[Show abstract][Hide abstract] ABSTRACT: Background:
Unicuspid aortic valve is an important subset of bicuspid aortic valve, and knowledge regarding its aortopathy pattern and surgical outcomes is limited. Our objectives were to characterize unicuspid aortic valve patients, associated aortopathy, and surgical outcomes.
From January 1990 to May 2013, 149 adult unicuspid aortic valve patients underwent aortic valve replacement or repair for aortic stenosis (n = 13), regurgitation (n = 13), or both (n = 123), and in 91 (61%) the aortic valve operation was combined with aortic repair. Data were obtained from the Cardiovascular Information Registry and medical record review. Three-dimensional imaging analysis was performed from preoperative computed tomography and magnetic resonance imaging scans. The Kaplan-Meier method was used for survival analysis.
Patients had a mean maximum aortic diameter of 44 ± 8 mm and variably involved the aortic root, ascending, or arch, or both. Patients with valve operations alone were more likely to be hypertensive (p = 0.01) and to have severe aortic stenosis (p = 0.07) than those who underwent concurrent aortic operations. There were no operative deaths, strokes, or myocardial infarctions. Patients undergoing aortic repair had better long-term survival. Estimated survival at 1, 5, and 10 years was 100%, 100%, and 100% after combined operations and was 100%, 88%, and 88% after valve operations alone (p = 0.01).
Patients with a dysfunctional unicuspid aortic valve frequently present with an ascending aneurysm that requires repair. Combined aortic valve operations and aortic repair was associated with significantly better long-term survival than a valve operation alone. Further study of this association may direct decisions about timing of surgical intervention.
The Annals of thoracic surgery 10/2015; DOI:10.1016/j.athoracsur.2015.07.058 · 3.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Chronic Q fever caused by Coxiella burnetii is uncommon in the United States and is most often associated with infective endocarditis. We present a 52-year-old woman with a history of aortic valve replacement and rheumatoid arthritis treated with Etanercept with chronic Q fever manifesting as prosthetic valve infective endocarditis. Explanted valve tissue showed organisms confirmed to be Coxiella burnetii by PCR (Polymerase chain reaction) sequencing. She subsequently reported consumption of unpasteurized cow milk which was the likely source of C. burnetii. She continues to do well 6 months after valve replacement on oral doxycycline and hydroxychloroquine.
[Show abstract][Hide abstract] ABSTRACT: Objective:
Quadricuspid aortic valve (QAV) morphology is rare (0.008%) but often dysfunctional, manifesting early or late in life. No large series have been evaluated. Current objectives are to characterize these patients, and assess repair possibilities and outcomes.
From 1989 to 2010, a total of 19,722 patients underwent aortic valve surgery at Cleveland Clinic. Thirty-one (0.0016%) patients had dysfunctional QAV and underwent repair or replacement for moderate to severe aortic regurgitation (n = 21), stenosis (n = 5), or both (n = 4). One additional patient with functional QAV required excision of fibroelastoma. The mean age was 58 ± 18 years. Ascending aortic diameter was ≥4 cm in 13 (42%) patients, and 7 required ascending repair (mean diameter: 4.8 ± 0.4 cm). Three patients had anomalous origin of coronary artery, and 1 required repair.
The aortic valve was repaired in 7 (23%) patients and replaced in 23 (73%). The decision of which procedure to use was based on intraoperative findings. The Ross procedure was performed in 1 patient who had endocarditis. Most patients in the repair group had leaflet prolapse that was repaired with accessory cusp excision and commisuroplasty. The mean gradient after repair was 14 ± 5 mm Hg. Bioprostheses were used in all replacements; median valve size was 25 mm (range: 21-27 mm). No operative mortality occurred. One patient suffered nonpermanent stroke after aortic valve replacement. There was no myocardial infarction, renal failure, respiratory failure, or reoperation for bleeding. The median follow-up time was 38 months; 1 patient required replacement 13 years after previous repair for recurrent regurgitation and stenosis.
Quadricuspid aortic valve dysfunction includes both regurgitation and stenosis; repair may be feasible in some patients with regurgitation, but most require replacement. Aortic root and ascending dilatation are frequent, and further studies are needed.
The Journal of thoracic and cardiovascular surgery 03/2015; 150(1). DOI:10.1016/j.jtcvs.2015.03.019 · 4.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Long-term survival of lung-transplant patients is 53% at 5 years and 31% at 10 years, lagging behind the survival of other solid organs recipients. Modern lung transplantation has seen a shift from early mortality and complications related to the bronchial anastomosis to late mortality secondary to progressive organ dysfunction; the complex disease process may include elements of bronchiolitis obliterans syndrome, obliterative bronchiolitis, chronic rejection, or chronic lung allograft dysfunction. Initial goals of bronchial artery revascularization include reducing the incidence of airway ischemia and improving bronchial healing. Benefits of restored bronchial artery circulation may extend beyond bronchial healing alone.
Thoracic Surgery Clinics 02/2015; 25(1):77-85. DOI:10.1016/j.thorsurg.2014.09.004 · 0.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: -Prior transcriptional studies of atrial fibrillation (AF) have been limited to specific transcripts, animal models, chronic AF, right atria, or small samples. We sought to characterize the left atrial transcriptome in human AF to distinguish changes related to AF susceptibility and persistence.
-Left atrial appendages from 239 patients stratified by coronary artery disease, valve disease and AF history (No AF history, AF history in sinus rhythm at surgery, AF history in AF at surgery) were selected for genome-wide mRNA microarray profiling. Transcripts were examined for differential expression with AF phenotype group. Enrichment in differentially expressed genes was examined in 3 gene set collections: A transcription factor (TF) collection, defined by shared conserved cis-regulatory motifs; a miRNA collection, defined by shared 3'UTR motifs; and a molecular function collection, defined by shared Gene-Ontology molecular function. AF susceptibility was associated with decreased expression of the targets of CREB/ATF family, HSF1, ATF6, SRF, and E2F1 TFs. Persistent AF activity was associated with decreased expression in genes and gene sets related to ion channel function consistent with reported functional changes.
-AF susceptibility was associated with decreased expression of targets of several transcription factors related to inflammation, oxidation, and cellular stress responses. In contrast, changes in ion channel expression were associated with AF activity, but were limited in AF susceptibility. Our results suggest that significant transcriptional remodeling marks susceptibility to AF, while remodeling of ion channel expression occurs later in the progression or as a consequence of AF.
[Show abstract][Hide abstract] ABSTRACT: Objective: Despite increasing efforts to prevent infection, the prevalence of hospital-associated Clostridium
difficile infections (CDI) is increasing. Heightened awareness prompted this study of the prevalence and
morbidity associated with CDI after cardiac surgery.
Methods: A total of 22,952 patients underwent cardiac surgery at Cleveland Clinic from January 2005 to
January 2011. CDI was diagnosed by enzyme immunoassay for toxins and, more recently, polymerase chain
reaction (PCR) testing. Hospital outcomes and long-term survival were compared with those of the remaining
population in propensity-matched groups.
Results: One hundred forty-five patients (0.63%) tested positive for CDI at a median of 9 days postoperatively,
135 by enzyme immunoassay and 11 by PCR. Its prevalence more than doubled over the study period. Seventyseven
patients (48%) were transfers from outside hospitals. Seventy-three patients (50%) were exposed
preoperatively to antibiotics and 79 (56%) to proton-pump inhibitors. Patients with CDI had more baseline comorbidities,
more reoperations, and received more blood products than patients who did not have CDI. Presenting
symptoms included diarrhea (107; 75%), distended abdomen (48; 34%), and abdominal pain (27; 19%). All
were treated with metronidazole or vancomycin. Sixteen patients (11%) died in hospital, including 5 of 10 who
developed toxic colitis; 3 of 4 undergoing total colectomy survived. Among matched patients, those with CDI
had more septicemia (P<.0001), renal failure (P ¼ .0002), reoperations (P<.0001), prolonged postoperative
ventilation (P<.0001), longer hospital stay (P<.0001), and lower 3-year survival, 52% versus 64% (P ¼ .03),
than patients who did not have CDI.
Conclusions: Although rare, the prevalence of CDI is increasing, contributing importantly to morbidity and
mortality after cardiac surgery. If toxic colitis develops, mortality is high, but colectomy may be lifesaving.
(J Thorac Cardiovasc Surg 2014;148:3157-65)
Journal of Thoracic and Cardiovascular Surgery 12/2014; 148(6):3157-65. DOI:10.1016/j.jtcvs.2014.08.017. · 4.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Cerebral angiography is an invasive procedure utilized without supporting guidelines in preoperative evaluations of infective endocarditis (IE). It is used to identify mycotic intracranial aneurysm, which is suspected to increase the risk of intracranial bleeding during cardiac surgery. Our objectives were to: (1) assess the utility of cerebral angiography by determining which subset of IE patients benefit from its performance; and (2) identify clinical and noninvasive screening tests that can preclude the need for invasive cerebral angiography. Retrospective analysis was performed of all patients treated surgically for IE from 7/2007 to 1/2012 and discharged with medical treatment for IE from 7/2007 to 7/2009 presenting to a large academic center. Of the 151 patients who underwent cerebral angiography, mycotic aneurysm was identified in seven (prevalence=4.6%; 95% CI 2.3-9.3%). Five had viridans group streptococci as the causative IE microorganism (p=0.0017). Noninvasive imaging and particularly absence of intracranial bleed on magnetic resonance imaging conveys a negative predictive value (NPV) of 0.977 (95% CI 0.879-0.996). Absence of a focal neurologic deficit or altered mental status convey a NPV of 0.990 (95% CI 0.945-0.998) and 0.944 (95% CI 0.883-0.974), respectively. Clinical suspicion for mycotic aneurysm and thus utilization of cerebral angiography is likely necessary only in the setting of acute neurologic deficits and when noninvasive imaging demonstrates acute intracranial bleed. A novel association between viridans group streptococci and intracranial mycotic aneurysm is demonstrated.
Vascular Medicine 10/2014; 19(6). DOI:10.1177/1358863X14557152 · 1.79 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Rifampin is recommended in the treatment regimen for staphylococcal prosthetic valve endocarditis (PVE), and for staphylococcal native valve endocarditis (NVE) treated with placement of prosthetic material at surgery. The evidence base for this is scant, and some clinicians opt to forgo rifampin. The purpose of this study was to examine if treatment with rifampin in patients with surgically-treated staphylococcal infective endocarditis (IE) results in better outcomes.
Methods: Patients operated for staphylococcal IE from April 1, 2008 to July 1, 2012 were identified from our institution’s IE registry. Treatment was defined as at least 3 days of rifampin post-op. The propensity to receive rifampin was calculated in a model that included NVE vs PVE, Staphylococcus species, left side involvement, invasive disease (extending beyond annulus), positive valve culture, past history of IE, presence of a pacemaker/defibrillator, end-stage renal disease, hepatitis C, and concomitant medications that could interact with rifampin. Cox proportional hazards regression was used to compare a composite outcome of death or reoperation for IE, between patients treated and not treated with rifampin, adjusted for age, sex and propensity to receive rifampin.
Results: 189 patients were identified. Mean age was 56 yrs, 66% were male, 50% had PVE, 60% had S. aureus or lugdunensis infection, 89% had left side involvement, and 57% had invasive disease. 51 (27%) received at least 3 days of rifampin post-op. The median time to event was 979 days (IQR 191 - 1918). Rifampin treatment was associated with PVE (OR 2.93, p 0.001), left side involvement (OR 3.91, p 0.04), invasive disease (OR 2.26, p 0.02), and concomitant potentially interacting medications (OR 2.13, p 0.04). Patients treated with rifampin had a similar hazard of death or reoperation for IE as those not treated (HR 1.09, 95% CI 0.63 – 1.83), after adjusting for age, sex and propensity to receive rifampin. Results were similar when treatment was defined as at least one dose of rifampin, any pre-op rifampin, or rifampin at hospital discharge.
Conclusion: Among patients with surgically treated staphylococcal IE there was insufficient evidence to claim a reoperation-free survival benefit from treatment with rifampin.
IDWeek 2014 Meeting of the Infectious Diseases Society of America; 10/2014
[Show abstract][Hide abstract] ABSTRACT: Purpose of review:
Current results of lung transplantation still lag behind those of other solid-organ transplants. Although bronchial dehiscence was the main cause of early mortality in the past, modern-day operative techniques and immunosuppression regiments have decreased, but not eliminated, this complication. Current barriers to long-term survival are chronic lung allograft dysfunction and infection. Bronchial artery revascularization was effective in decreasing bronchial anastomotic complications, but it was largely abandoned because of technical challenges.
Long-term follow-up in patients with bronchial artery revascularization has shown a survival advantage compared with the standard lung transplant technique. Recent data also show decreased infection, decreased early rejection and decreased bronchiolitis obliterans syndrome, in addition to confirming the known advantages in bronchial healing. Modifications of the technique have also made bronchial artery revascularization feasible in the pediatric population.
Bronchial artery revascularization, although initially designed for bronchial healing, has clinical advantages that extend long term, including survival, infection and decreased graft dysfunction. Its usage in lung transplantation needs to be revisited.
Current Opinion in Organ Transplantation 08/2014; 19(5). DOI:10.1097/MOT.0000000000000114 · 2.88 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Patients with TOF following complete repair and PS after surgical valvotomy often develop significant pulmonic regurgitation (PR), eventually requiring valve replacement (PVR). Though criteria exist for the timing of PVR in TOF, it remains less clear when to intervene in valvotomy patients and whether TOF recommendations can be applied. Our aim was to compare the structural and functional sequelae of valvotomy for pulmonic stenosis (PS) with complete repair for tetralogy of Fallot (TOF). We compared the clinical characteristics, electrocardiograms, echocardiograms, cardiac MRI and invasive hemodynamics of 109 adults (34 PS and 75 TOF) newly referred to a congenital heart disease center for evaluation of PR between 2005 and 2012. Both cohorts were similar in terms of baseline demographics and presenting NYHA function class. Valvotomy patients had a slightly greater degree of PR by echo, though it was similar by cardiac MRI. ECG QRS width was greater in TOF (114±27 vs. 150±28 ms, p<0.001). MRI right ventricular ejection fraction (49±8 vs. 41±11%, p=0.001) and left ventricular ejection fraction (59±7 vs. 52±10%, p=0.002) were lower in TOF. Pacemaker or defibrillator implantation was significantly higher in TOF (3% vs. 23%, p=0.011). In conclusion, patients post-valvotomy and complete repair present with similar degrees of PR and symptom severity. Biventricular systolic function and ECG QRS width appear less affected, suggesting morphologic changes in TOF and its repair that extend beyond the effects of PR. These findings suggest the need for developing disease-specific guidelines for patients with PR post-valvotomy.
The American Journal of Cardiology 07/2014; 114(2). DOI:10.1016/j.amjcard.2014.04.041 · 3.28 Impact Factor