Arun K Srinivasan

Children's Healthcare of Atlanta, Atlanta, Georgia, United States

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Publications (30)76.39 Total impact

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    ABSTRACT: Purpose Surgical correction of vesicoureteral reflux (VUR) is influenced by recurrent urinary tract infection (UTI) risk and the likelihood of spontaneous resolution. We aimed to identify factors associated with VUR resolution in children less than 2 years of age and to design a simple scoring tool to predict improvement and resolution. Materials and methods Children less than 2 years old with primary VUR were identified. Patient demographics, voiding cystourethrogram (VCUG) findings and clinical outcomes over time were assessed. Multivariate analysis with time to resolution was performed to identify factors predictive of VUR improvement and resolution. A random forest model was used to confirm the VUR index (VURx) with normalized importance. Results Two-hundred and twenty-nine children met all inclusion criteria. Mean age at initial VCUG was 0.46 ± 0.43 years. Median clinical follow-up was 1.6 years (range 0.5-4.4 years). Children with grade 4-5 reflux, complete ureteral duplication or periureteral diverticula, and filling phase VUR, as well as female gender, had significantly (p<0.01) longer time to improvement or resolution on multivariate survival analysis. VURx 1 to 5-6 had improvement/resolution rates of 89%, 69%, 53%, 16% and 11%, respectively. Conclusions Female gender, high-grade VUR, ureteral anomalies, and filling reflux are associated with longer time to improvement and non-resolution. VURx reliably predicts resolution of primary reflux in children less than 2 years of age.
    Journal of Pediatric Urology 07/2014; 10(6). DOI:10.1016/j.jpurol.2014.06.019 · 0.90 Impact Factor
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    ABSTRACT: To better elucidate the prevalence of perceived food sensitivity and characterize the sensitivity pattern in patients with clinically diagnosed chronic prostatitis/chronic pelvic pain syndrome. A total of 286 men meeting the National Institutes of Health criteria for chronic prostatitis were mailed a validated questionnaire designed to detect the effect of foods, beverages, and/or supplements on pelvic pain symptoms. The questionnaire assessed the effect of 176 individual comestibles on each patient's symptoms. The responses were numerically scored on a scale of -2 to +2, and the mean values were generated for each comestible. In addition, the participants were asked to complete the O'Leary-Sant Symptom and Problem Index and Chronic Prostatitis Symptom Index questionnaires. Of the 286 surveys, 95 were returned, yielding a response rate of 33.2%. Of those subjects who responded, 47.4% reported that the consumption of certain comestibles aggravated their symptoms, with the most aggravating being spicy foods, coffee, hot peppers, alcoholic beverages, tea, and chili. In contrast, the comestibles that alleviated the symptoms the most included docusate, pysllium, water, herbal teas, and polycarbophil. Many patients with chronic prostatitis/chronic pelvic pain syndrome have demonstrable food, beverage, and dietary supplement sensitivities. Dietary changes should be considered in the treatment of these patients.
    Urology 08/2013; 82(6). DOI:10.1016/j.urology.2013.07.015 · 2.19 Impact Factor
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    ABSTRACT: Objective: To, first, propose a novel scoring system to standardize reporting for percutaneous nephrolithotomy because the instruments currently available to predict the percutaneous nephrolithotomy outcomes are cumbersome, not validated, and of limited clinical utility; and, second, assess and predict the stone-free rates and perioperative parameters applying S.T.O.N.E. nephrolithometry. Materials and methods: Five reproducible variables available from preoperative noncontrast-enhanced computed tomography were measured: stone size (S), tract length (T), obstruction (O), number of involved calices (N), and essence or stone density (E). Results: A total of 117 patients were included. The mean score was 7.7 (range 4-11). The stone-free rate after the first procedure was 80%. There were 18 complications (21%). The most frequent complications were postoperative sepsis and bleeding. The S.T.O.N.E. score correlated with the postoperative stone-free status (P = .001). The patients rendered stone free had statistically significant lower scores than the patients with residual stones (6.8 vs 9.7, P = .002). Additionally, the score correlated with the estimated blood loss (P = .005), operative time (P = .001), and length of hospital stay (P = .001). Conclusion: The novel scoring system we have presented was found to predict treatment success and the risk of perioperative complications after percutaneous nephrolithotomy. Reproducible, standardized parameters obtained from computed tomography imaging can be used for preoperative patient counseling, surgical planning, and evaluation of surgical outcomes across institutions and within medical studies.
    Urology 03/2013; 81(6). DOI:10.1016/j.urology.2012.10.083 · 2.19 Impact Factor
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    ABSTRACT: What's known on the subject? and What does the study add? Off-clamp laparoscopic partial nephrectomy (LPN) is thought to preserve renal function by limiting warm ischaemia time (WIT) and consequently reperfusion injury. To date, studies using the off-clamp technique represent a heterogeneous group, with limited follow-up showing feasibility and safety in a restricted number of cases. We report the largest experience of off-clamp vs on-clamp LPN with perioperative outcomes and intermediate follow-up of renal functional outcomes with stratification by WIT.
    BJU International 11/2012; 111(4B). DOI:10.1111/j.1464-410X.2012.11573.x · 3.53 Impact Factor
  • Arun K. Srinivasan · Zeph Okeke · Arthur D. Smith
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    ABSTRACT: After successful percutaneous renal surgery, the goal should be to ensure good hemostasis and adequate drainage of the renal collecting system. The tools to meet these goals have been a subject of constant innovation and improvements. Urologists have tried to balance the above goals with patient comfort and optimal postoperative outcomes and thus minimize postoperative morbidity. In this chapter, we discuss the various options available for renal drainage after percutaneous renal surgery (PRS). Specifically, we describe the different types of nephrostomy tubes, “tubeless” or “stented percutaneous renal surgery” and “totally tubeless renal surgery.” We discuss the newer techniques of hemostasis after PRS described in the literature. This provides the reader with concise evidence and possible recommendations for the exit strategy following PRS.
    Smith's Textbook of Endourology, 01/2012: pages 326-333; , ISBN: 9781444335545
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    Arun K Srinivasan · Lane S Palmer · Jeffrey S Palmer
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    ABSTRACT: Inconspicous penis refers to a constellation of conditions that make the penis look diminutive and small. This could be secondary to short penile shaft often termed as micropenis. But more commonly, this inconspicuous appearance is secondary to other causes ranging from congenital conditions such as penoscrotal webbing or megaprepuce, developmental conditions like prepubic adiposity that overhang the penis, and iatrogenic causes like trapped penis after adhesions secondary to circumcision. In this paper, we propose to define these entities and provide their descriptions and then to describe their management including surgical correction.
    The Scientific World Journal 12/2011; 11(6):2559-64. DOI:10.1100/2011/238519 · 1.73 Impact Factor
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    ABSTRACT: Study Type – Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Minimizing renal ischemia and reperfusion injury is an area of active investigation and is particularly significant in cases of laparoscopic renal surgery where the kidney experiences warm ischemia. Reports of partial clamping, early unclamping, and off-clamp laparoscopic partial nephrectomy have demonstrated potential technical modifications that can offer a protective role in preserving renal function. We investigated off-clamp laparoscopic partial nephrectomy for tumours with varying clinical stage to determine feasibility, perioperative outcomes, and renal functional changes when compared to a contemporary cohort of standard laparoscopic partial nephrectomy with complete hilar clamping performed by a single surgeon.
    BJU International 10/2011; 109(9):1376-81. DOI:10.1111/j.1464-410X.2011.10592.x · 3.53 Impact Factor
  • Scott P Cuda · Arun K Srinivasan · Jonathan Kalisvaart · Andrew J Kirsch
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    ABSTRACT: The surgical approach to palpable and nonpalpable testicles has changed with increasing use of a single scrotal incision and laparoscopy, respectively. We identified current trends in the surgical approach to undescended testicles in the practice of a single surgeon at our institution. A total of 580 orchiopexies were performed in 554 patients by a single surgeon between January 2002 and July 2009. Study inclusion criteria were palpable and nonpalpable primary undescended testicles. Patients were stratified into groups based on the date of the initial procedure by year. A retrospective chart review was performed and the surgical approach in each patient was recorded as laparoscopic, transinguinal abdominal, inguinal or scrotal. During the 7-year period the percent of orchiopexies performed through a single scrotal incision increased from approximately 15% to a high of 63%. The overall percent of cases performed through a standard inguinal incision decreased from 65% to 17% and the percent performed through a transinguinal abdominal approach decreased from 15% to 0% in the 2 most recent years tabulated. The use of laparoscopy increased from 3% to 17%. Substantial trends were observed among the 3 groups. The percent of procedures performed through a scrotal incision increased during the 7-year period while the percent of inguinal and transinguinal abdominal procedures decreased concomitantly with no increase in morbidity. Selected use of scrotal approach orchiopexy is safe and effective for palpable undescended testicles.
    The Journal of urology 06/2011; 185(6 Suppl):2451-4. DOI:10.1016/j.juro.2011.01.010 · 4.47 Impact Factor
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    ABSTRACT: Criteria for success following endoscopic vesicoureteral reflux (VUR) surgery vary greatly. We sought to define outcomes based on radiographic and long-term clinical follow up. We reviewed the charts and interviewed parents of children who underwent endoscopic treatment for primary VUR (grades I-IV). All patients had a postoperative voiding cystourethrogram (VCUG) at mean of 3 months (1-21 months) and all cases of postoperative febrile urinary tract infection (FUTI) prompted repeat VCUG. Radiographic success was defined as no VUR on postoperative VCUG and clinical success as no FUTIs during follow up of 12-36 months. To demonstrate how criteria for success can affect outcomes, we calculated the success rates using different definitions. In 2004-2008, 336 patients (296 female and 40 male, mean age 4 years) were treated with dextranomer/hyaluronic acid via the Double-HIT method. Initial radiographic success was 90% (302/336). Of these, 19 (6%) developed FUTIs, 12 (4%) of whom had recurrent VUR, and 5 (2%) went on to open surgery. Of the radiographic failures, 18% were observed with no further treatment. Success defined clinically was 94% (281/300), and as 'radiographic cure and no clinical evidence of FUTIs' it was 82% (275/336). It is important to agree on a universal definition of success for VUR interventions to compare across studies and across therapies. Clinical success is more meaningful to the patient, and initial radiographic success could be followed by UTI necessitating further intervention. We question the need for routine postoperative VCUG.
    Journal of pediatric urology 05/2011; 8(3):297-303. DOI:10.1016/j.jpurol.2011.02.006 · 0.90 Impact Factor
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    ABSTRACT: Urethral-enteric fistulae with hypoplastic/atretic distal urethra in boys with anorectal malformations are amenable to management via sequential dilation of the distal urethra (P.A.D.U.A.) and subsequent repair of the fistula, but failure of this technique occasionally requires complex reconstruction. We present a novel surgical approach, along with long-term results, that incorporates rotation of the amputated fistula tract (RAFT) in boys with H-type urethral-enteric fistulae. The charts of four patients undergoing the RAFT procedure were reviewed. All had previously failed P.A.D.U.A. Surgical principles were similar in all cases: the fistula tract was amputated as close to the bowel as possible. A tubularized or on-layed urethra was then fashioned from preputial skin and anastomosed to the distal end of the urethral fistula. The distal end of the neourethra was then brought to the tip of the penis, or anastomosed to the proximal end of the patent distal urethra. Mean age was 12.3 months, and there was a mean follow up of 10.2 years. All four patients had a rectourethral fistula as a component of VACTERL, with a urethral deficit of 7-11 cm. All had a functionally intact urethra on reconstruction, with normal continence and bladder neck closure. Two patients needed further bladder augmentation with a Mitrofanoff channel for poor bladder compliance. Both boys who were post-pubertal in this series report normal sexual function with antegrade ejaculation. The RAFT technique represents a viable reconstructive option for congenital H-fistulae with distal urethral stenosis, with excellent long-term results. It provides boys with normal urethral function, along with intact urinary continence and antegrade ejaculation. This technique may be of particular utility in patients after failed P.A.D.U.A., or in whom a staged buccal onlay graft is not feasible.
    Journal of pediatric urology 04/2011; 8(2):166-73. DOI:10.1016/j.jpurol.2011.02.033 · 0.90 Impact Factor
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    ABSTRACT: Surgical site infections have been categorized by the Centers for Medicare and Medicaid Services as "never events". The incidence of surgical site infection following laparoscopic urological surgery and its risk factors are poorly defined. We evaluated surgical site infection following urological laparoscopic surgery and identified possible factors that may influence occurrence. Patients who underwent transperitoneal laparoscopic procedures during a 4-year period by a single laparoscopic surgeon were retrospectively reviewed. Surgical site infections were identified postoperatively and defined using the Centers for Disease Control criteria. Clinical parameters, comorbidities, smoking history, preoperative urinalysis and culture results as well as operative data were analyzed. Nonparametric testing using the Mann-Whitney U test, multivariable logistic regression and Spearman's rank correlation coefficient were used for data analysis. In 556 patients undergoing urological laparoscopic procedures 14 surgical site infections (2.5%) were identified at mean postoperative day 21.5. Of the 14 surgical site infections 10 (71.4%) were located at a specimen extraction site. Operative time, procedure type and increasing body mass index were significantly associated with the occurrence of surgical site infections (p = 0.007, p = 0.019, p = 0.038, respectively), whereas history of diabetes mellitus (p = 0.071) and intraoperative transfusion (p = 0.053) were found to trend toward significance. Age, gender, positive urine culture, steroid use, procedure type and smoking history were not significantly associated with surgical site infection. Body mass index and operative time remained significant predictors of surgical site infection on multivariate logistic regression analysis. Surgical site infection is an infrequent complication following laparoscopic surgery with the majority occurring at the specimen extraction site. Infection is associated with prolonged operative time and increasing body mass index.
    The Journal of urology 02/2011; 185(4):1289-93. DOI:10.1016/j.juro.2010.11.059 · 4.47 Impact Factor
  • Arun K. Srinivasan · Lane S. Palmer
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    ABSTRACT: Voiding dysfunction in children is a common problem constituting nearly 40% of patient visits to a pediatric urologist. Although most of these children present with incontinence either daytime, or nocturnal, or both, some present with recurrent urinary tract infection, hematuria, and pain. Voiding dysfunction could be an isolated problem or in other cases form part of a wider neurological disorder. In this chapter we discuss non-neurological voiding dysfunction in children. We describe the ICCS classification of voiding dysfunction, which forms the backbone for the present day work up for these children. The common presenting symptoms, appropriate work up, diagnosis, and management of these children are discussed in detail. KeywordsIncontinence-Enuresis-Children-Urodynamics-Biofeedback
    12/2010: pages 71-89;
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    ABSTRACT: To prospectively compare a novel type of valveless trocar that creates a curtain of pressurized carbon dioxide [CO(2)] gas (which maintains pneumoperitoneum at a lower gas flow rate) with standard trocars; to quantify the volume of CO(2) used; and to characterize CO(2) elimination during laparoscopic renal surgery. A total of 51 patients undergoing laparoscopic renal surgery by a single surgeon were prospectively evaluated using either the valveless trocar (n = 26) or standard trocars (n = 25). Patient demographics, operative time, volume of CO(2) gas consumed, CO(2) elimination, perioperative parameters, and postoperative complications were recorded and analyzed. Both patient cohorts were comparable in their preoperative demographics, including body mass index, the number of patients with chronic obstructive pulmonary disease, and smoking history. Mean operative time was lower in the valveless trocar cohort (124.1 minutes) compared with the conventional trocar group (145.6 minutes), P = .047. Use of the valveless trocar was associated with a lower volume of intraoperative CO(2) consumed (120.0 ± 82.8 vs 300.6 ± 191.5; P < .001) and reduced CO(2) elimination compared with standard trocar use after the first 16 minutes of insufflation (P < .05). Minimal complications occurred, including 2 cases of subcutaneous emphysema in the valveless trocar group, and 1 case of respiratory acidosis in the conventional trocar group. Use of a valveless trocar significantly reduced CO(2) consumption during transperitoneal laparoscopy. The valveless trocar also demonstrated significantly reduced CO(2) elimination and absorption when compared with the standard trocar.
    Urology 09/2010; 77(5):1126-32. DOI:10.1016/j.urology.2010.06.052 · 2.19 Impact Factor
  • Arun K Srinivasan · Amin Herati · Zeph Okeke · Arthur D Smith
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    ABSTRACT: Exit strategy after percutaneous nephrolithotomy (PCNL) is an area of continuing innovation to improve postoperative morbidity and operative outcomes for patients. The two important components of an exit strategy after PCNL are hemostasis and renal drainage. We review the different techniques of renal drainage after PCNL-ie, nephrostomy tube, ureteral stents, and totally tubeless strategy with critical discussion of available evidence for and against each of these techniques. We conclude that the optimal renal drainage method depends on patient characteristics and the operative course; hence, it should be individualized. To simplify this, we group patients undergoing PCNL as routine, problematic, and complicated, based on increasing complexity of the procedure and procedural complications. In routine PCNLs, we favor placement of an ureteral stent or a small-bore nephrostomy tube. In problematic and complicated PCNLs, we think the evidence directs toward placement of a nephrostomy tube, small bore being an option in problematic PCNLs.
    Journal of endourology / Endourological Society 10/2009; 23(10):1743-9. DOI:10.1089/end.2009.1545 · 1.71 Impact Factor
  • Arun K. Srinivasan · Lane S. Palmer
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    ABSTRACT: Robotic nephrectomy is not a common procedure in children. However, when it is performed, the sequence of steps is those used in adults. Fortunately, the indications for nephrectomy or nephroureterectomy are typically for benign disease and the non-functioning kidney rather than for malignancy. In this chapter, we aim to provide the reader with an understanding of performing robotic nephrectomy, nephroureterectomy, and adrenalectomy. KeywordsKidney–Robotic–Laparoscopy–Urology–Children–Nephrectomy
    12/2008: pages 123-136;
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    ABSTRACT: The surgical management of retroperitoneal fibrosis has traditionally involved open ureterolysis. We compared laparoscopic and open ureterolysis to determine if the minimally invasive approach offered advantages with respect to perioperative morbidity and treatment efficacy. We reviewed our retroperitoneal fibrosis database at a single institution to identify all patients who underwent open or laparoscopic ureterolysis between 1995 and 2005. Clinical, perioperative and outcome data were prospectively collected and compared between the open and laparoscopic ureterolysis cohorts. Subgroup analysis was performed on patients with primary retroperitoneal fibrosis comparing outcomes in open and laparoscopic ureterolysis groups. We identified 36 (51.4%) patients who underwent open ureterolysis and 34 (48.6%) who underwent laparoscopic ureterolysis. Conversion to open surgery was required in 17.6% of the laparoscopic ureterolysis cohort. The etiology of obstruction was primary idiopathic retroperitoneal fibrosis in 35 (50%) patients, whereas the remainder had secondary retroperitoneal fibrosis, largely related to gynecological malignancy. There was no difference between the 2 groups when comparing operative time, estimated blood loss, length of hospital stay, complications, transfusion requirements and postoperative resolution of ureteral obstruction. Subgroup analysis limited to patients with primary idiopathic retroperitoneal fibrosis demonstrated that those who underwent laparoscopic ureterolysis had a shorter hospital stay (3.4 vs 10.8, p <0.001) and were less likely to require transfusion (3.7% vs 13.7%, p = 0.007) compared to patients who underwent open surgery. Laparoscopic ureterolysis is an excellent option for patients with retroperitoneal fibrosis of all causes with morbidity and efficacy comparable to open surgery. In patients with primary idiopathic retroperitoneal fibrosis laparoscopy offers the added advantages of shorter hospital stay and reduced transfusion requirements.
    The Journal of urology 05/2008; 179(5):1875-8. DOI:10.1016/j.juro.2008.01.030 · 4.47 Impact Factor
  • Arun K Srinivasan · Edan Y Shapiro · Casey A Seideman · Robert M Moldwin
    The Journal of Urology 04/2008; 179(4):63-63. DOI:10.1016/S0022-5347(08)60187-1 · 4.47 Impact Factor
  • Arun K Srinivasan · Jaime Freyle · Jordan S Gitlin · Lane S Palmer
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    ABSTRACT: The risk factors for acute testicular torsion are poorly understood. Environmental factors have been implicated by some authors and discredited by others. The only previous known study in the United States did not demonstrate any seasonal correlation, although the study was done in a warmer climate. We sought to determine if environmental factors impact the incidence of testicular torsion in our temperate climate conditions with a large differential between the warmest and coldest temperatures. We retrospectively studied patients who were diagnosed with testicular torsion between January 1997 and December 2006. Data regarding weather conditions were collected, including season, temperature, humidity and atmospheric pressure at the time of onset of symptoms. Spearman's rank correlation was performed to assess the relationship between atmospheric temperature and frequency of testicular torsion. Multivariate analysis was performed to analyze the effect of covariables. A total of 58 children presented with testicular torsion. Mean temperature at onset of symptoms was 6.9C (range -12C to 23C). Of the patients 81% had symptom onset when the atmospheric temperature was less than 15C. Seasonal incidence of testicular torsion was 36.2%, 31%, 19% and 13.8% for spring, winter, summer and fall, respectively. Spearman's rank correlation test revealed a significant negative correlation between the incidence of testicular torsion and increasing temperature (r = -0.94, p <0.0001) and decreasing humidity (r = -0.44, p <0.001). After controlling for effects by patient age, atmospheric pressure and humidity by multivariate analysis a significant correlation was observed between testicular torsion and decreasing atmospheric temperature. None of the other atmospheric factors examined correlated with the incidence of testicular torsion. An increased incidence of testicular torsion is seen with decreasing atmospheric temperature and humidity, suggesting a possible etiological role.
    The Journal of urology 01/2008; 178(6):2585-8; discussion 2588. DOI:10.1016/j.juro.2007.08.049 · 4.47 Impact Factor
  • Arun K Srinivasan · Jonathan D Kaye · Robert Moldwin
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    ABSTRACT: Myofascial pain as a cause of chronic pelvic pain with or without pelvic organ pathology is well-documented in the literature. Causes of this pain are multifactorial, including specific pelvic organ pathologies, neuromuscular disorders, and psychologic causes. Management of this myofascial component of chronic pelvic pain involves a multidisciplinary approach including physicians, physical therapists, neurologists, and psychiatrists. Treatment strategies, including behavioral management, medications, physical therapy, trigger point injections, neuromodulation, botulinum toxin injection, and other lesser known treatment modalities, are discussed in detail in this article.
    Current Pain and Headache Reports 11/2007; 11(5):359-64. DOI:10.1007/s11916-007-0218-0 · 2.26 Impact Factor
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    ABSTRACT: The effect of using the left internal mammary artery in combined coronary and valve operations have not been fully investigated. We aimed to quantify the impact of the left internal mammary artery to the left anterior descending artery on early and mid-term outcomes in these patients. Data was collected prospectively on 630 consecutive patients who underwent revascularization of the left anterior descending artery with concomitant valve operations between April 1997 and March 2003. Multivariate logistic regression and Cox proportional hazards analyses were used to adjust in-hospital outcomes and Kaplan-Meier survival curves. A propensity score for left internal mammary artery use was constructed to control for selection bias. The left internal mammary artery was used in 478 (75.9%) patients. Univariate analyses found left internal mammary artery patients had significantly lower in-hospital mortality (6.3% versus 13.2%; p < 0.01) and postoperative renal failure (8.2% versus 13.8%; p = 0.038). After adjusting for treatment selection bias, in-hospital mortality (adjusted odds ratio, 0.77; p = 0.45) and renal failure (adjusted odds ratio, 0.94; p = 0.86) were no longer significantly different. A total of 171 (27.1%) deaths occurred during the follow-up, with a total follow-up of 2,325 patient-years. The crude relative risk for the left internal mammary artery was 0.67 (p = 0.015). After adjusting for the propensity score, the adjusted relative risk was 0.91 (p = 0.62). The left internal mammary artery does not adversely affect the short-term and medium-term outcomes in patients undergoing concomitant coronary and valve operations. Survival at 7 years was similar with or without the use of the left internal mammary artery.
    The Annals of thoracic surgery 08/2005; 80(1):163-9. DOI:10.1016/j.athoracsur.2005.01.056 · 3.85 Impact Factor

Publication Stats

486 Citations
76.39 Total Impact Points


  • 2014
    • Children's Healthcare of Atlanta
      Atlanta, Georgia, United States
  • 2013
    • Hofstra North Shore-LIJ School of Medicine
      New York, New York, United States
  • 2007–2012
    • North Shore-Long Island Jewish Health System
      • Smith Institute for Urology
      New York City, New York, United States
  • 2011
    • Emory University
      • Department of Pediatrics
      Atlanta, Georgia, United States
  • 2010–2011
    • Hofstra University
      Хемпстед, New York, United States
  • 2004
    • Blackpool Teaching Hospitals NHS Foundation Trust
      Blackpool, England, United Kingdom