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Mark J Russo,
David I Sternberg, Kimberly N Hong,
Robert A Sorabella,
Alan J Moskowitz,
Annetine C Gelijns,
Jessie R Wilt,
Frank D'Ovidio,
Steve M Kawut,
Selim M Arcasoy,
Joshua R Sonett
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ABSTRACT: The purpose of this study was to assess (1) the relationship between donor-recipient cytomegalovirus (CMV) serologic status and posttransplant survival in the current era and (2) temporal changes in posttransplant survival by CMV matching status.
De-identified data were obtained from the United Network for Organ Sharing. Based on pretransplant CMV serologic status (+ or -) of recipients (R) and donors (D), posttransplant survival was compared among three groups: D+ /R-, D+/- /R+, and D- /R-. Primary analysis focused on transplants performed January 1, 2000 to December 31, 2004, in recipients 18 years of age or older. To assess temporal trends in survival among groups, all lung transplants occurring between January 1, 1990, and December 31, 2004, were considered and divided into three periods based on transplant year: 1990 through 1994, 1995 through 1999, and 2000 through 2004. The primary outcome measure was survival, reported as rate of death per 100 patient-years. Kaplan-Meier analysis with log-rank test was used for time-to-event analysis.
During the current era (2000 through 2004), D+ /R- (n = 951), D+/- /R+ (n = 2,676), and D- /R- (n = 772) exhibited no differences in survival (p = 0.561), with rates of death per 100 patient-years of 16.6 (95% confidence interval, 14.9 to 18.5), 15.0 (95% confidence interval, 14.0 to 16.0), and 14.7 (95% confidence interval, 13.0 to 16.6), respectively. However, survival was significantly different for groups in the earlier eras of 1990 through 1994 (p < 0.001) and 1995 through 1999 (p < 0.001). During the three periods, survival improved significantly in D+ /R- (p < 0.001) and D+/- /R+ (p < 0.001), but survival in D- /R- (p = 0.351) did not change significantly with time.
In the current era, survival after lung transplantation is statistically equivalent regardless of CMV match status. Although in previous eras survival was worse among the D+/- /R+ and D+ /R- groups, in this era of aggressive CMV prophylaxis, CMV mismatch should not be sufficient grounds to decline a lung allograft offer.
The Annals of thoracic surgery 10/2007; 84(4):1129-34; discussion 1134-5. · 3.74 Impact Factor
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ABSTRACT: Minimally invasive cardiac surgical procedures have become ubiquitous over the past decade. In many cases, these techniques have been associated with decreased morbidity, shorter length of stay, decreased pain, faster recovery, and superior cosmetic results. The purpose of this study was to compare outcomes using a minimally invasive (mini-thoracotomy) versus standard (sternotomy) approach to the surgical resection of atrial masses.
Analysis was based on 34 consecutive patients who underwent atrial mass resection at the New York-Presbyterian Hospital/Columbia Presbyterian Medical Center in New York, NY. The reference (REF) group included 18 patients who underwent excision of an atrial mass via a standard approach (sternotomy). The minimally invasive (MI) group included 16 patients who underwent excision of an atrial mass via a mini-thoracotomy.
There were no statistically significant differences between the REF and MI groups based on demographic or preoperative characteristics. Tissue diagnosis of the masses resected included myxoma (n = 24), fibroblastoma (n = 3), B-cell lymphoma (n = 1), and other benign masses (n = 6). Cardiopulmonary bypass (70.5 versus 76.5 minutes; P = .57) and aortic cross-clamp times (32.7 versus 47.3 minutes; P = .14) did not differ significantly between the REF and MI groups, nor did intraoperative transfusion of packed red blood cells (0.35 versus 0.38 units; P = .93). As assessed by intraoperative trans-esophageal echocardiogram, there were no moderate to severe valvular abnormalities observed following chest closure. Intensive care unit length of stay (46.1 versus 26.2 hours; P = .15), overall hospital length of stay (6.39 versus 5.06 days; P= .18), and time to extubation (0.78 versus 0.44 days; P = .44) all trended toward shorter duration in the MI group compared with the REF group-although none of these differences achieved statistical significance. Postoperative transthoracic echocardiograms were obtained in 14 of 34 (41.2%) patients; none revealed any new or significant abnormalities. All patients survived to hospital discharge; one patient in the REF group expired during the follow-up period. Among the 34 patients, 26 patients (76.4%) were at least 2 years postoperative from their resection; 25 of the 26 (96.1%) were alive at 2-year follow-up, and the remaining 8 were alive at 1-year follow-up. All patients were free of recurrence at last follow-up. CONCLUSIONS. Minimally invasive atrial mass excisions can be accomplished reliably without compromising complete tumor resection and without significant increases in operative times or serious adverse events. In addition, measures of recovery time in this study suggest faster recovery among the MI group, which is consistent with the proposed advantages by proponents of minimally invasive surgery.
Heart Surgery Forum 02/2007; 10(1):E50-4. · 0.63 Impact Factor
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ABSTRACT: The purpose of this study was to evaluate diffusing tip laser energy in surgical atrial fibrillation ablation using a canine model. This is the first report to describe the pathological and histological findings using a laser energy source.
The surgical atrial fibrillation ablation procedure was performed through a left atriotomy; the pulmonary veins were encircled in 16 dogs using a diode laser (980 nm) with a diffusing tip that permits linear ablation perpendicular to the fiber direction. Lesion durations were 45 seconds with a power density of 3.8 or 4.5 W/cm. Six animals were allowed to survive 4 hours after the procedure, with the remainder sacrificed at 1 week (n = 1), 4 weeks (n = 3), and 6 weeks (n = 6). Electrophysiologic effectiveness was judged using unipolar or bipolar pacing from the pulmonary veins after attempting isolation. Hearts were harvested for histologic examination using standard trichrome staining.
All animals tolerated the procedure. The animals required an average of 5.6 +/- 0.82 lesions to complete the procedure. All animals had confirmed isolation of the pulmonary veins as judged by unipolar or bipolar pacing, and this isolation persisted in those animals that were allowed to survive. Pathology revealed all lesions to be transmural with an average tissue thickness of 3.62 +/- 1.50 mm (range, 0.95 mm to 7.06 mm).
Diffusing tip laser technology reproducibly makes rapid, transmural, and electrophysiologically effective atrial lesions.
The Annals of thoracic surgery 01/2007; 82(6):2260-4. · 3.74 Impact Factor
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ABSTRACT: Surgical atrial fibrillation ablation (SAFA) has not achieved the efficacy of Cox's original maze procedure, although technical improvements continue to be made. It is possible that biologic factors determine SAFA success. Therefore we examined how patient-specific characteristics affected SAFA success in 353 atrial fibrillation (AF) patients who underwent SAFA at a single institution. Among these, 257 (72.8%) had continuous AF and 96 (27.2%) had intermittent AF. For 297 patients (84.1%) postoperative follow-up was > 3 months. We compared SAFA success in patients whose procedure involved only pulmonary vein isolation with those whose procedure involved extensive lesion sets. Multivariate analysis included AF duration, left atrial size, preoperative atrial flutter, concomitant procedures, lesion sets, and energy source. Early SAFA success was classified as freedom from AF between postoperative months 3 and 6, and intermediate success between postoperative months 6 and 12. Receiver-operating characteristic (ROC) curves and stratum-specific likelihood ratios (SSLR) were generated to compare intermediate failure by left atrial size (LAS) thresholds. SAFA was more successful in the intermittent than the continuous AF group (n = 66, 86% vs n = 165, 71%; P = .014). When pulmonary vein isolation was compared only to more extensive lesion sets, there was no difference in success in the intermittent (34, 91% vs 32, 81%; P = .24) or continuous groups (67, 73% vs. 98, 69%; P = .603). Success for intermittent AF patients was not correlated with variables considered; in continuous AF patients, predictors included presence of concomitant mitral valve repair/replacement (P = .075), decreasing LAS (P = .025) and absence of preoperative atrial flutter (P = .001). In the continuous AF group, ROC curves and corresponding areas under the curve (AUC) were 0.60 (0.50-0.71) for failure at 6 months to 1 year. SSLR analysis generated 2 strata for LAS: < 8 cm with SSLR = 0.87 (0.74-1.0) and < or = 8 cm SSLR = 2.98 (1.07-8.3). In patients with intermittent AF, SAFA achieved acceptable results regardless of tested preoperative and intraoperative variables. In continuous AF, patient-specific characteristics affected success more than intraoperative variables. Failure was more than 3-fold greater in continuous AF patients with an LAS < or = 8 cm. In both patient types, more extensive lesion sets were not shown to improve outcomes. Future improvements in SAFA may depend on pharmacologic and/or surgical substrate modification.
Heart Surgery Forum 01/2007; 10(6):E468-72. · 0.63 Impact Factor
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ABSTRACT: This study compares posttransplantation outcomes of survival and morbidity among recipients with and without diabetes mellitus (DM).
The United Network of Organ Sharing (UNOS) provided deidentified patient-level data. Primary analysis focused on 20,412 first-time heart transplant recipients aged > or = 18 years who underwent transplantation between January 1, 1995, and December 31, 2005. To determine severity of DM, DM recipients were stratified by their aggregate number of diabetes-related complications (DRCs), including pretransplantation history of renal failure (serum creatinine = 2.5 mg/dL), peripheral vascular disease, cerebrovascular accident, and severe obesity (body mass index > or = 35 kg/m2). Kaplan-Meier analysis was performed to compare time to event. Although posttransplantation survival was significantly better (P<0.001) among patients without DM (median survival 10.1 years) than among those with DM (9.0 years), survival did not differ (P=0.08) between those without DM (10.1 years) and those with uncomplicated DM (0 DRCs; 9.3 years). Among those with DM, survival was worse with each additional DRC: 0 DRC, 9.3 years; 1 DRC, 6.7 years; and > or = 2 DRCs, 3.6 years. Although acute rejection and transplant coronary artery disease-free survival did not differ between groups, renal failure and severe infection-free survival were worse in those with DM and were inversely related to the number of DRCs.
Posttransplantation survival among patients with uncomplicated DM was not significantly different than that among nondiabetics. However, when stratified by disease severity, recipients with more severe diabetes had significantly worse survival than nondiabetics. Therefore, although DM alone should not be a contraindication to heart transplantation, given the critical shortage of transplantable organs, maximal benefit may be achieved by exploring alternative treatment options in patients with severe DM. These include use of high-risk transplant lists and destination therapy.
Circulation 12/2006; 114(21):2280-7. · 14.74 Impact Factor
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ABSTRACT: To investigate the effect of epicardial fat on surgical atrial fibrillation ablation performance using an in vitro model. Two tissue models were employed to investigate standard penetration and maximal lesion depth performance of bipolar radiofrequency (RF), microwave, and laser energy sources.
Ventricular veal tissue was utilized in various thicknesses (3 mm, 5 mm, 7 mm, 15 mm). Epicardial fat was modeled by layering porcine fat (1 mm, 2 mm and 4 mm) on moistened tissue. In each group, 8 to 10 lesions were created. Post ablation, tissue samples were sectioned and ablation depth of each myocardial section measured using 1% tetrazolium tetrachloride dye solution.
The laser energy source produced nearly 100% transmural lesions in almost all study groups irrespective of myocardium thickness and fat thickness. The microwave device maintained transmurality in all 3-mm and most 5-mm myocardium trials but fell to near zero with all 7-mm myocardium trials. The bipolar RF maintained transmurality only when no fat was applied. In the maximal lesion depth models, the laser was capable of producing lesions >8 mm with no fat and >6 mm with either 2 mm or 4 mm of fat present. The microwave produced lesions in the no fat (>6 mm) and 2-mm (>4 mm) fat group. The bipolar RF produced 83% transmurality with no fat and zero percent transmurality with 2 mm of fat present.
Epicardial fat can severely limit transmurality in energy sources that utilize conductive heating. Laser energy was uniformly superior at producing both transmural and deep lesions irrespective of the presence of fat.
Journal of Cardiac Surgery 22(6):521-4. · 0.87 Impact Factor
