S E Fremes

University of Toronto, Toronto, Ontario, Canada

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Publications (178)974.62 Total impact

  • European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 04/2014; · 2.40 Impact Factor
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    ABSTRACT: Background There is increasing demand for transcatheter aortic valve replacement (TAVR) as the primary treatment option for patients with severe aortic stenosis (AS) who are high risk surgical candidates or inoperable. We used mathematical simulation models to estimate the hypothetical effectiveness of TAVR with increasing wait-times. Methods We applied discrete event modelling, using data from the Placement of Aortic Transcatheter Valves (PARTNER) trials. We compared TAVR to medical therapy in the inoperable cohort, and compared TAVR to conventional aortic valve surgery in the high risk cohort. One-year mortality and wait-time deaths were calculated in different scenarios by varying TAVR wait-times from 10 days to 180 days, while maintaining a constant wait-time for surgery at a mean of 15.6 days Results In the inoperable cohort, the 1-year mortality for medical therapy was 50%. When the TAVR wait-time was 10 days, the TAVR wait-time mortality was 1.9% with a 1 year mortality of 31.5%. TAVR wait-time deaths increased to 28.9% with a 180-day wait, with a 1-year mortality of 41.4%. In the high risk cohort, the wait-time deaths and 1-year mortality for the surgical patients were 2.5% and 27% respectively. The TAVR wait-time deaths increased from 2.2% with a 10-day wait to 22.4% with a 180-day wait, and a corresponding increase in 1-year mortality from 24.5% to 32.6%. Mortality with TAVR exceeded surgery when TAVR wait-times exceeded 60 days. Conclusion Modest increases in TAVR wait-times have substantial impact on the effectiveness of TAVR in both inoperable patients and high risk surgical candidates.
    The Canadian journal of cardiology 01/2014; · 3.12 Impact Factor
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    ABSTRACT: Neointimal hyperplasia secondary to vascular smooth muscle cell (VSMC) activation limits the long-term patency of saphenous vein grafts (SVGs). We compared markers of vascular injury and VSMC activation in SVGs harvested using the pedicled 'no-touch' (NT) vs the conventional (CON) technique. Patients undergoing coronary artery bypass surgery were enrolled in the PATENT SVG trial (clinicaltrials.gov NCT01488084). Patients were randomly allocated to have SVGs harvested with the NT technique from one leg and the CON method from the other. SVG segments underwent morphometry, histological and electron microscopy assessments and transcript measurements of VSMC activation and differentiation markers. Leg wound functional recovery and harvest site complications were assessed using a quality-of-life questionnaire. A total of 17 patients (65.3 ± 7.3 years) were enrolled. SVGs harvested using the NT vs CON technique exhibited preserved intimal, medial and adventitial architecture. CON harvest was associated with greater medial Kruppel-like factor 4 transcript levels (0.26 ± 0.05 vs 0.11 ± 0.02, P < 0.05). CON samples had significantly lower medial serum response factor (0.53 ± 0.11 vs 1.44 ± 0.50, P < 0.05) and myocardin (0.59 ± 0.08 vs 1.33 ± 0.33, P < 0.05) transcript levels. MicroRNA-145, an inhibitor of VSMC activation and differentiation, was higher in the NT vs CON samples (1.84 ± 1.03 vs 0.50 ± 0.19, P < 0.05). Leg assessment scores were worse in the NT legs at 3 months, but similar to CON scores at 12 months. SVGs harvested using the 'NT' technique exhibit an early molecular and morphological pattern consistent with decreased VSMC activation compared with CON harvesting. Functional leg recovery was similar in both groups at 12 months. Larger studies are required to corroborate these findings.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 12/2013; · 2.40 Impact Factor
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    ABSTRACT: To identify novel predictors for coronary artery bypass grafting failure, we probed for associations with known clinical and biochemical risk factors for atherosclerosis. We also used microarray analysis to identify novel single nucleotide polymorphisms to better understand the genetics and pathogenesis of graft occlusion. The present study was a nested case-control substudy of the Radial Artery Patency Study 5-year follow-up data. From 1996 to 2001, 87 patients underwent coronary artery bypass grafting. Of these, 26 patients (29.9%) had an occluded study graft (saphenous vein or radial artery) at 8.0 ± 1.1 years. The clinical parameters, late angiography, blood biomarker levels, and surgical outcomes data were included in a multivariate analysis to determine the independent predictors of graft failure. The risk factors of graft failure were fibrinogen (odds ratio [OR], 3.94; 95% confidence interval [CI], 1.33-11.63; P = .01), creatinine (OR, 1.06; 95% CI, 1.02-1.10; P = .006), and diabetes mellitus (OR, 5.15; 95% CI, 1.08-24.59; P = .04). High-density lipoprotein (OR, 0.74; 95% CI, 0.53-1.02; P = .06) was weakly protective; however, low-density lipoprotein and total cholesterol were not predictors. We then identified the association of several human single nucleotide polymorphisms with graft failure, including mutations in glutathione-S-transferase α3. Human coronary arteries and bypass grafts demonstrated increased protein expression of glutathione-S-transferase α3, a known cardioprotective factor, in the atherosclerotic regions and surrounding adventitial tissues. We identified diabetes as a potential clinical predictor and plasma fibrinogen, creatinine, and high-density lipoprotein as potential novel biomarkers. These might help risk stratify patients for the development of graft failure. We also demonstrated a novel association between glutathione-S-transferase α3 and graft failure.
    The Journal of thoracic and cardiovascular surgery 12/2013; · 3.41 Impact Factor
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    ABSTRACT: IMPORTANCE Ischemic heart disease is the leading cause of death globally. Coronary artery bypass graft (CABG) surgery and percutaneous coronary intervention (PCI) are the revascularization options for ischemic heart disease. However, the choice of the most appropriate revascularization modality is controversial in some patient subgroups. OBJECTIVE To summarize the current evidence comparing the effectiveness of CABG surgery and PCI in patients with unprotected left main disease (ULMD, in which there is >50% left main coronary stenosis without protective bypass grafts), multivessel coronary artery disease (CAD), diabetes, or left ventricular dysfunction (LVD). EVIDENCE REVIEW A search of OvidSP MEDLINE, EMBASE, and Cochrane databases between January 2007 and June 2013, limited to randomized clinical trials (RCTs) and meta-analysis of trials and/or observational studies comparing CABG surgery with PCI was performed. Bibliographies of relevant studies were also searched. Mortality and major adverse cardiac and cerebrovascular events (MACCE, defined as all-cause mortality, myocardial infarction, stroke, and repeat revascularization) were reported wherever possible. FINDINGS Thirteen RCTs and 5 meta-analyses were included. CABG surgery should be recommended in patients with ULMD, multivessel CAD, or LVD, if the severity of coronary disease is deemed to be complex (SYNTAX >22) due to lower cardiac events associated with CABG surgery. In cases in which coronary disease is less complex (SYNTAX ≤22) and/or the patient is a higher surgical risk, PCI should be considered. For patients with diabetes and multivessel CAD, CABG surgery should be recommended as standard therapy irrespective of the severity of coronary anatomy, given improved long-term survival and lower cardiac events (5-year MACCE, 18.7% for CABG surgery vs 26.6% for PCI; P = .005). Overall, the incidence of repeat revascularization is higher after PCI, whereas stroke is higher after CABG surgery. Current literature emphasizes the importance of a heart-team approach that should consider coronary anatomy, patient characteristics, and local expertise in revascularization options. Literature pertaining to revascularization options in LVD is scarce predominantly due to LVD being an exclusion factor in most studies. CONCLUSIONS AND RELEVANCE Both CABG surgery and PCI are reasonable options for patients with advanced CAD. Patients with diabetes generally have better outcomes with CABG surgery than PCI. In cases of ULMD, multivessel CAD, or LVD, CABG surgery should be favored in patients with complex coronary lesions and anatomy and PCI in less complicated coronary disease or deemed a high surgical risk. A heart-team approach should evaluate coronary disease complexity, patient comorbidities, patient preferences, and local expertise.
    JAMA The Journal of the American Medical Association 11/2013; 310(19):2086-95. · 29.98 Impact Factor
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    ABSTRACT: Occlusion of the left atrial appendage (LAA) is a potential alternative to anticoagulation for patients with atrial fibrillation (AF); however, evidence of its safety and efficacy is lacking. The Left Atrial Appendage Occlusion Study II (LAAOS II) explored the feasibility of a definitive trial of LAA occlusion for stroke prevention in AF. A cross-sectional study of 1889 consecutive patients undergoing cardiac surgery was performed to determine the prevalence of AF and risk factors for stroke. We also randomized 51 patients with AF and increased stroke risk to LAA occlusion (n = 26) or no occlusion and oral anticoagulation (n = 25) to assess the rate of recruitment and the safety of LAA amputation. In the cross-sectional study, 204 patients (10.8%) had AF and 98 (5.2%) met trial eligibility. Fifty-one patients were recruited into the trial at a rate of 1.6 patients per centre per month. No patient with occlusion had significant bleeding at the LAA site. At 1 year, 4 patients (15.4%) in the occlusion arm and 5 patients (20.0%) in the no-occlusion arm experienced death, myocardial infarction (MI), stroke, noncerebral systemic emboli, or major bleeding (relative risk [RR], 0.71; 95% confidence interval [CI], 0.19-2.66; P = 0.61). The predominant component of the composite was stroke, with 1 in the occlusion arm and 3 in the no-occlusion arm. LAA occlusion can be safely performed at the time of cardiac surgery. A large trial to evaluate the clinical efficacy of LAA occlusion in patients undergoing cardiac surgery is possible in motivated centres with some modifications to the design of LAAOS II.
    The Canadian journal of cardiology 09/2013; · 3.12 Impact Factor
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    ABSTRACT: Transcatheter aortic valve implantation with the self-expandable CoreValve (CV) and the balloon-expandable Edwards SAPIEN (ES) bioprostheses has been widely used for the treatment of severe aortic stenosis. However, a direct comparison of the hemodynamic results associated with these 2 prostheses is lacking. The aim of the present study was to compare the hemodynamic performance of both bioprostheses. A total of 41 patients who underwent transcatheter aortic valve implantation with the CV prosthesis were matched 1:1 for prosthesis size (26 mm), aortic annulus size, left ventricular ejection fraction, body surface area, and body mass index with patients who underwent transcatheter aortic valve implantation with the ES prosthesis. Doppler-echocardiographic data were prospectively collected before the intervention and at hospital discharge, and all examinations were sent to, and analyzed in, a central echocardiography core laboratory. The mean transprosthetic residual gradient was lower (p = 0.024) in the CV group (7.9 ± 3.1 mm Hg) than in the ES group (9.7 ± 3.8 mm Hg). The effective orifice area tended to be greater in the CV group (1.58 ± 0.31 cm(2) vs 1.49 ± 0.24 cm(2), p = 0.10). The incidence of severe prosthesis-patient mismatch was, however, similar between the 2 groups (effective orifice area indexed to the body surface area ≤0.65 cm(2)/m(2); CV 9.8%, ES 9.8%, p = 1.0). The incidence of paravalvular aortic regurgitation was greater with the CV (grade 1 or more in 85.4%, grade 2 or more in 39%) than with the ES (grade 1 or more in 58.5%, grade 2 or more in 22%; p = 0.001). The number and extent of paravalvular leaks were greater in the CV group (p <0.01 for both comparisons). In conclusion, transcatheter aortic valve implantation with the CV prosthesis was associated with a lower residual gradient but a greater rate of paravalvular aortic regurgitation compared to the ES prosthesis. The potential clinical consequences of the differences in hemodynamic performance between these transcatheter heart valves needs to be addressed in future studies.
    The American journal of cardiology 01/2013; · 3.58 Impact Factor
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    The American Journal of Cardiology 01/2013; · 3.21 Impact Factor
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    ABSTRACT: Transcatheter aortic valve implantation (TAVI) has emerged as an important treatment for patients with severe symptomatic aortic stenosis who are at high operative risk, but accurate estimates of serious adverse effects in contemporary practice are not available. To quantify the adverse effects associated with TAVI, and to evaluate whether the type of transcatheter valve and the route of valve implantation are associated with differences in adverse outcomes. PubMed to 5 May 2012. All studies that included at least 100 patients who had TAVI and reported at least 1 outcome of interest. Two reviewers abstracted the data independently. A random-effects model was used to combine data on adverse outcomes and conduct stratified analyses. A total of 49 studies enrolling 16 063 patients met the inclusion criteria. Overall 30-day and 1-year survival after TAVI were 91.9% (95% CI, 91.1% to 92.8%) and 79.2% (CI, 76.9% to 81.4%), respectively. Heart block requiring permanent pacemaker implantation was the most common adverse outcome (13.1%) and was 5 times more common with the CoreValve (Medtronic, Minneapolis, Minnesota) than the Sapien valve (Edwards Lifesciences, Irving, California) implanted using the transarterial route (25.2% vs. 5.0%, respectively). The overall rate of vascular complications was 10.4% and was highest with transarterial implantation of the Sapien valve (22.3%). Acute renal failure requiring renal replacement therapy was the third most common complication, occurring in 4.9% of patients. Rates of major vascular complications may be overestimated owing to rapidly evolving TAVI technology. The most common adverse effects associated with TAVI are heart block, vascular complications, and renal failure. The type of transcatheter valve and the route of implantation are associated with observed variations in the risks for some adverse effects. Heart and Stroke Foundation of Canada.
    Annals of internal medicine 01/2013; 158(1):35-46. · 13.98 Impact Factor
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    ABSTRACT: BACKGROUND: Graft Imaging to Improve Patency (GRIIP), a single-center, randomized blinded clinical trial, reported that intraoperative graft assessment with graft revision according to a priori criteria of transit time flowmetry (TTF) and intraoperative fluorescent angiography did not improve graft patency at one year after coronary artery bypass grafting (CABG) when compared with standard intraoperative management. The objective of this study is to investigate whether other TTF values are more predictive of the saphenous vein graft (SVG) failure and/or clinical outcomes. METHODS: This is a case control retrospective study of 65 SVGs from 44 patients from GRIIP. Study outcomes were graft patency at 12 months and major adverse cardiac events (MACE; death, myocardial infarction, repeat revascularization). RESULTS: Twenty-two SVGs were occluded. In receiver operating characteristic curve analysis, TTF mean flow was significantly predictive of one-year SVG failure (area under the curve = 0.698, p < 0.01), and 31 mL/min was the best cut-off value (p = 0.017, sensitivity 63.6%, specificity 67.4%). The risk of graft occlusion was 14/28, 50% for grafts with mean flow <31 mL/min and 8/37, 21.6% for grafts with mean flow ≥31 mL/min. In logistic regression models, mean flow was a significant predictor of early SVG failure (Odds Ratio 0.95 [0.91-0.99] per mL/min, p = 0.014) whereas other TTF values, patient comorbidities, and/or medication at discharge were not. However, TTF values were not predictive of MACE. CONCLUSIONS: TTF can identify non-functional grafts during CABG, but is of questionable value to improve one-year graft patency.
    Journal of Cardiac Surgery 11/2012; · 1.35 Impact Factor
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    ABSTRACT: The purpose of this study was to present radial and saphenous vein graft (SVG) occlusion results more than 5 years following coronary artery bypass surgery. In the RAPS (Radial Artery Patency Study) study, complete graft occlusion was less frequent in radial artery compared with SVG 1 year post-operatively while functional occlusion (Thrombolysis In Myocardial Infarction flow grade 0, 1, 2) was similar. A total of 510 patients <80 years of age undergoing primary isolated nonemergent coronary artery bypass grafting with 3-vessel disease were initially enrolled in 9 Canadian centers. Target vessels for the radial artery and study SVG were the right and circumflex coronary arteries, which had >70% proximal stenosis. Within-patient randomization was performed; the radial artery was randomized to either the right or circumflex territory and the study SVG was used for the other territory. The primary endpoint was functional graft occlusion by invasive angiography at least 5 years following surgery. Complete graft occlusion by invasive angiography or computed tomography angiography was a secondary endpoint. A total of 269 patients underwent late angiography (234 invasive angiography, 35 computed tomography angiography) at a mean of 7.7 ± 1.5 years after surgery. The frequency of functional graft occlusion was lower in radial arteries compared with SVGs (28 of 234 [12.0%] vs. 46 of 234 [19.7%]; p = 0.03 by McNemar's test). The frequency of complete graft occlusion was also significantly lower in radial compared with SVGs (24 of 269 [8.9%] vs. 50 of 269 [18.6%]; p = 0.002). Radial arteries are associated with reduced rates of functional and complete graft occlusion compared with SVGs more than 5 years following surgery. (Multicentre Radial Artery Patency Study: 5 Year Results; NCT00187356).
    Journal of the American College of Cardiology 07/2012; 60(1):28-35. · 14.09 Impact Factor
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    ABSTRACT: Patients with severe symptomatic aortic stenosis have a poor prognosis with medical management alone, and balloon aortic valvuloplasty has failed to provide durable clinical benefit. Open surgical replacement of the aortic valve can improve symptoms and survival. Recently, transcatheter aortic valve implantation (TAVI) has been demonstrated to improve survival, quality of life, and functional status in nonoperable patients and to be a viable option for patients in whom the risk of open surgical morbidity or mortality is high. This Canadian Cardiovascular Society position statement represents the consensus of a representative group of cardiologists and cardiac surgeons as to the current, but evolving, role of this less-invasive new therapy. Specific recommendations are provided for selection of patients for TAVI vs surgical aortic valve replacement for native valves and for bioprostheses, approaches to patient evaluation for TAVI, appropriate constitution of multidisciplinary teams involved in performing TAVI, essential facilities that are needed to perform TAVI safely and effectively, and training/qualifications for TAVI operators. Cost considerations, complication rates, and the quality of the available evidence are also discussed. It is hoped that this consensus document will prove to be a useful resource for health professionals, institutions, departments, and decision-making bodies dealing with this important and rapidly evolving therapy.
    The Canadian journal of cardiology 06/2012; 28(5):520-8. · 3.12 Impact Factor
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    ABSTRACT: Antithrombotic therapy in valvular disease is important to mitigate thromboembolism, but the hemorrhagic risk imposed must be considered. The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. In rheumatic mitral disease, we recommend vitamin K antagonist (VKA) therapy when the left atrial diameter is > 55 mm (Grade 2C) or when complicated by left atrial thrombus (Grade 1A). In candidates for percutaneous mitral valvotomy with left atrial thrombus, we recommend VKA therapy until thrombus resolution, and we recommend abandoning valvotomy if the thrombus fails to resolve (Grade 1A). In patients with patent foramen ovale (PFO) and stroke or transient ischemic attack, we recommend initial aspirin therapy (Grade 1B) and suggest substitution of VKA if recurrence (Grade 2C). In patients with cryptogenic stroke and DVT and a PFO, we recommend VKA therapy for 3 months (Grade 1B) and consideration of PFO closure (Grade 2C). We recommend against the use of anticoagulant (Grade 1C) and antiplatelet therapy (Grade 1B) for native valve endocarditis. We suggest holding VKA therapy until the patient is stabilized without neurologic complications for infective endocarditis of a prosthetic valve (Grade 2C). In the first 3 months after bioprosthetic valve implantation, we recommend aspirin for aortic valves (Grade 2C), the addition of clopidogrel to aspirin if the aortic valve is transcatheter (Grade 2C), and VKA therapy with a target international normalized ratio (INR) of 2.5 for mitral valves (Grade 2C). After 3 months, we suggest aspirin therapy (Grade 2C). We recommend early bridging of mechanical valve patients to VKA therapy with unfractionated heparin (DVT dosing) or low-molecular-weight heparin (Grade 2C). We recommend long-term VKA therapy for all mechanical valves (Grade 1B): target INR 2.5 for aortic (Grade 1B) and 3.0 for mitral or double valve (Grade 2C). In patients with mechanical valves at low bleeding risk, we suggest the addition of low-dose aspirin (50-100 mg/d) (Grade 1B). In valve repair patients, we suggest aspirin therapy (Grade 2C). In patients with thrombosed prosthetic valve, we recommend fibrinolysis for right-sided valves and left-sided valves with thrombus area < 0.8 cm(2) (Grade 2C). For patients with left-sided prosthetic valve thrombosis and thrombus area ≥ 0.8 cm(2), we recommend early surgery (Grade 2C). These antithrombotic guidelines provide recommendations based on the optimal balance of thrombotic and hemorrhagic risk.
    Chest 02/2012; 141(2 Suppl):e576S-600S. · 5.85 Impact Factor
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    ABSTRACT: The purpose of this study was to evaluate the long-term safety and effectiveness of drug-eluting stents (DES) for the treatment of saphenous vein graft (SVG) disease. DES are frequently implanted for SVG interventions, but some studies have shown that they are not effective in reducing target vessel revascularization (TVR) over longer-term follow-up. Some studies suggest there is increased mortality with DES compared with bare-metal stents (BMS). We performed propensity score matching analysis using a population-based cohort that included 709 well-matched pairs (n = 1,418) who received DES or BMS for the treatment of SVG disease from 2003 to 2008. Outcomes of interest included repeat TVR, myocardial infarction, and death. The mean age of the propensity-matched cohort was 69 years, 50% had diabetes, and the mean age of SVG was 10.6 years. At 4-year follow-up, the rate of repeat TVR was 21% in the DES group and 27.6% in the BMS group (p = 0.004). DES implantation was associated with the largest TVR reduction among patients with diabetes and patients receiving longer stents (≥30 mm) and the number of procedures needed to prevent a TVR at 4 years was 8 and 7, respectively. The composite rate of myocardial infarction or death was not significantly different between DES and BMS at 4 years (27.8% vs. 32.6%, p = 0.09). Implantation of DES in the treatment of SVG disease is associated with substantial reduction of repeat revascularization, without evidence of an increased risk of myocardial infarction or death at longer-term follow-up.
    JACC Cardiovascular Interventions 09/2011; 4(9):965-73. · 6.55 Impact Factor
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    ABSTRACT: Although unfractionated heparin (UFH) is used routinely after heart valve surgery at many institutions, cardiovascular surgery patients have a particularly high risk for developing heparin-induced thrombocytopenia (HIT). The aim of this study was to compare the efficacy and safety of low-molecular-weight heparin (LMWH) or UFH after heart valve surgery by conducting a retrospective evaluation of consecutive cardiovascular surgery patients in whom the LMWH dalteparin (n = 100) was used as the postoperative anticoagulant. This group was compared to an earlier group of patients who received UFH (n = 103). The main outcomes included the efficacy of the anticoagulant regimens (determined by the incidence of valve thrombosis, arterial thromboembolic events, and venous thromboembolic events) and the safety (determined by major bleeding, HIT, thrombotic events in HIT-positive cases, and death). Overall, there were for fewer thrombotic events in the LMWH-treated group (4% vs 11%, p = 0.11). There was a higher rate of bleeding events in the UFH-treated group (10% vs 3%, p = 0.08). Six patients in the UFH-treated group developed HIT, 4 of whom had thrombotic events (HIT with thrombosis). In the LMWH-treated group, 3 patients developed HIT, 1 of whom had HIT with thrombosis. In conclusion, in this study, an LMWH regimen after heart valve surgery was effective and safe, with fewer thrombotic, bleeding, HIT, and HIT with thrombosis events.
    The American journal of cardiology 02/2011; 107(4):591-4. · 3.58 Impact Factor
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    ABSTRACT: The internal thoracic artery (ITA) has been universally accepted as a superior conduit for patients undergoing coronary artery bypass operations. The harvesting of the ITA is a routine procedure. Rarely, one encounters an ITA densely adherent to the overlying periosteum. We describe a technique of safely harvesting such an ITA using an orthopedic chisel. It is harvested along with a thin bone-flap and periosteum, giving a patent and uninjured ITA.
    The Annals of thoracic surgery 08/2010; 90(2):681-2. · 3.74 Impact Factor
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    ABSTRACT: Patients who received clopidogrel prior to coronary bypass surgery are at increased risk for bleeding that must be balanced with risk of ongoing ischemia if coronary artery bypass grafting is delayed. This study aimed to evaluate the impact of clopidogrel on mortality and major bleeding in patients undergoing urgent coronary bypass surgery. We reviewed 451 consecutive patients who underwent urgent isolated coronary bypass surgery; 262 had not received clopidogrel, whereas 189 received clopidogrel < or = 5 days preoperative. The primary endpoint was in-hospital death, massive transfusion or massive blood loss. Patient characteristics were almost similar between groups. There was no difference in in-hospital death or massive bleeding indices between groups (clopidogrel: 7% vs. no clopidogrel: 6%, P = 0.9). No difference was observed even after adjusting for the date of stopping clopidogrel preoperatively. Multivariate regression analysis showed that clopidogrel or the duration it was stopped preoperatively, did not predict adverse outcomes. Significant independent predictors included preoperative renal dysfunction, hemoglobin level and peripheral vascular disease. clopidogrel, or the time it was stopped prior to surgery, was not a risk factor for in-hospital death, massive bleeding, or other poor early outcomes in patients undergoing urgent coronary artery bypass surgery.
    Interactive Cardiovascular and Thoracic Surgery 05/2010; 10(5):732-6. · 1.11 Impact Factor
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    ABSTRACT: The benefit of stentless valves remains in question. In 1999, a randomized trial comparing stentless and stented valves was unable to demonstrate any hemodynamic or clinical benefits at 1 year after implantation. This study reviews long-term outcomes of patients randomized in the aforementioned trial. Between 1996 and 1999, 99 patients undergoing aortic valve replacement were randomized to receive either a stented Carpentier-Edwards pericardial valve (CE) (Edwards Lifesciences, Irvine, Calif) or a Toronto Stentless Porcine Valve (SPV) (St Jude Medical, Minneapolis, Minn). Among these, 38 patients were available for late echocardiographic follow-up (CE, n = 17; SPV, n = 21). Echocardiographic analysis was undertaken both at rest and with dobutamine stress, and functional status (Duke Activity Status Index) was compared at a mean of 9.3 years postoperatively (range, 7.5-11.1 years). Clinical follow-up was 82% complete at a mean of 10.3 years postoperatively (range, 7.5-12.2 years). Preoperative characteristics were similar between groups. Effective orifice areas increased in both groups over time. Although there were no differences in effective orifice areas at 1 year, at 9 years, effective orifice areas were significantly greater in the SPV group (CE, 1.49 +/- 0.59 cm(2); SPV, 2.00 +/- 0.53 cm(2); P = .011). Similarly, mean and peak gradients decreased in both groups over time; however, at 9 years, gradients were lower in the SPV group (mean: CE, 10.8 +/- 3.8 mm Hg; SPV, 7.8 +/- 4.8 mm Hg; P = .011; peak: CE, 20.4 +/- 6.5 mm Hg; SPV, 14.6 +/- 7.1 mm Hg; P = .022). Such differences were magnified with dobutamine stress (mean: CE, 22.7 +/- 6.1 mm Hg; SPV, 15.3 +/- 8.4 mm Hg; P = .008; peak: CE, 48.1 +/- 11.8 mm Hg; SPV, 30.8 +/- 17.7 mm Hg; P = .001). Ventricular mass regression occurred in both groups; however, no differences were demonstrated between groups either on echocardiographic, magnetic resonance imaging, or biochemical (plasma B-type [brain] natriuretic peptide) assessment (P = .74). Similarly, Duke Activity Status Index scores of functional status improved in both groups over time; however, no differences were noted between groups (CE, 27.5 +/- 19.1; SPV, 19.9 +/- 12.0; P = .69). Freedom from reoperation at 12 years was 92% +/- 5% in patients with CEs and 75% +/- 5% in patients with SPVs (P = .65). Freedom from valve-related morbidity at 12 years was 82% +/- 7% in patients with CEs and 55% +/- 7% in patients with SPVs (P = .05). Finally, 12-year actuarial survival was 35% +/- 7% in patients with CEs and 52% +/- 7% in patients with SPVs (P = .37). Although offering improved hemodynamic outcomes, the SPV did not afford superior mass regression or improved clinical outcomes up to 12 years after implantation.
    The Journal of thoracic and cardiovascular surgery 04/2010; 139(4):848-59. · 3.41 Impact Factor
  • The Journal of thoracic and cardiovascular surgery 01/2010; 139(1):239-41; author reply 241. · 3.41 Impact Factor
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    ABSTRACT: This trial aimed to determine whether intraoperative graft assessment with criteria for graft revision would decrease the proportion of patients with 1 or more graft occlusions or stenoses or major adverse cardiac events 1 year after coronary artery bypass grafting. A single-center, randomized, single-blinded, controlled clinical trial was designed. Patients were randomized to either of 2 groups: intraoperative graft patency assessment using indocyanine-green fluorescent angiography and transit-time flowmetry, with graft revision according to a priori criteria (imaging group), or standard intraoperative management (control group). Patients underwent follow-up angiography at 1 year. Between September 2005 and August 2008, 156 patients undergoing isolated coronary bypass grafting were enrolled (imaging, n = 78; control, n = 78). Demographic and angiographic characteristics were similar between groups. Operative, crossclamp, and cardiopulmonary bypass times were all nonsignificantly longer in the imaging arm. The number of grafts per patients was similar (imaging, 3.0 +/- 0.7; control, 3.0 +/- 0.7). The frequency of major adverse cardiac events (death, myocardial infarction, repeat revascularization) was not different between groups at 1 year postoperatively (imaging, 7.7%; control, 7.7%). One-year angiography was performed in 107 patients (imaging, 55 patients/160 grafts; control, 52 patients/152 grafts). The proportion of patients with 1 graft occlusion or more was comparable in the imaging (30.9%) and control (28.9%) groups (relative risk [95% confidence interval], 1.1 [0.6-1.9]; P = .82), as were other graft patency end points. The incidence of saphenous vein graft occlusion was high in both groups. Routine intraoperative graft assessment is safe but does not lead to a marked reduction in graft occlusion 1-year after bypass grafting. The incidence of saphenous vein graft failure remains high despite contemporary practice and routine intraoperative graft surveillance.
    The Journal of thoracic and cardiovascular surgery 12/2009; 139(2):294-301, 301.e1. · 3.41 Impact Factor

Publication Stats

3k Citations
974.62 Total Impact Points

Institutions

  • 1984–2014
    • University of Toronto
      • • Division of Cardiac Surgery
      • • Institute for Clinical Evaluative Sciences
      • • Sunnybrook Health Sciences Centre
      • • Department of Surgery
      Toronto, Ontario, Canada
  • 1993–2011
    • Sunnybrook Health Sciences Centre
      • Division of Cardiology
      Toronto, Ontario, Canada
  • 2004–2008
    • Institute for Clinical Evaluative Sciences
      Toronto, Ontario, Canada
  • 2006
    • Women's College Hospital
      Toronto, Ontario, Canada
  • 2001–2004
    • UHN: Toronto General Hospital
      Toronto, Ontario, Canada
  • 2003
    • The Toronto Centre for Phenogenomics
      Toronto, Ontario, Canada
  • 2000
    • St. Paul's Hospital
      Saskatoon, Saskatchewan, Canada
  • 1996
    • University of British Columbia - Vancouver
      • Department of Surgery
      Vancouver, British Columbia, Canada
  • 1991
    • St. Michael's Hospital
      Toronto, Ontario, Canada
  • 1990
    • Toronto Western Hospital
      Toronto, Ontario, Canada