare Outcomes and Policy
- Department of Vascular Surgery, Frankel Cardiovascular Center
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22
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Watt TM, Kleeman KC, Brescia AA, Seymour EM, Kirakosyan A, Khan SP, Rosenbloom LM, Murray SL, Romano MA, Bolling SF. Inflammatory and Antioxidant Gene Transcripts: A Novel Profile in Postoperative Atrial Fibrillation. Semin Thorac Cardiovasc Surg 2020; 33:948-955. [DOI: 10.1053/j.semtcvs.2020.11.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/17/2020] [Indexed: 01/11/2023]
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23
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Atreya AR, Kawamoto K, Yelavarthy P, Arain MA, Cohen DG, Wanamaker BL, El Ela AA, Romano MA, Grossman PM. Acute Myocardial Infarction and Papillary Muscle Rupture in the COVID-19 Era. JACC Case Rep 2020; 2:1637-1641. [PMID: 32839759 PMCID: PMC7438054 DOI: 10.1016/j.jaccas.2020.06.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Accepted: 06/26/2020] [Indexed: 11/26/2022]
Abstract
Mechanical complications of acute myocardial infarction are infrequent in the modern era of primary percutaneous coronary intervention, but they are associated with high mortality rates. Papillary muscle rupture with acute severe mitral regurgitation is one such life-threatening complication that requires early detection and urgent surgical intervention. (Level of Difficulty: Beginner.).
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Affiliation(s)
- Auras R Atreya
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Kris Kawamoto
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Prasanthi Yelavarthy
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Mansoor A Arain
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - David G Cohen
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Brett L Wanamaker
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Ashraf Abou El Ela
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Matthew A Romano
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
| | - Paul M Grossman
- Division of Cardiovascular Medicine and Cardiac Surgery, Frankel Cardiovascular Center, Michigan Medicine, University of Michigan, Ann Arbor, Michigan
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Palmer ST, Romano MA, Bolling SF, Fukuhara S. Surgical strategies for a failed Watchman device. JTCVS Tech 2020; 4:160-164. [PMID: 34317997 PMCID: PMC8305713 DOI: 10.1016/j.xjtc.2020.08.025] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 08/11/2020] [Accepted: 08/11/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- Sarah T Palmer
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Shinichi Fukuhara
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
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Watt TMF, Murray SL, Brescia AA, Burn DA, Wisniewski A, Khan SP, Romano MA, Bolling SF, The Michigan Mitral Research Group Mmrg. Anticoagulation following mitral valve repair. J Card Surg 2020; 35:2887-2894. [PMID: 32741031 DOI: 10.1111/jocs.14902] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND AIM Anticoagulation after mitral valve repair is controversial and guidelines are not well-established. This study evaluated the association between postoperative warfarin use and complications after mitral valve repair, including bleeding and thromboembolic incidents, readmission, and mortality. METHODS This retrospective study investigated 1097 patients who underwent elective mitral valve repair between April 2003 and March 2017, and was naïve to atrial fibrillation or prior cardiac surgery. This cohort had no other indication for or against anticoagulation. About 775 patients were placed on warfarin with international normalized ratio goal 2.5 and 322 patients were not anticoagulated. The association between anticoagulation and complications was assessed with univariate comparisons between groups and multiple logistic regression. RESULTS Postoperative warfarin use was associated with a reduced composite of bleeding and thromboembolic complications (pulmonary embolism, TIA, stroke, pericardial effusion or cardiac tamponade, gastrointestinal bleeding, and reoperation for bleeding) with an odds ratio of 0.29 (95% confidence interval, 0.13-0.64, P = .003). There was no difference in 30-day or 6-month mortality or readmission rate between groups. Long-term survival estimates were superior in the warfarin group (10-year: 92% vs 85%; log-rank P < .001). CONCLUSIONS Our analysis showed that postoperative warfarin use was associated with an overall reduced composite of bleeding and thromboembolic incidents and superior long-term survival. These findings suggest that anticoagulation with warfarin following mitral valve repair may be a safe and effective means for avoiding postoperative complications and that a large prospective randomized clinical trial is warranted.
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Affiliation(s)
- Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Shannon L Murray
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | | | - David A Burn
- Department of Mathematics, Quinnipiac University, Hamden, Connecticut
| | | | - Shazli P Khan
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
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Iribarne A, Thourani VH, Cleveland JC, Malaisrie SC, Romano MA, Moon MR, Ramakrishna H, Mewhort HEM, Halkos M, Sultan I, Kindler C, Firstenberg MS, Dayan V, Kasirajan V, Salerno C, Phillips A. Cardiac surgery considerations and lessons learned during the COVID‐19 pandemic. J Card Surg 2020. [PMCID: PMC7404588 DOI: 10.1111/jocs.14798] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The COVID‐19 pandemic has transformed cardiac surgical practices. Limitations in intensive care resources and personal protective equipment have required many practices throughout the globe to pause elective operations and now slowly resume operations. However, much of cardiac surgery is not elective and patients continue to require surgery on an urgent or emergent basis during the pandemic. This continued need for providing surgical services has introduced several unique considerations ranging from how to prioritize surgery, how to ensure safety for cardiac surgical teams, and how best to resume elective operations to ensure the safety of patients. Additionally, the COVID‐19 pandemic has required a careful analysis of how best to carry out heart transplantation, extra‐corporeal membrane oxygenation, and congenital heart surgery. In this review, we present the many areas of multidisciplinary consideration, and the lessons learned that have allowed us to carry out cardiac surgery with excellence during the COVID‐19 pandemic. As various states experience plateaus, declines, and rises in COVID‐19 cases, these considerations are particularly important for cardiac surgical programs throughout the globe.
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Affiliation(s)
- Alexander Iribarne
- Section of Cardiac Surgery, Heart & Vascular Center Dartmouth‐Hitchcock Medical Center Lebanon New Hampshire
| | - Vinod H. Thourani
- Department of Cardiovascular Surgery, Marcus Valve Center Piedmont Heart Institute Atlanta Georgia
| | - Joseph C. Cleveland
- Division of Cardiothoracic Surgery University of Colorado Anschutz Medical Center Aurora Colorado
| | | | - Matthew A. Romano
- Department of Cardiac Surgery University of Michigan Ann Arbor Michigan
| | - Marc R. Moon
- Divison of Cardiothoracic Surgery Washington University Medical Center St. Louis Missouri
| | | | | | - Michael Halkos
- Department of Cardiothoracic Surgery Emory University Medical Center Atlanta Georgia
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery University of Pittsburgh Medical Center Pittsburgh Pennsylvania
| | - Christine Kindler
- Department of Cardiothoracic Surgery Einstein Healthcare Network Philadelphia Pennsylvania
| | | | - Victor Dayan
- Department of Cardiac Surgery University of the Republic of Uruguay Montevideo Uruguay
| | - Vigneshwar Kasirajan
- Division of Cardiothoracic Surgery, Pauley Heart Center Virginia Commonwealth University Richmond Virginia
| | - Chris Salerno
- Department of Cardiothoracic Surgery Ascension Medical Group Indianapolis Indiana
| | - Alistair Phillips
- Department of Thoracic and Cardiovascular Surgery Cleveland Clinic Cleveland Ohio
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Si MS, Conte JV, Romano JC, Romano MA, Andersen ND, Gerdisch MW, Kupferschmid JP, Fiore AC, Bakhos M, Bonilla JJ, Burke JR, Rankin JS, Wei LM, Badhwar V, Turek JW. Unicuspid Aortic Valve Repair Using Geometric Ring Annuloplasty. Ann Thorac Surg 2020; 111:1359-1366. [PMID: 32619617 DOI: 10.1016/j.athoracsur.2020.04.147] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 02/01/2020] [Accepted: 04/02/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Unicuspid aortic valves (Sievers type 2 bicuspid) are characterized by major fusion and clefting of the right-left coronary commissure, and minor fusion of the right-noncoronary commissure. Repair has been difficult because of two fusions, variable relative sinus sizes, and peripheral leaflet deficiencies or tears after balloon valvuloplasty. METHODS Twenty unicuspid aortic valves patients underwent valve repair in nine institutions. Right-left major fusion and right-noncoronary minor fusion occurred in 17 of 20 (85%). Commissurotomy was performed on the minor fusion, and a bicuspid annuloplasty ring with circular base geometry and two 180-degree subcommissural posts was sutured beneath the annulus, equalizing the annular circumferences of the fused and nonfused cusps. The nonfused leaflet was plicated, and the cleft in the major fusion was closed linearly until leaflet effective heights and lengths became greater than 8 mm and equal, respectively. RESULTS Average age (mean ± SD) was 22.3 ± 12.3 years (range, 13 to 58), 12 of 20 (60%) were symptomatic, 10 of 20 (50%) required aortic aneurysm resection. Pre-repair hemodynamic data included mean systolic valve gradient 25.8 ± 12.9 mm Hg, aortic insufficiency grade 2.9 ± 1.2, and annular diameter 24.7 ± 3.3 mm. No mortality or major complications occurred. Post-repair annular (ring) size was 20.5 ± 1.3 mm, mean gradient fell to 16.2 ± 5.9 mm Hg, and aortic insufficiency grade decreased to 0.1 ± 0.3 (P < .001). At an average follow-up of 11 months (range, 1 to 22), all 20 patients were asymptomatic and had returned to full activity. CONCLUSIONS Aortic ring annuloplasty reduced annular diameter effectively, recruiting more leaflet to midline coaptation. Minor fusion commissurotomy and annular remodeling to 180-degree commissures converted UAV repair to a simple and reproducible procedure.
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Affiliation(s)
| | - John V Conte
- Pennsylvania State University, Hershey, Pennsylvania
| | | | | | | | | | | | - Andrew C Fiore
- St Louis University Cardinal Glennon Children's Hospital, St Louis, Missouri
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Romano MA. Commentary: The tricuspid valve: No longer forgotten but still unknown. JTCVS Tech 2020; 3:168-169. [PMID: 34317857 PMCID: PMC8302932 DOI: 10.1016/j.xjtc.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 05/26/2020] [Accepted: 06/02/2020] [Indexed: 12/04/2022] Open
Affiliation(s)
- Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
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Affiliation(s)
- Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Curtis S Bergquist
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
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Mokbel M, Zamani H, Lei I, Chen YE, Romano MA, Aaronson KD, Haft JW, Pagani FD, Tang PC. Histidine-Tryptophan-Ketoglutarate Solution for Donor Heart Preservation Is Safe for Transplantation. Ann Thorac Surg 2020; 109:763-770. [PMID: 31470011 DOI: 10.1016/j.athoracsur.2019.07.012] [Citation(s) in RCA: 6] [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] [Received: 01/31/2019] [Revised: 05/16/2019] [Accepted: 07/01/2019] [Indexed: 11/24/2022]
Abstract
BACKGROUND Various solutions are used for donor heart preservation. We examined the outcomes in our heart transplant population where histidine-tryptophan-ketoglutarate (HTK) solution has been used for heart preservation since 2004. METHODS This was a retrospective review of the United Network for Organ Sharing (UNOS) database (2004-2016) comparing our heart transplant outcomes with other national centers. Propensity matching in a 1:3 ratio was performed to adjust for preoperative recipient variables. RESULTS After propensity matching comparing UNOS outcomes (n = 1080) with our institutional data (n = 360), there was no difference in matched preoperative variables. Donor hearts were similar for donor age, sex, donor-to-recipient size ratio, LVEF, and ischemic time. Our HTK cohort had a larger proportion with donor cardiac arrest (26.3% vs 6.1%, P < .001) and longer cardiac arrest duration (22.1 ± 16.0 vs 17.2 ± 14.0 minutes, P = .052). Our primary graft dysfunction (PGD) rate requiring mechanical support was 4.2% (n = 1). Postoperative mechanical support use for PGD included extracorporeal membrane oxygenation in 9 (60.0%), intraaortic balloon pump in 4 (26.7%), right ventricular assist device in 3 (20%), and biventricular assist device in 3 (20%). Overall survival at our institution was similar to the national average (P = .649). Survival at 1, 5, and 10 years with HTK was 92.2%, 81.3%, and 70.8%, and for the UNOS population was 91.6%, 80.3%, and 62.0%, respectively. CONCLUSIONS Use of HTK solution for donor hearts was associated with a low rate of severe PGD. Overall survival was not significantly different from other institutions using a variety of preservation solutions in the UNOS database during the same period. HTK solution is efficacious for preservation of donor hearts.
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Affiliation(s)
| | | | | | | | | | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
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Tang PC, Sarsour N, Haft JW, Romano MA, Konerman M, Colvin M, Koelling T, Aaronson KD, Pagani FD. Aortic Valve Repair Versus Replacement Associated With Durable Left Ventricular Assist Devices. Ann Thorac Surg 2020; 110:1259-1264. [PMID: 32105716 DOI: 10.1016/j.athoracsur.2020.01.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Revised: 12/16/2019] [Accepted: 01/06/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Aortic valve (AV) repair (AVr) using a central coaptation stitch or bioprosthetic AV replacement (AVR) are most commonly performed at the time of durable left ventricular assist device implant to address AV insufficiency (AI). METHODS Prospective data collection on 46 patients undergoing left ventricular assist device implant from 2007 through 2018 who received concomitant AVr (n = 40) or AVR (n = 6) was retrospectively analyzed to assess freedom from recurrent aortic insufficiency. Paired Wilcoxon rank-sum test was used to compare echocardiographic findings. Mantel-Cox statistics were used to analyze survival. RESULTS For AVr, central coaptation led to a mean decrease in AI severity by 2.1 ± 1.0 grades (P < .001). Three patients (7.5%) had recurrence of at least moderate AI by 3 years. In comparison, all patients in the AVR group had mild or less AI on subsequent follow-up. Success of AVr in downgrading AI severity was associated with a smaller aortic root diameter (P = .011) and sinotubular junction diameter (P = .003). An aortic root diameter greater than 3.5 cm was predictive of less improvement in AI severity compared with 3.5 cm or less (1.83 ± 1.03 versus 2.47 ± 0.80 grades of improvement; P = .038). Duration of cardiopulmonary bypass was 32 minutes longer and duration of aortic cross-clamp was 38 minutes longer for AVR versus AVr cohorts. No difference in 30-day (P = .418) or overall survival (P = .572) between the AVr and AVR groups was seen. CONCLUSIONS Aortic valve repair for addressing AI has a recurrence rate of 7.5% at 3 years. Success in downgrading AI is more likely with a smaller aortic root. No difference in survival was observed between AVr and AVR.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan.
| | - Nadeen Sarsour
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Matthew Konerman
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Monica Colvin
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Todd Koelling
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Keith D Aaronson
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Michigan
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Romano MA. Commentary: Hybrid double-valve cardiac surgery: Less time at the pump in a complex setting. JTCVS Tech 2020; 2:39-40. [PMID: 34317744 PMCID: PMC8298849 DOI: 10.1016/j.xjtc.2020.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 02/18/2020] [Accepted: 02/20/2020] [Indexed: 11/18/2022] Open
Affiliation(s)
- Matthew A. Romano
- Address for reprints: Matthew A. Romano, MD, Department of Cardiac Surgery, University of Michigan, 5162 Cardiovascular Center, SPC 5864, 1500 E Medical Center Dr, Ann Arbor, MI 48109.
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Williams AM, Brescia AA, Watt TMF, Romano MA, Bolling SF. Transcatheter therapy for tricuspid regurgitation: The surgical perspective. Prog Cardiovasc Dis 2019; 62:473-478. [PMID: 31801700 DOI: 10.1016/j.pcad.2019.11.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 11/27/2019] [Indexed: 10/25/2022]
Abstract
Tricuspid regurgitation (TR) remains a complex valve pathology affecting nearly two million people in the United States. Although it can present as a primary valve pathology, TR often presents as a late finding in patients with severe pulmonary disease or end-stage chronic heart failure. Surgical repair of isolated TR or TR from left-sided pathology has been associated with high morbidity and mortality. Furthermore, surgery for patients with TR and advanced cardiac disease has been associated with poor long-term outcomes. In recent years, transcatheter technology has emerged to target high-risk surgical patients with TR. Currently, multiple new transcatheter strategies to treat TR have shown initial benefit. However, further development of this technology is required. The aim of this perspective is to provide an overview of TR pathophysiology and to highlight the successful aspects of surgery for TR that provide insight for further translation of transcatheter strategies for patients with TR. These include replication of successful surgical techniques (ring-based annuloplasty and valve replacement) and the goal of achieving no to minimal residual TR following intervention. Earlier implementation of transcatheter valve repair to minimize TR progression and further development of transcatheter valve replacement strategies are also next steps in the translation of this technology.
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Affiliation(s)
- Aaron M Williams
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | | | - Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA.
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Romano MA. Minimally Invasive Thoracoscopic Exclusion of the Left Atrial Appendage Following Watchman Device With an AtriCure ProV LAA Exclusion Device. Innovations (Phila) 2019; 14:509-511. [PMID: 31739720 DOI: 10.1177/1556984519882948] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This is a case report of a minimally invasive exclusion of the left atrial appendage with a ProV AtriClip following a Watchman device implantation with residual flow into the left atrial appendage.
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Affiliation(s)
- Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI, USA
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Abstract
Intravenous drug use has increased substantially over the past decade, with heroin abuse more than doubling. Injection drug use-related infective endocarditis hospitalizations have similarly increased over the same period. Right-sided infective endocarditis is strongly associated with intravenous drug use, and 90% of right-sided endocarditis involves the tricuspid valve. During the period of the opioid epidemic, tricuspid-related endocarditis rates have increased, while the incidence of surgery for tricuspid endocarditis has increased as much as five-fold. Within this context, optimizing surgical technique for valve repair is increasingly important. In this report, we examine the indications for tricuspid valve surgery for endocarditis, describe specific techniques for tricuspid valve leaflet repair and augmentation, and assess postoperative care and surgical outcomes after both tricuspid valve repair and replacement for infective endocarditis.
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Affiliation(s)
| | - Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Aaron M Williams
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, MI
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Brescia AA, Ward ST, Watt TMF, Rosenbloom LM, Baker M, Khan S, Ziese E, Romano MA, Bolling SF. Outcomes of Guideline-Directed Concomitant Annuloplasty for Functional Tricuspid Regurgitation. Ann Thorac Surg 2019; 109:1227-1232. [PMID: 31479635 DOI: 10.1016/j.athoracsur.2019.07.035] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 05/29/2019] [Accepted: 07/08/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Despite guideline recommendations, rates of concomitant tricuspid valve repair are suboptimal, possibly due to fear of complications. We reviewed morbidity, mortality, recurrent tricuspid regurgitation, and right ventricular remodeling after guideline-directed concomitant tricuspid valve repair. METHODS We performed guideline-directed concomitant tricuspid valve repair on 171 consecutive patients who underwent left-sided valve surgery (degenerative mitral surgery or aortic valve replacement) between May 2012 and March 2016. Exclusion criteria included functional mitral regurgitation, rheumatic disease, active endocarditis, and concomitant coronary artery bypass grafting or complex aortic surgery. RESULTS Mean age was 68 ± 12 years, and 47% (81 of 171) were women. Preoperative atrial fibrillation was present in 57% (98 of 171), and preoperative tricuspid regurgitation was moderate or higher in 64% (108 of 171). The rate of de novo pacemaker placement was 4.1% (7 of 171), and the 30-day mortality rate was 0.6% (1 of 171). Estimated survival was 95% ± 4% at 1 year and 92% ± 5% at 5 years. Freedom from moderate or worse residual/recurrent tricuspid regurgitation was 93% ± 6% at 6 months and 89% ± 8% at 3 years. Quantitative echocardiography found no significant increase in right ventricular dimensions or area at 1 year in subgroup analysis. Mean echocardiographic follow-up was 14.1 months, and mean clinical follow-up was 33.9 months. CONCLUSIONS Guideline-directed concomitant tricuspid valve repair resulted in excellent safety end points and survival. At 14 months, freedom from moderate or worse tricuspid regurgitation was high, right ventricular performance did not worsen, and the pacemaker rate was comparable to rates after isolated mitral repair. Given these findings, adherence to current guidelines regarding functional tricuspid regurgitation should be encouraged.
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Affiliation(s)
| | - Sarah T Ward
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Liza M Rosenbloom
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Megan Baker
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Shazli Khan
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Emilie Ziese
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
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- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
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38
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Watt TMF, Brescia AA, Murray SL, Burn DA, Wisniewski A, Romano MA, Bolling SF. Degenerative Mitral Valve Repair Restores Life Expectancy. Ann Thorac Surg 2019; 109:794-801. [PMID: 31472142 DOI: 10.1016/j.athoracsur.2019.07.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 06/26/2019] [Accepted: 07/01/2019] [Indexed: 11/17/2022]
Abstract
BACKGROUND Mitral valve repair (MVr) for severe, degenerative mitral regurgitation is the gold standard, because medical management carries poor prognosis. However, despite clear benefit of MVr, many eligible patients are untreated. This study investigated whether MVr restores patients to normal life expectancy, at any age of operation, by comparing long-term survival of patients after MVr with the life expectancy of the general United States population. METHODS This retrospective study investigated 1011 patients with degenerative mitral regurgitation who underwent isolated MVr between 2003 and 2017. Parametric distribution analysis was applied to long-term post-MVr mortality data, and Weibull probability plots provided the best-fit distribution by Anderson-Darling Goodness-of-Fit testing. Confidence intervals of the estimated distribution were used to compare additional life expectancy after MVr to the general US population across multiple decades of life. Patients after MVr were categorized by age into decade (range, 20-89 years). RESULTS The life expectancy of patients after MVr matched the life expectancy of the general US population at any age between 40 and 89 years. Lower-bound one-sided 95% confidence intervals for additional life expectancy were not appreciably different from corresponding median additional life expectancy of the general population. There were few deaths in the 20- to 39-year-old group, limiting predictability, but survival also appeared normative. CONCLUSIONS These findings suggest that degenerative MVr restores anticipated life expectancy to that of the general population, regardless of age. Although our findings underscore the importance of repair for degenerative mitral disease, larger studies with longer term follow-up are needed to reinforce this finding, particularly for younger patients.
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Affiliation(s)
- Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
| | | | - Shannon L Murray
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - David A Burn
- Department of Mathematics, Quinnipiac University, Hamden, Connecticut
| | | | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
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Tang PC, Haft JW, Romano MA, Bitar A, Hasan R, Palardy M, Aaronson KD, Pagani FD. Right ventricular failure following left ventricular assist device implantation is associated with a preoperative pro-inflammatory response. J Cardiothorac Surg 2019; 14:80. [PMID: 31023326 PMCID: PMC6482580 DOI: 10.1186/s13019-019-0895-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [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: 01/22/2019] [Accepted: 04/01/2019] [Indexed: 01/20/2023] Open
Abstract
Background Systemic inflammation during implant of a durable left ventricular assist device (LVAD) may contribute to adverse outcomes. We investigated the association of the preoperative inflammatory markers with subsequent right ventricular failure (RVF). Materials and methods Prospective data was collected on 489 patients from 2003 through 2017 who underwent implantation of a durable LVAD. Uni- and multivariable correlation with leukocytosis was determined using linear and binary logistic regression. The population was also separated into low (< 10.5 K/ul, n = 362) and high (> 10.5 K/ul, n = 127) white blood cell count (WBC) groups. Mantel-Cox statistics was used to analyze survival data. Results Postop RVF was associated with a higher preop WBC (11.3 + 5.7 vs 8.7 + 3.1) and C-reactive protein (CRP, 5.6 + 4.4 vs 3.3 + 4.7) levels. Multivariable analysis identified an independent association between increased WBC preoperatively with increased lactate dehydrogenase (LDH, P < 0.001), heart rate (P < 0.001), CRP (P = 0.006), creatinine (P = 0.048), and INR (P = 0.049). The high WBC group was more likely to be on preoperative temporary circulatory support (17.3% vs 6.4%, P < 0.001) with a trend towards greater use of an intra-aortic balloon pump (55.9% vs 47.2%, P = 0.093). The high WBC group had poorer mid-term survival (P = 0.042). Conclusions Postop RVF is associated with a preoperative pro-inflammatory environment. This may be secondary to the increased systemic stress of decompensated heart failure. Systemic inflammation in the decompensated heart failure may contribute to RVF after LVAD implant.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, 5158 Cardiovascular Center, SPC 5864, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5864, USA.
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, 5158 Cardiovascular Center, SPC 5864, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5864, USA
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, 5158 Cardiovascular Center, SPC 5864, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5864, USA
| | - Abbas Bitar
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Reema Hasan
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Maryse Palardy
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, MI, USA
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, 5158 Cardiovascular Center, SPC 5864, 1500 E. Medical Center Drive, Ann Arbor, MI, 48109-5864, USA
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Tang PC, Haft JW, Romano MA, Bitar A, Hasan R, Palardy M, Wu X, Aaronson KD, Pagani FD. Right ventricular function and residual mitral regurgitation after left ventricular assist device implantation determines the incidence of right heart failure. J Thorac Cardiovasc Surg 2019; 159:897-905.e4. [PMID: 31101350 DOI: 10.1016/j.jtcvs.2019.03.089] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 02/19/2019] [Accepted: 03/26/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND The effect of significant mitral regurgitation (MR) on outcomes after continuous flow left ventricular assist device (cfLVAD) implantation remains unclear. METHODS We performed a retrospective review of prospectively collected data from 159 patients with preoperative severe MR who underwent cfLVAD implantation (2003-2017). Two-step cluster analysis using the log-likelihood distance for post-cfLVAD implantation parameters, which included right ventricular (RV) dysfunction, MR severity, and tricuspid regurgitation (TR) severity. Post-cfLVAD implantation echocardiographic parameters were obtained within the first month. RESULTS Cluster analysis resulted in 3 groups. Group 1 (n = 67) had mild or less MR with moderate-severe RV dysfunction (RVD). Group 2 (n = 43) had moderate-severe MR with moderate-severe RVD. Group 3 (n = 49) had moderate MR with mild RVD. Group 2 had the largest proportion with Interagency Registry for Mechanically Assisted Circulatory Support score of 1 (30.2%) and 2 (41.9%). They were more likely to undergo temporary mechanical circulatory support (18.6%) and tricuspid valve procedure (62.8%). Group 2 had the highest rate of stroke (30.2%; P = .02), hemolysis (39.5%; P = .01), device thrombosis (30%; P = .01), and worst survival (46.5%; P = .01). Survival at 5 years for groups 1, 2, and 3 were 56.0%, 17.6%, and 55.8%. Regression analysis of the entire population showed that greater MR severity after cfLVAD was associated with RV failure (P < .05; odds ratio, 1.6) and RV assist device use (P = .09; odds ratio, 1.6). After excluding tricuspid valve repairs, MR severity had a positive correlation with TR severity (R = 0.33; P < .01). CONCLUSIONS After cfLVAD implantation, moderate-severe MR and RVD predicted RV failure. Patients with preoperative moderate-severe MR and TR coupled with moderate-severe RVD might benefit the most from mitral and tricuspid valve intervention.
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Affiliation(s)
- Paul C Tang
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich.
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Abbas Bitar
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Reema Hasan
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Maryse Palardy
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Xiaoting Wu
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Frankel Cardiovascular Center, Ann Arbor, Mich
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Stojanovska J, Lumeng CN, Griffin C, Hernando D, Hoffmann U, Haft JW, Kim KM, Burant CF, Singer K, Tsodikov A, Long BD, Romano MA, Tang PC, Yang B, Chenevert TL. Water-fat magnetic resonance imaging quantifies relative proportions of brown and white adipose tissues: ex-vivo experiments. J Med Imaging (Bellingham) 2018; 5:024007. [PMID: 30137870 PMCID: PMC6025480 DOI: 10.1117/1.jmi.5.2.024007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2018] [Accepted: 06/08/2018] [Indexed: 12/12/2022] Open
Abstract
Quantifying the amount of brown adipose tissue (BAT) within white adipose tissue (WAT) in human depots may serve as a target to combat obesity. We aimed to quantify proton density fat fraction (PDFF) of BAT and WAT in relatively pure and in mixed preparation using water–fat imaging. Three ex-vivo experiments were performed at 3 T using excised interscapular BAT and inguinal/subcutaneous WAT from mice. The first two experiments consisted of BAT and WAT in separate tubes, and the third used mixed preparation with graded quantities of BAT and WAT. To investigate the influence of partial volume on PDFF metrics, low (2.66 mm3) and high spatial resolution (0.55 mm3 acquired voxels) in two orthogonal three-dimensional sections were compared. The low-resolution acquisitions are corrected for T2* and multipeak lipid spectrum, thus considered “quantitative,” whereas the high-resolution acquisitions are not corrected but were performed to better spatially segment BAT from WAT zones. As potential BAT metrics, we quantified the average PDFF and the volume of tissue having PDFF ≤50% (VOLPDFF≤50%) based on the PDFF histogram. In the first experiment, the average PDFF of BAT was 23±6% and 21±7.6% and the average PDFF of WAT was 76±7% and 87±7% using high- and low-resolution techniques, respectively. A similar trend with excellent reproducibility in average PDFF of BAT and WAT was observed in the second experiment. In the third experiment over the four acquisitions, the BAT-dominant tube demonstrated lower PDFF (mean ± SD) of 55±2% than WAT-dominant (69±4%) and WAT-only tubes (88±4%). Estimating VOLPDFF≤50%, the BAT-dominant tube demonstrated higher volume of 0.26 cm3 than WAT-dominant (0.16 cm3) and WAT-only tubes (0.01 cm3). The presence of BAT exhibits a lower PDFF relative to WAT, thus allowing segmentation of low PDFF tissue for quantification of volume representative of BAT. Future studies will determine the clinical relevance of BAT volume within human depots.
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Affiliation(s)
- Jadranka Stojanovska
- Michigan Medicine, Division of Cardiothoracic Radiology, Department of Radiology, Ann Arbor, Michigan, United States
| | - Carey N Lumeng
- Michigan Medicine, Department of Pediatrics and Molecular Physiology, Ann Arbor, Michigan, United States
| | - Cameron Griffin
- Michigan Medicine, Division of Pediatric Endocrinology, Ann Arbor, Michigan, United States
| | - Diego Hernando
- University of Wisconsin, Wisconsin Institutes for Medical Research, Medical Physics Department, Madison, Wisconsin, United States
| | - Udo Hoffmann
- Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts, United States
| | - Jonathan W Haft
- Michigan Medicine, Frankel Cardiovascular Center, Department of Cardiac Surgery, Ann Arbor, Michigan, United States
| | - Karen M Kim
- Michigan Medicine, Frankel Cardiovascular Center, Department of Cardiac Surgery, Ann Arbor, Michigan, United States
| | | | - Kanakadurga Singer
- Michigan Medicine, Division of Pediatric Endocrinology, Department of Pediatrics and Communicable Diseases, Ann Arbor, Michigan, United States
| | - Alex Tsodikov
- School of Public Health, Ann Arbor, Michigan, United States
| | - Benjamin D Long
- University of Michigan Medical School, Cardiovascular Center, Ann Arbor, Michigan, United States
| | - Matthew A Romano
- Michigan Medicine, Cardiovascular Center, Ann Arbor, Michigan, United States
| | - Paul C Tang
- Michigan Medicine, Cardiovascular Center, Ann Arbor, Michigan, United States
| | - Bo Yang
- Michigan Medicine, Cardiovascular Center, Ann Arbor, Michigan, United States
| | - Thomas L Chenevert
- Michigan Medicine, Department of Radiology-MRI, Ann Arbor, Michigan, United States
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Romano MA, Koeckert M, Mumtaz MA, Slachman FN, Patel HJ, Chitwood WR, Barnhart GR, Grossi EA. Permanent Pacemaker Implantation After Rapid Deployment Aortic Valve Replacement. Ann Thorac Surg 2018; 106:685-690. [PMID: 29705366 DOI: 10.1016/j.athoracsur.2018.03.055] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [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: 11/10/2017] [Revised: 02/25/2018] [Accepted: 03/19/2018] [Indexed: 01/23/2023]
Abstract
BACKGROUND Expandable, rapid deployment aortic valves may interfere with the cardiac conduction system, which can lead to permanent pacemaker implantation (PPI). We sought to characterize PPI after rapid deployment aortic valve replacement with the Edwards Intuity valve system (Edwards Lifesciences, Irvine, CA) and investigate associated factors. METHODS We analyzed 708 patients from 29 centers in the Multicenter Experience With Rapid Deployment Edwards Intuity Valve System for Aortic Valve Replacement (TRANSFORM) trial undergoing rapid deployment aortic valve replacement with or without coronary artery bypass graft surgery without preexisting pacemakers. Intrinsic conduction status was recorded as well as PPI incidence through 1 year. The PPI indications were categorized based on expert review of patient PPI source documents. Multivariate analysis was conducted to identify characteristics associated with PPI. RESULTS After rapid deployment aortic valve replacement, the PPI incidence through 30 days (PPI30) was 13.6%, with 10.9% due to atrioventricular block. In the 423 of 708 patients (59.7%) without any baseline conduction abnormalities, all-cause PPI30 was 8%, 5% for atrioventricular block. For PPIs inserted before discharge, the median time to PPI was 5 days, with 22% placed within 48 hours. Independent predictors of PPI30 were baseline right bundle branch block (odds ratio 7.35, p < 0.0001), female gender (2.62, p = 0.004), larger valve size (1.20, p = 0.016), and atrioventricular block (1.80, p = 0.062). Subset analysis revealed a greater than twofold difference in PPI30 among the largest enrolling centers. CONCLUSIONS Patient factors associated with PPI after rapid deployment aortic valve replacement were right bundle branch block, atrioventricular block, female gender, and larger valve size. Interestingly, a strong center-level effect was associated with PPI. This effect may reflect differences in practice patterns, such as postoperative drug management or timing to PPI. These findings provide a deeper understanding of PPI after rapid deployment aortic valve replacement and help guide clinical practice and patient management.
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Affiliation(s)
- Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan.
| | - Michael Koeckert
- Department of Cardiothoracic Surgery, New York University School of Medicine, New York, New York
| | - Mubashir A Mumtaz
- Cardiovascular and Thoracic Surgery, Pinnacle Health, Harrisburg, Pennsylvania
| | - Frank N Slachman
- Mercy Medical Group, Mercy General Hospital, Sacramento, California
| | - Himanshu J Patel
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - W Randolph Chitwood
- Department of Cardiovascular Sciences, East Carolina University, Greenville, North Carolina
| | - Glenn R Barnhart
- Swedish Heart and Vascular Institute, Structural Heart Program, Seattle, Washington
| | - Eugene A Grossi
- Department of Cardiothoracic Surgery, New York University School of Medicine, New York, New York
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Affiliation(s)
- William B. Weir
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Matthew A. Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Steven F. Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
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Weir WB, Romano MA, Bolling SF. Functional Tricuspid Regurgitation and Ring Annuloplasty Repair. Cardiovascular Innovations and Applications 2018. [DOI: 10.15212/cvia.2017.0025] [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: 11/18/2022] Open
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Cavallin MD, Wilk R, Oliveira IM, Cardoso NCS, Khalil NM, Oliveira CA, Romano MA, Romano RM. The hypothalamic-pituitary-testicular axis and the testicular function are modulated after silver nanoparticle exposure. Toxicol Res (Camb) 2018; 7:102-116. [PMID: 30090567 PMCID: PMC6060733 DOI: 10.1039/c7tx00236j] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 11/22/2017] [Indexed: 01/28/2023] Open
Abstract
Silver nanoparticles (AgNPs) are widely used in industrial and medical applications and humans may be exposed through different routes, increasing the risk of toxicity. We investigated the transcript expression of genes involved in the regulation of the hypothalamic-pituitary-testicular (HPT) axis and the parameters associated with sperm functionality after prepubertal exposure. AgNPs modulated the transcript expression of genes involved in the control of the HPT axis and spermatogenesis in the groups treated with lower doses, while the functional parameters related to sperm and puberty were affected in the groups administered higher doses. These results suggest that the HPT axis is disrupted by AgNPs during the prepubertal and pubertal periods, which are highly susceptible windows for the endocrine-disrupting chemical activity.
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Affiliation(s)
- M D Cavallin
- Laboratory of Reproductive Toxicology , Department of Pharmacy , State University of Centro-Oeste , Rua Simeao Camargo Varela de Sa , 03 , 85040-080 , Parana , Brazil .
| | - R Wilk
- Laboratory of Reproductive Toxicology , Department of Pharmacy , State University of Centro-Oeste , Rua Simeao Camargo Varela de Sa , 03 , 85040-080 , Parana , Brazil .
| | - I M Oliveira
- Laboratory of Reproductive Toxicology , Department of Pharmacy , State University of Centro-Oeste , Rua Simeao Camargo Varela de Sa , 03 , 85040-080 , Parana , Brazil .
| | - N C S Cardoso
- Laboratory of Reproductive Toxicology , Department of Pharmacy , State University of Centro-Oeste , Rua Simeao Camargo Varela de Sa , 03 , 85040-080 , Parana , Brazil .
| | - N M Khalil
- Laboratory of Nanotechnology , Department of Pharmacy , State University of Centro-Oeste , Rua Simeao Camargo Varela de Sa , 03 , 85040-080 , Parana , Brazil
| | - C A Oliveira
- Laboratory of Hormonal Dosages , Department of Animal Reproduction , Faculty of Veterinary Medicine , University of Sao Paulo , Av. Prof. Dr. Orlando Marques de Paiva , 87 , 05508-270 , Sao Paulo , Brazil
| | - M A Romano
- Laboratory of Reproductive Toxicology , Department of Pharmacy , State University of Centro-Oeste , Rua Simeao Camargo Varela de Sa , 03 , 85040-080 , Parana , Brazil .
| | - R M Romano
- Laboratory of Reproductive Toxicology , Department of Pharmacy , State University of Centro-Oeste , Rua Simeao Camargo Varela de Sa , 03 , 85040-080 , Parana , Brazil .
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Cowger JA, Aaronson KD, Romano MA, Haft J, Pagani FD. Consequences of aortic insufficiency during long-term axial continuous-flow left ventricular assist device support. J Heart Lung Transplant 2014; 33:1233-40. [DOI: 10.1016/j.healun.2014.06.008] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2014] [Revised: 06/05/2014] [Accepted: 06/18/2014] [Indexed: 10/25/2022] Open
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Min L, Mazzurco L, Gure TR, Cigolle CT, Lee P, Bloem C, Chan CL, Romano MA, Nallamothu BK, Langa KM, Prager RL, Malani PN. Longitudinal functional recovery after geriatric cardiac surgery. J Surg Res 2014; 194:25-33. [PMID: 25483736 DOI: 10.1016/j.jss.2014.10.043] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Revised: 10/21/2014] [Accepted: 10/23/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND Impaired functional and cognitive status is an important outcome for older adults undergoing major cardiac surgery. We conducted this pilot study to gauge feasibility of assessing these outcomes longitudinally, from preoperatively up to two time points postoperatively to assess for recovery. METHODS We interviewed patients aged ≥ 65 y preoperatively and repeated functional and cognitive assessments at 4-6 wk and 4-6 mo postoperatively. Simple unadjusted linear regression was used to test whether baseline measures changed at each follow-up time point. Then we used a longitudinal model to predict postoperative recovery overall, adjusting for comorbidity. RESULTS A total of 62 patients (age 74.7 ± 5.9) underwent scheduled cardiac surgery. Preoperative activities of daily living (ADL) impairment was associated with poorer functional recovery at 4-6 wk postoperatively with each baseline ADL impairment conferring recovery of 0.5 fewer ADLs (P < 0.05). By 4-6 mo, we could no longer detect a difference in recovery. Preoperative cognition and physical activity were not associated with postoperative changes in these domains. CONCLUSIONS A preoperative and postoperative evaluation of function and cognition was integrated into the surgical care of older patients. Preoperative impairments in ADLs may be a means to identify patients who might benefit from careful postoperative planning, especially in terms of assistance with self-care during the first 4-6 wk after cardiac surgery.
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Affiliation(s)
- Lillian Min
- Divisions of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan; Veterans Affairs Ann Arbor Healthcare System, Geriatric, Research, Education, and Clinical Center (GRECC), Ann Arbor, Michigan.
| | - Lauren Mazzurco
- Divisions of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan; Veterans Affairs Ann Arbor Healthcare System, Geriatric, Research, Education, and Clinical Center (GRECC), Ann Arbor, Michigan
| | - Tanya R Gure
- Divisions of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Christine T Cigolle
- Divisions of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan; Department of Family Medicine, University of Michigan, Ann Arbor, Michigan; Veterans Affairs Ann Arbor Healthcare System, Geriatric, Research, Education, and Clinical Center (GRECC), Ann Arbor, Michigan
| | - Pearl Lee
- Divisions of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan; Veterans Affairs Ann Arbor Healthcare System, Geriatric, Research, Education, and Clinical Center (GRECC), Ann Arbor, Michigan
| | - Cathie Bloem
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Chiao-Li Chan
- Divisions of Geriatric and Palliative Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Brahmajee K Nallamothu
- Division of Cardiovascular Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan; Veterans Affairs Ann Arbor Healthcare System, Geriatric, Research, Education, and Clinical Center (GRECC), Ann Arbor, Michigan; Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Kenneth M Langa
- Division of General Medicine, Department of Medicine, University of Michigan, Ann Arbor, Michigan; Veterans Affairs Ann Arbor Healthcare System, Geriatric, Research, Education, and Clinical Center (GRECC), Ann Arbor, Michigan
| | - Richard L Prager
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Preeti N Malani
- Divisions of Infectious Disease, Department of Medicine, University of Michigan, Ann Arbor, Michigan; Veterans Affairs Ann Arbor Healthcare System, Geriatric, Research, Education, and Clinical Center (GRECC), Ann Arbor, Michigan
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Abstract
Objective: Cardiopulmonary bypass can result in hemodilution due to the crystalloid prime, increasing the need for blood transfusion. Alternative perfusion techniques have the potential to decrease this hemodilution. The objective of this study was to determine whether a protocol of retrograde autologous prime (RAP) and venous antegrade prime (VAP) reduces the need for blood transfusion and increases the hematocrit following cardiac surgery. Methods: We performed a retrospective review of 140 consecutive non-randomized patients who underwent cardiac surgery with cardiopulmonary bypass between November 2011 and September 2012. RAP and VAP techniques were used in 70 patients while the other 70 were managed with conventional perfusion strategies. The primary outcome measure was a composite outcome of any blood transfusion or a discharge hematocrit less than 27%. Results: Baseline demographics and patient characteristics were similar between the two groups, with the exception of the RAP/VAP group having a lower baseline creatinine. There was a trend toward decreased perioperative blood transfusions in the RAP/VAP group (13/70, 19%) compared with the non-RAP/VAP group (23/70, 33%, p=0.053). RAP/VAP patients had a significantly higher hematocrit at hospital discharge (30.0 ± 4.3% vs. 28.3 ± 4.1%, p=0.012). The number of patients receiving a transfusion or being discharged with an hematocrit less than 27% was significantly less in the RAP/VAP group (21 vs. 41, p=0.001). This effect persisted on multivariable analysis. Conclusions: RAP and VAP perfusion techniques may reduce hemodilution, potentially resulting in less blood transfusions and higher postoperative hematocrits. These techniques should be considered in all patients undergoing cardiac surgery with cardiopulmonary bypass.
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Affiliation(s)
- NR Teman
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - N Delavari
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - MA Romano
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - RL Prager
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - B Yang
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, MI, USA
| | - JW Haft
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, MI, USA
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Stulak JM, Lee D, Haft JW, Romano MA, Cowger JA, Park SJ, Aaronson KD, Pagani FD. Gastrointestinal bleeding and subsequent risk of thromboembolic events during support with a left ventricular assist device. J Heart Lung Transplant 2014; 33:60-4. [DOI: 10.1016/j.healun.2013.07.020] [Citation(s) in RCA: 125] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Revised: 07/24/2013] [Accepted: 07/31/2013] [Indexed: 11/16/2022] Open
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Cowger JA, Romano MA, Shah P, Shah N, Mehta V, Haft JW, Aaronson KD, Pagani FD. Hemolysis: a harbinger of adverse outcome after left ventricular assist device implant. J Heart Lung Transplant 2013; 33:35-43. [PMID: 24418732 DOI: 10.1016/j.healun.2013.08.021] [Citation(s) in RCA: 128] [Impact Index Per Article: 11.6] [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: 03/19/2013] [Revised: 08/20/2013] [Accepted: 08/20/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The clinical relevance of elevated serum markers of hemolysis during left ventricular assist device (LVAD) support has not been fully ascertained. METHODS Lactate dehydrogenase (LDH) and serum free hemoglobin (sfHg) values were tallied monthly in 182 patients on HeartMate II (Thoratec, Pleasanton, CA) LVAD support. Peak values for each marker were identified, and 2 hemolysis definitions were applied to the cohort: Hemolysis according to Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) criteria (sfHg > 40 mg/dl with signs/symptoms) and/or hemolysis defined by an LDH ≥ 600 IU/liter (2.5-times the upper limit of laboratory normal). Kaplan-Meier survival free from death, urgent United Network of Organ Sharing 1A transplant for thrombosis, device exchange for thrombosis, and stroke/peripheral embolism was estimated, and Cox hazard ratios (HR) with the 95% confidence interval (95% CI) were calculated. Areas under the receiver-operating characteristic curves (AUCs) for predicting 1-year event-free survival were calculated. RESULTS Hemolysis occurred in 32 patients (18%) by INTERMACS criteria and in 68 (37%) patients by LDH criteria. Over a median (25(th), 75(th)) support of 427 days (245, 793 days), there were 78 events. One year event-free survival after the onset of INTERMACS-defined hemolysis was 16% ± 8.3% compared with 85% ± 3.2% in non-hemolyzers (HR, 14.7; 95% CI, 7.9-27; AUC 0.70 ± 0.05; p < 0.001; ). One year event-free survival after the onset of LDH-defined hemolysis was 32% ± 7.2% compared with 89% ± 3.2% in those with persistent LDH values < 600 IU/liter (HR, 8.0; 95% CI, 4.4-14; AUC 0.87 ± 0.04; p < 0.001). Patients who met the LDH hemolysis definition had longer times from hemolysis onset to clinical events and larger magnitudes of risk for embolism and device exchange for thrombosis than those with INTERMACS hemolysis. CONCLUSIONS Serum hemolysis marker elevations are associated with increased events in LVAD patients. LDH monitoring provides an earlier diagnosis of adverse events than sfHg, supporting need for a new INTERMACS definition of VAD-associated hemolysis.
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Affiliation(s)
- Jennifer A Cowger
- Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, Michigan.
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Palak Shah
- Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Neha Shah
- Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Vivek Mehta
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Jonathan W Haft
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Michigan
| | - Keith D Aaronson
- Division of Cardiovascular Medicine, University of Michigan Health System, Ann Arbor, Michigan
| | - Francis D Pagani
- Department of Cardiac Surgery, University of Michigan Health System, Ann Arbor, Michigan
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