Juan A Crestanello

The Ohio State University, Columbus, OH, United States

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Publications (54)114.25 Total impact

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    ABSTRACT: We studied the association between components of chronic lung disease (CLD) assessment and operative outcomes in patients undergoing aortic valve replacement (AVR) for aortic stenosis. From 2011 to 2012, 9,177 patients included in The Society of Thoracic Surgeons (STS) Cardiac Surgery Database underwent AVR for aortic stenosis with complete pulmonary function tests (PFT) and CLD data (31% of AVRs). We evaluated markers of CLD and their association with operative mortality, pulmonary morbidity, and length of hospital stay using multivariable logistic regression analysis. In a selected population of AVR patients with PFTs, CLD was prevalent in 50% (mild, 25.6%; moderate, 13.2%; severe, 11.2%). Predicted forced expiratory volume in 1 second (FEV1) was obtained in all patients and diffusion capacity of the lung for carbon monoxide (DLCO), arterial oxygen tension (PaO2), and arterial carbon dioxide tension (PaCO2) in 31%. The STS predicted risk of operative mortality, mortality, pulmonary morbidity, and hospital stay increased with severity of CLD and with low FEV1, DLCO, and PaO2. Moderate and severe CLD were independently associated with operative mortality (odds ratio [OR] 2.88, 95% confidence interval [CI]: 2.0-4.5), pulmonary morbidity (OR 2.33, 95% CI: 1.93-2.8), and prolonged hospital stay (OR 2.73, 95% CI: 2.17-3.45). Low FEV1 was independently associated with pulmonary morbidity and prolonged hospital stay. Low PaO2 and DLCO were independently associated with a combined mortality and pulmonary morbidity endpoint. CLD is associated with adverse operative outcomes in selected patients with aortic stenosis undergoing AVR. FEV1, DLCO, and PaO2 may add important information to current risk adjustment models beyond the broad CLD classification. Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
    The Annals of thoracic surgery. 12/2014; 98(6):2068-77.
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    ABSTRACT: Background: Cardiac ischemia-reperfusion (IR) leads to myocardial dysfunction by increasing production of reactive oxygen species (ROS). Mitochondrial H(+) leak decreases ROS formation; it has been postulated that increasing H(+) leak may be a mechanism of decreasing ROS production after IR. Ischemic preconditioning (IPC) decreases ROS formation after IR, but the mechanism is unknown. We hypothesize that pharmacologically increasing mitochondrial H(+) leak would decrease ROS production after IR. We further hypothesize that IPC would be associated with an increase in the rate of H+ leak. Methods: Isolated male Sprague-Dawley rat hearts were subjected to either Control or IPC. Mitochondria were isolated at end equilibration, end ischemia, and end reperfusion. Mitochondrial membrane potential (mΔΨ) was measured using a tetraphenylphosphonium electrode. Mitochondrial uncoupling was achieved by adding increasing concentrations of FCCP. Mitochondrial ROS production was measured by fluorometry using Amplex-Red. Pyridine dinucleotide levels were measured using HPLC. Results: Prior to IR, increasing H+ leak decreased mitochondrial ROS production. After IR, ROS production was not affected by increasing H+ leak. H(+) leak increased at end ischemia in Control mitochondria. IPC mitochondria showed no change in the rate of H(+) leak throughout IR. NADPH levels decreased after IR in both IPC and Control mitochondria while NADH increased. Conclusion: Pharmacologically increasing H(+) leak is not a method of decreasing ROS production after IR. Replenishing the NADPH pool may be a means of scavenging the excess ROS thereby attenuating oxidative damage after IR.
    American journal of physiology. Heart and circulatory physiology. 08/2014;
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    ABSTRACT: Endothelial cell dysfunction is the hallmark of every cardiovascular disease/condition, including atherosclerosis and ischemia/reperfusion injury. Fluid shear stress acting on the vascular endothelium is known to regulate cell homeostasis. Altered hemodynamics is thought to play a causative role in endothelial dysfunction. The dysfunction is associated with/preceded by mitochondrial oxidative stress. Studies by our group and others have shown that the form and/or function of the mitochondrial network are affected when endothelial cells are exposed to shear stress in the absence or presence of additional physico-chemical stimuli. The present review will summarize the current knowledge on the interconnections among intracellular Ca2+–nitric oxide–mitochondrial reactive oxygen species, mitochondrial fusion/fission, autophagy/mitophagy, and cell apoptosis vs. survival. More specifically, it will list the evidence on potential regulation of the above intracellular species and processes by the fluid shear stress acting on the endothelium under either physiological flow conditions or during reperfusion (following a period of ischemia). Understanding how the local hemodynamics affects mitochondrial physiology and the cell redox state may lead to development of novel therapeutic strategies for prevention or treatment of the endothelial dysfunction and, hence, of cardiovascular disease.
    Cellular and Molecular Bioengineering 01/2014; · 1.44 Impact Factor
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    ABSTRACT: We report a patient with congenital absence of the left pericardium with development of progressive annuloaortic ectasia and aortic insufficiency during a 12-year period. The patient was treated with a Bentall procedure. Pathologic examination of the aorta revealed cystic medial necrosis. The surgical management and a possible association between congenital absence of pericardium and Marfan syndrome are discussed.
    The Annals of thoracic surgery 12/2013; 96(6):2243-5. · 3.45 Impact Factor
  • Journal of cardiothoracic and vascular anesthesia 06/2013; 27(3):e26-e28. · 1.06 Impact Factor
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    ABSTRACT: BACKGROUND: The association between postoperative hyponatremia (Na < 135 mEq/L) and outcomes after cardiac surgery has not been established. We studied the prevalence of postoperative hyponatremia and its effects on outcomes after cardiac surgery. STUDY DESIGN: We studied 4,850 patients who underwent cardiac surgery from 2002 to 2008. We used multivariable logistic and Cox regression analysis to study the association between postoperative hyponatremia and mortality, length of hospital stay (LOS), and complications. RESULTS: Postoperative hyponatremia was present in 59%. Hyponatremic patients were older (mean ± SD, 62 ± 13 vs 61 ± 14 years, p = 0.001), had lower left ventricle ejection fraction (mean ± SD, 44% ± 16% vs 48% ± 13%, p < 0.001), higher mean pulmonary artery pressures (mean ± SD, 30 ± 11 vs 27 ± 9 mmHg, p < 0.001), lower glomerular filtration rate (mean ± SD, 72 ± 29 vs 74 ± 27 mg/min/1.73 m(2), p = 0.01), higher EuroSCORE (median, 15% vs 6%, p < 0.001), higher New York Heart Association class IV (31% vs 26%, p = 0.002), prevalence of COPD (23% vs 14%, p < 0.001), and peripheral vascular disease (16% vs 12%, p < 0.001). Hyponatremia increased overall (24% vs 18.2%, p < 0.001) and late mortality (18.6% vs 13.9%, p < 0.001) and length of stay (LOS; 11 vs 7 days, p < 0.001). Mortality increased with the severity of the hyponatremia. After adjusting for baseline and procedure variables, postoperative hyponatremia was associated with increase in mortality (hazard ratio 1.22, 95% CI 1.06-1.4, p = 0.004), LOS (multiplier 1.34, 95% CI 1.22-1.49, p < 0.001), infectious (odds ratio [OR] 2.32, 95% CI 1.48-3.62, p < 0.001), pulmonary (OR 1.82, 95% CI 1.49-2.21, p < 0.001), and renal failure complications (OR 2.46, 95% CI 1.58-3.81, p < 0.001) and need for dialysis (OR 3.66, 95% CI 1.72-7.79, p = 0.001). CONCLUSIONS: Hyponatremia is common after cardiac surgery and is an independent predictor of increased mortality, length of hospital stay, and postoperative complications.
    Journal of the American College of Surgeons 04/2013; · 4.50 Impact Factor
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    ABSTRACT: OBJECTIVE: Left ventricular dysfunction and preoperative hyponatremia are associated with adverse outcomes after cardiac surgery. However, the interactions between them are unknown. Thus, we evaluated the interaction of low left ventricular ejection fraction (<40%) and preoperative hyponatremia (Na <135 mEq/L) with morbidity and mortality after cardiac surgery. METHODS: The interaction of hyponatremia and ejection fraction with hospital complications, length of stay, and mortality was analyzed using logistic and Cox regression analysis in 2247 patients who underwent cardiac surgery between 2005 and 2008 at The Ohio State University Wexner Medical Center. RESULTS: Of the patients, 68.5% had normal ejection fraction. Hyponatremia was present in 18% of patients with normal ejection fraction and 35% of patients with low ejection fraction. Hyponatremic patients had higher rates of New York Heart Association class III and IV, more comorbidities, and higher Society of Thoracic Surgeons score and European System for Cardiac Operative Risk Evaluation irrespectively of their ejection fraction. The correlation between preoperative sodium and ejection fraction was weak (r(2) = 0.04). Hyponatremia increased the rate of postoperative complications and hospital stay, and decreased 1- and 3-year survivals in patients with both normal and low ejection fraction. Hyponatremia was independently associated with longer hospital stay for normal ejection fraction (multiplier, 1.18; confidence interval, 1.09-1.27; P < .001) and low ejection fraction (multiplier, 1.10; confidence interval, 1.0-1.21; P = .05), increased need for dialysis for normal ejection fraction (odds ratio, 2.16; confidence interval, 1.08-4.32; P = .03), and increased risk of mortality for normal ejection fraction (hazard ratio, 1.56; confidence interval, 1.20-2.05; P = .001), but not for patients with low ejection fraction (hazard ratio, 1.21; confidence interval, 0.89-1.65; P = .21). CONCLUSIONS: Hyponatremia is more common in patients with low ejection fraction. Although preoperative hyponatremia is independently associated with adverse outcomes in patients with normal ejection fraction, an association with adverse outcomes in patients with low ejection fraction was not demonstrated.
    The Journal of thoracic and cardiovascular surgery 04/2013; · 3.41 Impact Factor
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    ABSTRACT: OBJECTIVES We reviewed our single-centre experience with emergent operative repair of Stanford Type A aortic dissections, with particular attention to outcomes in the elderly.METHODS Consecutive adult patients undergoing emergent operative repair of acute Type A aortic dissections between February 2004 and December 2011 at a single institution were identified. Patients were stratified into elderly (≥70 years) and control cohorts (<70 years). Kaplan-Meier analysis was used to evaluate survival.RESULTSA total of 117 patients undergoing emergent repair of Type A aortic dissection were identified during the study period, including 31 (26.5%) elderly and 86 (73.5%) control patients. The mean age in the elderly cohort was 78.0 ± 4.7 years, with 41.9% (13 of 31) being 80 years or older. The elderly and control groups were well matched with regard to preoperative comorbidities (each P > 0.05) and the presence of malperfusion at presentation (elderly: 19.4 vs controls: 27.9%, P = 0.35). The most common site of tear involved the proximal ascending aorta (elderly: 83.9 vs controls: 84.9%), with fewer cases affecting the aortic arch (12.9 vs 14.0%; P = 0.75). Operative data, including cardiopulmonary bypass and aortic cross-clamp time, concomitant aortic valve procedures and arch replacement were also similar between cohorts. Fewer elderly patients underwent hypothermic circulatory arrest (67.7 vs 90.7%, P = 0.002). Overall survival to discharge was 87.2% (n = 102), with no difference in the elderly (83.9%; n = 26) vs controls (88.4%; n = 76; P = 0.52). The 30-day (elderly: 82.8 vs controls: 86.2%), 90-day (elderly: 79.0 vs controls: 84.8%) and 1-year (elderly: 75.4 vs controls: 84.8%) survivals were also comparable.CONCLUSIONS Excellent operative outcomes can be achieved in elderly patients undergoing emergent repair of Type A aortic dissections. Advanced patient age should therefore not serve as an absolute contraindication to operative repair in this high-risk cohort.
    Interactive Cardiovascular and Thoracic Surgery 04/2013; · 1.11 Impact Factor
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    ABSTRACT: Purpose Obesity in heart failure may be associated with improved outcomes. We sought to assess the impact of pre-transplant body mass index (BMI) on post-heart transplant survival. Methods and Materials We analyzed The United Network for Organ Sharing data registry for adult orthotopic heart transplant recipients from 1987 to 2012. Recipients with right or bi-ventricular support or total artificial hearts were excluded. Patients were stratified based on body mass index (BMI in kg/m²) at time of transplant based on conventional thresholds for transplantation into BMI 15-18.4 (UNDERWEIGHT), 18.5- 29.9 (NORMAL), 30-34.9 (OVERWEIGHT) and 35-40 (OBESE). Kaplan-Meier estimates were used to evaluate survival. Results 52,903 heart transplant recipients were identified and 45,261 were included. Of the overall cohort, 78.4% - NORMAL, 15.2% - OVERWEIGHT, 3.3% - UNDERWEIGHT and 3.1% - OBESE. Pre-transplant BMI affected survival significantly at 30 days, 1, 5, and 10 years post-transplant (p<0.0001). [figure 1] In the proportional hazards model, OVERWEIGHT and UNDERWEIGHT patients had decreased survival. Factors negatively affecting survival include female donor to male recipients, African-American recipients, pulmonary hypertension, LVAD, increasing age and ischemic times. Conclusions In a population based analysis, BMI influences survival in the short and long term. Underweight recipients may not have physiologic reserves for optimum results. View Within Article
    The Journal of Heart and Lung Transplantation 04/2013; 32(4):S39. · 5.11 Impact Factor
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    ABSTRACT: BACKGROUND: -We tested the ability of a novel automated 3-D algorithm to model and quantify the aortic root from 3-D TEE and CT data. METHODS AND RESULTS: -We compared the quantitative parameters obtained by automated modeling from 3-D TEE (n=20) and CT data (n=20) to those made by 2-D TEE and targeted 2-D from 3-D TEE and CT in patients without valve disease ("normals"). We also compared the automated 3-D TEE measurements in severe AS (n=14), dilated root without AR (n=15) and dilated root with AR (n=20). The automated 3-D TEE saggital annular diameter was significantly greater than the 2-D TEE measurements (p=0.004). This was the also true for the 3-D TEE and CT coronal annular diameters (p<0.01). The average 3-D TEE and CT annular diameter was greater than both their respective 2-D and 3-D sagittal diameters (p<0.001). There was no significant difference in 2-D and 3-D measurements of the sino-tubular junction and sinus of Valsalva diameters (p>0.05) in normals, but these were significantly different (p<0.05) in abnormals. The 3 automated inter-commissural distance and leaflet length and height did not show significant differences in the normals (p>0.05), but all three were significantly different compared to the abnormal group (p<0.05). The automated 3-D annulus-commissure-coronary ostia distances in normals showed significant difference between 3-D TEE and CT (p<0.05); also these parameters by automated 3-D TEE were significantly different in abnormal (p<0.05). Lastly, the automated 3-D measurements showed excellent reproducibility for all parameters. CONCLUSIONS: -Automated quantitative 3-D modeling of the aortic root from 3-D TEE or CT data is technically feasible and provides unique data which may aid surgical and trans-catheter interventions.
    Circulation Cardiovascular Imaging 12/2012; · 5.80 Impact Factor
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    ABSTRACT: OBJECTIVE: To study the effect of preoperative hyponatremia (Na <135 mEq/L) on outcomes after cardiac surgery. METHODS: From 2002 to 2008, 4370 patients had cardiac surgery at our institution (CABG in 2238, valve in 597, CABG valve in 537, other in 998). The institution electronic medical records, STS database, and Social Security death index data were analyzed. The association of hyponatremia with mortality, hospital length of stay (LOS), and complications was analyzed using regression analysis. RESULTS: Prevalence of hyponatremia was 21%. Patients with preoperative hyponatremia had lower left ventricular ejection fraction (39% ± 17% versus 46% ± 14%, P < 0.001) and glomerular filtration rate (69 ± 32 mg/min/1.73 m(2)versus 74 ± 27 mg/min/1.73 m(2), P < 0.001) and higher median EuroSCORE (19% versus 9%, P < 0.001), NYHA class 3-4 (77% versus 65%, P < 0.001), prevalence of chronic obstructive pulmonary disease (25% versus 18%, P < 0.001), and arteriopathy (20% versus 13%, P < 0.001). Hyponatremia was associated with increased early mortality (9% versus 4%, P < 0.001), late mortality (24% versus 16%, P < 0.001), and LOS (13 versus 8 d, P < 0.001). Mortality increased with the severity of hyponatremia. After adjusting for baseline and operative variables, hyponatremia was associated with increased hazard of mortality (hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.14-1.52, P < 0.001), risk of early mortality (odds ratio [OR] 1.52, 95% CI 1.09-2.12, P < 0.001), late mortality (HR 1.37, 95% CI 1.16-1.62, P < 0.001), LOS (multiplier 1.26, 95% CI 1.15-1.39, P < 0.001), operative complications (OR 1.30, 95% CI 1.00-1.69, P = 0.051), and dialysis (OR 1.64, 95% CI 1.11-2.44, P = 0.013). CONCLUSIONS: Preoperative hyponatremia is common, especially in high-risk patients. It is an independent risk factor for mortality, prolonged hospitalization, and complications after cardiac surgery.
    Journal of Surgical Research 06/2012; · 2.02 Impact Factor
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    ABSTRACT: Mitochondrial superoxide radical (O(2)(•¯)) production increases after cardiac ischemia/reperfusion (IR). Ischemic preconditioning (IPC) preserves mitochondrial function and attenuates O(2)(•¯) production, but the mechanism is unknown. Mitochondrial membrane potential (mΔΨ) is known to affect O(2)(•¯) production; mitochondrial depolarization decreases O(2)(•¯) formation. We examined the relationship between O(2)(•¯) production and mΔΨ during IR and IPC. Rat hearts were subjected to Control or IPC. Mitochondria were isolated at end equilibration (End EQ), end ischemia (End I), and end reperfusion (End RP). mΔΨ was measured using a tetraphenylphosphonium electrode. Mitochondrial O(2)(•¯) production was measured by electron paramagnetic resonance using DMPO spin trap. Cytochrome c levels were measured using high-pressure liquid chromatography. IPC preserved mΔΨ at End I (-156 ± 5 versus -131 ± 6 mV, P < 0.001) and End RP (-168 ± 2 versus -155 ± 2 mV, P < 0.05). At End RP, IPC attenuated O(2)(•¯) production (2527 ± 221 versus 3523 ± 250 AU/mg protein, P < 0.05). IPC preserved cytochrome c levels (351 ± 14 versus 269 ± 16 picomoles/mg protein, P < 0.05) at End RP, and decreased mitochondrial cristae disruption (10% ± 4% versus 33% ± 7%, P < 0.05) and amorphous density formation (18% ± 4% versus 28% ± 1%, P < 0.05). We conclude that IPC preserves mΔΨ, possibly by limiting disruption of mitochondrial inner membrane. IPC also decreases mitochondrial O(2)(•¯) production and preserves mitochondrial ultrastructure after IR. While it was previously held that slight decreases in mΔΨ decrease O(2)(•¯) production, our results indicate that preservation of mΔΨ is associated with decreased O(2)(•¯) and preservation of cardiac function in IPC. These findings indicate that the mechanism of IPC may not involve mΔΨ depolarization, but rather preservation of mitochondrial electrochemical potential.
    Journal of Surgical Research 06/2012; 178(1):8-17. · 2.02 Impact Factor
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    The Annals of thoracic surgery 06/2012; 93(6):2117-8; author reply 2118. · 3.45 Impact Factor
  • The Journal of Heart and Lung Transplantation 04/2012; 31(4 (supp 1)):S187. · 5.11 Impact Factor
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    ABSTRACT: We present a case of a patient who underwent successful concomitant surgical management of his massive pulmonary embolism and severe multivessel coronary disease. His presentation with shortness of breath prompted a comprehensive evaluation, which revealed both problems. This experience emphasizes the importance of considering both problems, because treating one but not the other could be catastrophic.
    Heart Surgery Forum 02/2012; 15(1):E56-8. · 0.63 Impact Factor
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    Critical care (London, England) 01/2012; 16(1):405. · 4.72 Impact Factor
  • 61st annual scientific sessions and expo; 01/2012
  • Juan A Crestanello
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    ABSTRACT: Functional mitral regurgitation (MR) is common in patients with chronic heart failure and adversely affects survival and quality of life. Surgery is effective in improving symptoms and reverse remodeling of the ventricle. However, its effect on survival is unclear. Indications for surgery are challenging given the elevated surgical risk of these patients, lack of prospective randomized data, and uncertain long-term results in the historical series. A systematic approach to functional mitral regurgitation that addresses both the mitral insufficiency and the ventricular remodeling with careful patient selection can achieve reliable, reproducible, and lasting results. This article reviews the surgical procedures to treat functional mitral regurgitation and presents an algorithm for their application in patients with congestive heart failure.
    Current Heart Failure Reports 12/2011; 9(1):40-50.
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    ABSTRACT: Absence of myocardial hyperenhancement on cardiac magnetic resonance imaging (CMR) predicts functional improvement after coronary artery bypass graft surgery (CABG). However, not all patients with absence of hyperenhancement improve their left ventricular ejection fraction (LVEF) after CABG. We sought to identify other characteristics associated with improvement in LVEF after CABG. Preoperative CMR was obtained in 95 patients who underwent CABG from 2003 to 2007 at The Ohio State University Medical Center. Follow-up LVEF was assessed by echocardiogram between 3 wk and 2 y postoperatively (mean: 7±0.5 mo). Improvement in LVEF was defined as a postoperative increase in LVEF≥10%. CMR and clinical factors were analyzed for predictors of functional improvement. Mean age was 61±1 y with 79 males. LVEF improved from 28%±2% preoperatively, to 38%±2% postoperatively (P<0.0001). Forty-three patients improved their LVEF. Patients who improved their LVEF had a lower preoperative LVEF (P=0.0001) and higher anterior wall viability (P=0.03). Preoperative LVEF (odds ratio 0.89, 95% CI 0.83-0.95, P=0.001) and left ventricular end systolic volume index (odds ratio 0.97, 95% CI 0.95-0.99, P=0.015) were predictors of improvement in LVEF by multivariable logistic regression analysis. Recruitment of viable non functioning myocardium of the anterior wall is responsible for the improvement in ejection fraction. Low LVEF, non-remodeled left ventricle, and anterior wall viability predict improvement in ejection fraction after CABG. These criteria may help clinicians select patients who would benefit from surgical revascularization.
    Journal of Surgical Research 12/2011; 171(2):416-21. · 2.02 Impact Factor
  • Michael S Firstenberg, Juan Crestanello
    The Annals of thoracic surgery 03/2011; 91(3):988-9; author reply 989. · 3.45 Impact Factor