Harish Ramakrishna

Mayo Clinic - Scottsdale, Scottsdale, Arizona, United States

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Publications (34)28.05 Total impact

  • Journal of cardiothoracic and vascular anesthesia. 10/2014; 28(5):1414-20.
  • Efrain Israel Cubillo, Ricardo A Weis, Harish Ramakrishna
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    ABSTRACT: Recent clinical advances with new mechanical circulatory systems have led to additional strategies in the treatment of end-stage heart failure. The third-generation HeartWare Left Ventricular Device (LVAD) System utilizes a blood pump and a driveline (cable) that exits the patient's skin connecting the implanted pump to an externally worn controller. We report a rare case of a HeartWare LVAD driveline rewiring after accidental (presumed) transection of the driveline system.
    The Journal of emergency medicine. 09/2014;
  • Journal of Cardiothoracic and Vascular Anesthesia 09/2014; · 1.45 Impact Factor
  • Journal of cardiothoracic and vascular anesthesia. 06/2014; 28(3):819-25.
  • Harish Ramakrishna, Kent H Rehfeldt, Octavio E Pajaro
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    ABSTRACT: From uncertain beginnings over four decades ago, heart transplantation is now the definitive therapy for end-stage heart failure. This review will attempt to comprehensively cover the broad gamut of anesthetic, hemodynamic, antimicrobial, immunosuppressive and hemostatic agents used by the cardiothoracic anesthesiologist in the perioperative management of patients with end-stage heart disease.
    Current clinical pharmacology. 02/2014;
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    ABSTRACT: The number of patients with end stage liver disease is growing worldwide. This is likely a result of advances in medical science that have allowed these patients to lead longer lives since the incidence of diseases such as alcoholic cirrhosis and viral hepatitis have remained stable or even decreased in recent years, at least in more developed nations. Many of these patients will require anesthetic care at some point. The understanding and application of basic principles of pharmacokinetics is paramount to the practice of anesthesia. An understanding of pharmacokinetic principles provides the anesthesiologist with a scientific foundation for achieving therapeutic objectives associated with the use of any drug; however, pathologic conditions often alter the expected kinetic profile of many drugs. This is particularly true in the anesthetic management of the patient with hepatic pathology as the liver plays a central role in the absorption, distribution, and elimination kinetics of most drugs and many active and inactive drug metabolites. We review normal liver physiology, pathophysiology of liver disease in general, and how liver failure affects the pharmacokinetics and pharmacodynamics of anesthetic agents; providing some specific examples.
    Current clinical pharmacology. 02/2014;
  • Eduardo S Rodrigues, Harish Ramakrishna, Octavio E Pajaro
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    ABSTRACT: In the past two decades, lung transplantation has become an increasingly important surgical option for the patient with end stage lung disease. Compared with the other solid organ transplants (heart, liver and kidney), lung transplantation carries immense clinical and logistic challenges; long-term organ viability is particularly problematic, with an expected five-year mortality of 40-50%. The number of lung transplants performed in the U.S. has been increasing steadily since 1988, when UNOS (United Network for Organ Sharing) started recording statistical data. In that year, 33 cases of lung transplantation were performed. As of today, a total of 23,815 lung transplants have been performed, and the largest number of yearly lung transplants (n=1,822) was performed in 2009. From appropriate patient selection, to optimal organ selection, surgical procedure, and immediate and long-term postoperative care, the medical process involves multiple healthcare providers and requires a very well-organized and committed healthcare system to achieve optimal surgical results. Understanding the pharmacology involved in the care of the lung transplant patient is of utmost importance to achieve appropriate organ preservation, immunosuppression, hemodynamic stability, and adequate anesthetic depth, while avoiding drug toxicity and side effects. The purpose of this review is to summarize the pharmacokinetics and pharmacodynamics of the medications most commonly administered to this patient population, throughout the perioperative period.
    Current clinical pharmacology. 02/2014;
  • Harish Ramakrishna, Kamrouz Ghadimi, John G T Augoustides
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    ABSTRACT: Incidental moderate mitral regurgitation (MR) in patients presenting for coronary artery bypass grafting (CABG) is not only common but also probably adversely affects clinical outcome. The echocardiographic evaluation of incidental MR must be comprehensive and integrated, as it remains a cornerstone in management decisions. Current guidelines support surgical mitral intervention in this setting as a reasonable option, reflecting clinical equipoise towards moderate MR in the setting of planned CABG. There are currently 2 major randomized trials in progress that will test whether surgical correction of moderate MR combined with CABG improves major clinical outcomes as compared to CABG alone. These landmark trials will be completed in the near future. In the interim, significant progress in the fields of cardiac resynchronization therapy, transcatheter mitral valve intervention, and minimally invasive mitral valve surgery promise to affect the management alternatives for moderate MR in patients undergoing CABG regardless of operative risk. It is likely that in the coming decade there will be less tolerance for incidental moderate MR given its already known outcome effects and the multimodal interventions that continue to mature with better safety profiles.
    Journal of cardiothoracic and vascular anesthesia 02/2014; 28(1):189-93. · 1.06 Impact Factor
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    ABSTRACT: Recent evidence has shown that moderate mitral regurgitation is common and clinically relevant in patients presenting for surgical and transcatheter aortic valve replacement for aortic stenosis. Prospective multicenter clinical trials are now indicated to resolve the clinical equipoise about whether or not mitral valve intervention also is indicated at the time of aortic valve intervention. Advances in three-dimensional transesophageal echocardiography, transcatheter mitral interventions, and surgical aortic valve replacement, including the advent of sutureless valves, likely will expand the therapeutic possibilities for moderate mitral regurgitation in the setting of aortic valve interventions for severe aortic stenosis.
    Journal of cardiothoracic and vascular anesthesia 01/2014; · 1.06 Impact Factor
  • Journal of cardiothoracic and vascular anesthesia 10/2013; · 1.06 Impact Factor
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    ABSTRACT: Cardiothoracic and vascular critical care has emerged as a subspecialty due to procedural breakthroughs, an aging population, and a multidisciplinary collaboration. This subspecialty now has a dedicated professional society, recently published guidelines, and plans for standardized certification. This paradigm shift represents a major collaboration opportunity for our specialty. The rise of evidence-based perioperative practice has produced a culture of large trials in our specialty to search for solutions to the challenging outcome questions. Besides the growth in the development of evidence, the consensus conference format and postpublication peer review have both emerged as effective processes for identifying the most relevant high-quality evidence. The quest for best perioperative practice has highlighted the importance of teamwork at all phases of care with respect to transitions in care, blood component transfusion, and research misconduct. The emergence of ultrasound as a standard for central vascular access also has been emphasized in recent multisociety guidelines. There also has been a paradigm shift in the management of patients with coronary artery disease. Recent guidelines have emphasized the roles of the cardiac anesthesiologist and the interventional cardiologist as part of the heart team approach. Major recent trials in comparative effectiveness have challenged the advantages of percutaneous coronary intervention, off-pump coronary artery bypass surgery, and intra-aortic balloon counterpulsation. The year 2012 has witnessed the emergence of new paradigms of care in our specialty with the emphasis on teamwork, safety, and quality. These processes will further improve perioperative outcome.
    Journal of cardiothoracic and vascular anesthesia 02/2013; 27(1):86-91. · 1.06 Impact Factor
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    ABSTRACT: Transcatheter aortic valve replacement (TAVR) is entering its second decade. Three major clinical challenges have emerged from the first decade of experience: vascular complications, stroke, and paravalvular leak (PVL). Major vascular complications remain common and independently predict major bleeding, transfusion, renal failure, and mortality. Although women are more prone to vascular complications, overall they have better survival than men. Further predictors of major vascular complications include heavily diseased femoral arteries and operator experience. Strategies to minimize vascular complications include a multimodal approach and sleeker delivery systems. Although cerebral embolism is very common during TAVR, it mostly is asymptomatic. Major stroke independently predicts prolonged recovery and increased mortality. Identified stroke predictors include functional disability, previous stroke, a transapical approach, and atrial fibrillation. Embolic protection devices are in development to mitigate the risk of embolic stroke after TAVR. PVL is common and significantly decreases survival. Undersizing of the valve prosthesis can be minimized with 3-dimensional imaging by computed tomography or echocardiography to describe the elliptic aortic annulus accurately. The formal grading of PVL severity in TAVR is based on its percentage of the circumferential extent of the aortic valve annulus. Further emerging management strategies for PVL include a repositionable valve prosthesis and transcatheter plugging. The first decade of TAVR has ushered in a new paradigm for the multidisciplinary management of valvular heart disease. The second decade likely will build on this wave of initial success with further significant innovations.
    Journal of cardiothoracic and vascular anesthesia 11/2012; · 1.06 Impact Factor
  • Journal of cardiothoracic and vascular anesthesia 10/2012; · 1.06 Impact Factor
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    ABSTRACT: The operating room offers a unique setting where anesthetics, preoperative medications, patient comorbidities, and surgery all merge. Anesthesiologists are responsible for combining these concerns into a dependable and safe approach. From formulation to administration, enhancements in nearly every aspect of a given drug have improved the ability of anesthesiologists to accomplish this. Some of these methodologies, including novel anesthetics and analgesics, drug delivery and administration including infusion pumps, antithrombotics, and a reappraisal of previous medications are highlighted in this review. While these advancements are significant, patients and healthcare systems globally are rightfully demanding safer application of drugs at every level. On May 1, 2012, a report issued by the Institute of Medicine advised the United States Food and Drug Administration to undertake a much more rigorous patient-centered effort to evaluate a drugs safety over its entire life-cycle. This recommendation is in agreement with the objectives of the Anesthesia Patient Safety Foundation. With these mutual goals shared by many stakeholders and their continued efforts, the future of the estimated 200 million global surgeries to be undertaken this year hopefully provides a safer experience while under anesthesia.
    Current pharmaceutical design 07/2012; · 4.41 Impact Factor
  • Source
    Clint G Humpherys, Steven T Morozowich, Harish Ramakrishna
    Annals of Cardiac Anaesthesia 07/2012; 15(3):250-1.
  • Kent H Rehfeldt, Harish Ramakrishna
    Journal of cardiothoracic and vascular anesthesia 03/2012; 26(3):359-61. · 1.06 Impact Factor
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    ABSTRACT: There have been rapid advances in oral anticoagulation. The oral factor Xa inhibitors rivaroxaban and apixaban and the oral direct thrombin inhibitor dabigatran recently have been rigorously evaluated. These novel anticoagulants will usher in a new paradigm for perioperative anticoagulation. Perioperative blood conservation in cardiac surgery recently has been highlighted in the updated guidelines by the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. These recommendations reflect a comprehensive evaluation of the recent evidence to optimize transfusion practice. Transcatheter mitral valve repair continues to mature. Transcatheter aortic valve implantation for aortic stenosis has entered the clinical mainstream, with randomized trials showing its superiority over medical management and its equivalency to surgical valve replacement in high-risk patients. This transformational technology represents a major leadership opportunity for the cardiac anesthesiologist. Minimally invasive valve surgery has shown effectiveness in high-risk patients. Radial access is equivalent to femoral access for percutaneous coronary intervention in acute coronary syndromes but significantly reduces the risk of local vascular complications. Recent trials have further clarified the roles of medical therapy, percutaneous coronary intervention, and coronary artery bypass surgery in patients with significant coronary artery disease and left ventricular dysfunction. The past year has witnessed major advances in cardiovascular practice with new drugs, new devices, and new guidelines. The coming year most likely will advance these achievements to enhance the care of patients.
    Journal of cardiothoracic and vascular anesthesia 02/2012; 26(1):3-10. · 1.06 Impact Factor
  • Erica Stein, Harish Ramakrishna, John G T Augoustides
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    ABSTRACT: Surgical excellence in pulmonary thromboendarterectomy (PTE) for chronic thromboembolic pulmonary hypertension (CTEPH) has begun to spread around the world. The perioperative mortality for this procedure is typically under 10%. The maximal benefit from PTE is derived in those patients who have a high proximal clot burden that is surgically accessible, as outlined by the Jamieson classification. Residual pulmonary hypertension after successful PTE is common and increasingly is managed with maintenance oral pulmonary vasodilator therapy such as endothelin antagonists, phosphodiesterase inhibitors, and/or prostaglandins. The role of pulmonary vasodilator therapy in CTEPH before PTE is limited and should not delay definitive surgical therapy. Although plain deep hypothermic circulatory arrest (DHCA) is the classic technique for CTEPH, alternatives such as DHCA with antegrade cerebral perfusion are feasible as well. Prolonged mechanical ventilation after PTE remains common in part because of reperfusion pulmonary edema. Careful perioperative management can reduce the incidence of this syndrome. Because ventilator-associated pneumonia is also a common complication after PTE, it represents a major opportunity for outcome improvement, particularly because there are multiple modalities for its prevention and prompt diagnosis.
    Journal of cardiothoracic and vascular anesthesia 05/2011; 25(4):744-8. · 1.06 Impact Factor
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    ABSTRACT: The aortic valve treatment revolution continues with the maturation of aortic valve repair and the dissemination of transcatheter aortic valve implantation. The recent publication of comprehensive multidisciplinary guidelines for diseases of the thoracic aorta has assigned important roles for the cardiovascular anesthesiologist and perioperative echocardiographer. Although intense angiotensin blockade improves outcomes in heart failure, it might further complicate the maintenance of perioperative systemic vascular tone. Ultrafiltration as well as intensive medical management guided by the biomarker brain natriuretic peptide improves outcomes in heart failure. Continuous-flow left ventricular assist devices have further improved outcomes in the surgical management of heart failure. Major risk factors for bleeding in the setting of these devices include advanced liver disease and acquired von Willebrand syndrome. The metabolic modulator perhexiline improves myocardial diastolic energetics to achieve significant symptomatic improvement in hypertrophic cardiomyopathy. A landmark report was also published recently that outlines the major areas for future research and clinical innovation in this disease. Landmark trials have documented the outcome importance of perioperative cerebral oxygen saturation monitoring as well as the outcome advantages of the Sano shunt over the modified Blalock-Taussig shunt in the Norwood procedure. Furthermore, the development and evaluation of pediatric-specific ventricular assist devices likely will revolutionize the mechanical management of pediatric heart failure. A multidisciplinary review has highlighted the priorities for future perioperative trials in congenital heart disease. These pervasive developments likely will influence the future training models in pediatric cardiac anesthesia.
    Journal of cardiothoracic and vascular anesthesia 02/2011; 25(1):6-15. · 1.06 Impact Factor
  • Harish Ramakrishna, Octavio E Pajaro
    Annals of Cardiac Anaesthesia 01/2011; 14(3):174-5.

Publication Stats

59 Citations
28.05 Total Impact Points


  • 2010–2014
    • Mayo Clinic - Scottsdale
      Scottsdale, Arizona, United States
  • 2012
    • University of Pennsylvania
      • Department of Anesthesiology and Critical Care
      Philadelphia, PA, United States
    • University of Wisconsin, Madison
      • Department of Anesthesiology
      Madison, MS, United States
  • 2008–2012
    • Mayo Foundation for Medical Education and Research
      • Department of Anesthesiology
      Scottsdale, AZ, United States
  • 2011
    • The Ohio State University
      • Department of Oral & Maxillofacial Surgery
      Columbus, OH, United States
  • 2009
    • Hospital of the University of Pennsylvania
      • Division of Cardiothoracic Surgery
      Philadelphia, Pennsylvania, United States