Jonathan W Haft

Concordia University–Ann Arbor, Ann Arbor, Michigan, United States

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Publications (62)140.67 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: This is a review of the University of Michigan experience with extracorporeal life support (ECLS) also known as extracorporeal membrane oxygenation (ECMO). Two thousand patients were managed with ECMO from 1973-2010. The first thousand were reported previously.Of the 2000 patients, 74% and were weaned from ECLS, and 64% survived to hospital discharge In patients with respiratory failure, survival to hospital discharge was 84% in 799 neonates, 76% in 239 children, and 50% in 353 adults. Survival in patients with cardiac failure was 45% in 361 children, and 38% in 119 adults. ECLS during cardiac arrest (ECPR) was performed in 129 patients, with 41% surviving to discharge. Survival decreased from 74% to 55% between the first and second thousand patients. The most common complication was bleeding at sites other than the head, with an incidence of 39%, and the least frequent complication was pump malfunction, with a 2% incidence. Intracranial bleeding or infarction occurred in 8% of patients, with a 43% survival rate. This is the largest series of ECLS at one institution reported in the world to date. Our experience has shown that ECLS saves lives of moribund patients with acute pulmonary and cardiac failure in all age groups.
    ASAIO journal (American Society for Artificial Internal Organs: 1992) 09/2014; · 1.39 Impact Factor
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    ABSTRACT: Interfacility transport of patients on extracorporeal membrane oxygenation (ECMO) has been performed in large numbers at only a few programs. Limited data are available on outcomes after ECMO transport to justify expanding or discontinuing these programs.
    The Annals of thoracic surgery. 08/2014;
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    ABSTRACT: Abstract BACKGROUND: Centrifugal pumps are used increasingly for temporary mechanical support for the treatment of cardiogenic shock. However, centrifugal pumps can generate excessive negative pressure and are afterload sensitive. A previously developed modified roller pump mitigates these limitations both in vitro and in preliminary animal experiments. We report the results of intermediate-term testing of our evolving pump technology, known as the BioVAD. METHODS: The BioVAD was implanted in 6 adult male sheep (62.5 ± 3.9 kg), with drainage from the left atrium and reinfusion into the descending aorta. The sheep were monitored for 5 days. Heparin was given during the initial implantation, but no additional anticoagulants were given. Data collected included hemodynamic status, pump flow and pressures, laboratory values to monitor end-organ function and hemolysis, pathologic specimens to evaluate for thromboembolic events and organ ischemia, and explanted pump evaluation results. RESULTS: All animals survived the planned experimental duration and there were no pump malfunctions. Mean BioVAD flow was 3.57 ± 0.30 L/min (57.1 mL/kg/min) and mean inlet pressure was -30.51 ± 4.25 mm Hg. Laboratory values, including plasma free hemoglobin, creatinine, lactate, and bilirubin levels, remained normal. Three animals had small renal cortical infarcts, but there were no additional thromboembolic events or other abnormalities seen on pathologic examination. No thrombus was identified in the BioVAD blood flow path. CONCLUSIONS: The BioVAD performed well for 5 days in this animal model of temporary left ventricular assistance. Its potential advantages over centrifugal pumps may make it applicable for short-term mechanical circulatory support.
    The Annals of Thoracic Surgery 07/2014; 98(1):97-102. · 3.45 Impact Factor
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    ABSTRACT: Although left ventricular assist device (LVAD) management strategies are undertaken to reduce the development of aortic insufficiency (AI), the effect of AI on patient morbidity and mortality is not known.
    06/2014;
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    ABSTRACT: Postcardiotomy shock affects 0.5% to 6% of cardiac operations and is associated with a high mortality. Many of these patients had their procedures performed at lower-volume cardiac surgery centers with limited resources. The objective of this study was to determine the outcomes in patients in postcardiotomy shock who were transferred to a tertiary care center for escalated care. We performed a retrospective review of 104 postcardiotomy shock patients transferred to our institution between 2004 and 2012. Univariable and multivariable analyses were performed to determine predictors of in-hospital and overall survival. Seventy-eight percent of patients were receiving temporary mechanical support. The in-hospital mortality in our series was 46%. Multivariable predictors of in-hospital mortality included higher initial creatinine level on arrival and a history of known heart failure. Multivariable predictors of overall mortality included higher initial creatinine and lactate levels, lower initial ejection fraction, and a history of heart failure and hypertension. The Kaplan-Meier estimation of 5-year survival was 39% in all patients and 72% in patients who survived to hospital discharge. Patients with postcardiotomy cardiac failure transported to a tertiary care center for advanced cardiac support had a nearly 50% survival, with excellent long-term survival of those discharged alive. Preservation of end-organ function, often with mechanical support, can improve survival.
    The Annals of thoracic surgery 05/2014; · 3.45 Impact Factor
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    ABSTRACT: It has been suggested that pulsatile blood flow is superior to continuous flow in cardiopulmonary bypass (CPB). However, adoption of pulsatile flow (PF) technology has been limited due to practically and complexity of creating a consistent physiologic pulse. A pediatric pulsatile rotary ventricular pump (PRVP) was designed to address this problem. We evaluated the PRVP in an animal model, and determined its ability to generate PF during CPB.The PRVP (modified peristaltic pump, with tapering of the outlet of the pump chamber) was tested in 4 piglets (10-12kg). Cannulation was performed with right atrial and aortic cannulae, and pressure sensors were inserted into the femoral arteries. Pressure curves were obtained at different levels of flow and compared with both the animal's baseline physiologic function and a continuous flow (CF) roller pump.Pressure and flow waveforms demonstrated significant pulsatility in the PRVP setup compared to CF at all tested conditions. Measurement of hemodynamic energy data, including the percent pulsatile energy and the surplus hydraulic energy, also revealed a significant increase in pulsatility with the PRVP (p <0.001).PRVP creates physiologically significant PF, similar to the pulsatility of a native heart, and has the potential to be easily implemented in pediatric CPB.
    ASAIO journal (American Society for Artificial Internal Organs: 1992) 03/2014; · 1.39 Impact Factor
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    ABSTRACT: The optimal management of functional tricuspid regurgitation (FTR) in the setting of mitral valve operations remains controversial. The objective of this study is to compare the outcomes of congestive heart failure patients who underwent a prophylactic tricuspid operation for FTR as a component of their initial mitral valve procedure with those who underwent a redo tricuspid operation at a later date for residual FTR. Patients with FTR repaired as a redo operation between 2004 and 2012 were identified. These patients were propensity-matched 1:2 with contemporaneous patients with FTR or tricuspid dilatation who underwent tricuspid repair at the same time as mitral valve repair. Demographic information, postoperative complications, and short-term and long-term mortality rates were compared between groups. There were 21 patients treated with redo tricuspid valve repair matched with 42 patients treated prophylactically. There were 3 deaths at 30 days in the redo group (14%), compared with zero in the prophylactic group (p = 0.03). Overall long-term mortality in the redo group was 29% (6 of 21), with a mean 31 months of follow-up, but was only 14% (6 of 42) in the prophylactic group, with a mean 25 months of follow-up. Kaplan-Meier long-term survival analysis did not reveal a difference between groups (log-rank p = 0.37) once the perioperative period was survived. Redo tricuspid valve repair for residual FTR can be performed with acceptable short-term and long-term mortality. However, treatment of FTR at the time of the initial intervention should be considered, because it is safe and effective. A randomized, controlled trial of prophylactic tricuspid operation for FTR at the time of the mitral operation may be warranted.
    The Annals of thoracic surgery 02/2014; · 3.45 Impact Factor
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    ABSTRACT: Background While left ventricular assist device (LVAD) management strategies are undertaken to reduce aortic insufficiency (AI) development, the impact of AI on patient morbidity and mortality is not known. Methods Patients undergoing HeartMate II implant were prospectively followed with serial echocardiograms. Kaplan-Meier methods and log rank testing were used to estimate and compare mortality and freedom from ≥moderate right ventricular hypokinesis (RVHK), ≥moderate mitral regurgitation (MR), and hemolysis based on AI severity. Mixed modelling was used to examine for correlates of AI development in the pre- and post-operative setting and to investigate impact of AI on postoperative MR and RVHK. Results There were 930 echocardiograms completed on 166 patients. During 291 person-years of follow-up, ≥mild-moderate AI developed in 70 (0.38 persons per year (PPY)), ≥moderate AI in 36 (0.17 PPY), ≥moderate to severe AI in 11 (0.039 PPY), and ≥severe AI in 2 (0.0069 PPY). Overall 2 YR survival and 2 YR survival following onset of ≥moderate AI was 87±6.2% and 65±11%, respectively, compared with 76±5.1% and 76±5.1%, respectively in those with less AI (p=0.57). Patients with moderate AI were not more likely to develop MR, hemolysis events or worsening RVHK, but patients with preexisting RVHK appeared to be less tolerant of AI. Three of 35 deaths could be directly attributed to AI and no reoperations were performed solely for AI. Conclusions AI is common after LVAD implant but did not impact survival in this cohort. Except in those with significant RV dysfunction, this calls into question need for echocardiogram guided device settings to ensure aortic valve opening.
    The Journal of Heart and Lung Transplantation. 01/2014;
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    ABSTRACT: The clinical relevance of elevated serum markers of hemolysis during left ventricular assist device (LVAD) support has not been fully ascertained. Lactate dehydrogenase (LDH) and serum free hemoglobin (sfHg) values were tallied monthly in 182 patients on HeartMate II (Thoratec, Pleasanton, CA) LVAD support. Peak values for each marker were identified, and 2 hemolysis definitions were applied to the cohort: Hemolysis according to Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) criteria (sfHg > 40 mg/dl with signs/symptoms) and/or hemolysis defined by an LDH ≥ 600 IU/liter (2.5-times the upper limit of laboratory normal). Kaplan-Meier survival free from death, urgent United Network of Organ Sharing 1A transplant for thrombosis, device exchange for thrombosis, and stroke/peripheral embolism was estimated, and Cox hazard ratios (HR) with the 95% confidence interval (95% CI) were calculated. Areas under the receiver-operating characteristic curves (AUCs) for predicting 1-year event-free survival were calculated. Hemolysis occurred in 32 patients (18%) by INTERMACS criteria and in 68 (37%) patients by LDH criteria. Over a median (25(th), 75(th)) support of 427 days (245, 793 days), there were 78 events. One year event-free survival after the onset of INTERMACS-defined hemolysis was 16% ± 8.3% compared with 85% ± 3.2% in non-hemolyzers (HR, 14.7; 95% CI, 7.9-27; AUC 0.70 ± 0.05; p < 0.001; ). One year event-free survival after the onset of LDH-defined hemolysis was 32% ± 7.2% compared with 89% ± 3.2% in those with persistent LDH values < 600 IU/liter (HR, 8.0; 95% CI, 4.4-14; AUC 0.87 ± 0.04; p < 0.001). Patients who met the LDH hemolysis definition had longer times from hemolysis onset to clinical events and larger magnitudes of risk for embolism and device exchange for thrombosis than those with INTERMACS hemolysis. Serum hemolysis marker elevations are associated with increased events in LVAD patients. LDH monitoring provides an earlier diagnosis of adverse events than sfHg, supporting need for a new INTERMACS definition of VAD-associated hemolysis.
    The Journal of heart and lung transplantation: the official publication of the International Society for Heart Transplantation 01/2014; 33(1):35-43. · 3.54 Impact Factor
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    ABSTRACT: To determine the impact of coronary computed tomography angiography (CCTA) on treatment decisions made by cardiac surgeons and to explore barriers to implementation of CCTA as first-line imaging workup before coronary artery bypass. Tertiary academic medical center retrospective cohort study. Questionnaires administered to three cardiac surgeons regarding diagnosis and treatment decisions with level of confidence in decision making for 30 chest pain patients, after reviewing deidentified catheter coronary angiogram (CCA) and CCTA images on the same patients, several weeks apart. All surgeons tended to report more severe disease with CCTA than CCA (P < .05). Treatment decisions differed in 12 (40%), 14 (47%), and 18 (60%) patients within each individual surgeon based on CCTA images compared to CCA images (P = .11, .01, and .02, respectively). Confidence levels were significantly higher with CCA for the diagnosis and treatment of coronary artery disease for all three surgeons (P < .05). There was a tendency toward more invasive treatment choices (angioplasty, stent insertion, or coronary artery bypass graft) when making treatment decisions based upon CCTA images. Severity of disease may be overestimated by cardiac surgeons when using CCTA as a decision-making test, tending toward more invasive treatment choices compared to CCA. Additionally, cardiac surgeons may be more confident with their diagnosis and treatment based on CCA. These may be important limitations in the application of CCTA in clinical practice and may reflect the maturation of CCTA use in practice, diffusion of the technology and/or a reflection of the technology itself.
    Academic radiology 09/2013; 20(9):1083-90. · 2.09 Impact Factor
  • Surgical Infections 05/2013; · 1.87 Impact Factor
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    ABSTRACT: Background The clinical relevance of elevated serum markers of hemolysis during LVAD support has not been fully ascertained. Methods Lactate dehydrogenase (LDH) and serum free hemoglobin (sfHg) values were tallied monthly in 182 patients on HeartMate II LVAD support. Peak values for each marker were identified and two hemolysis definitions were then applied to the cohort: Hemolysis according to INTERMACS criteria (sfHg >40 mg/dL with signs/symptoms) and/or hemolysis defined by an LDH ≥600 IU/L (2.5x the upper limit of laboratory normal). Kaplan-Meier survival free from death, urgent UNOS 1A transplant for thrombosis, device exchange for thrombosis, and stroke/peripheral embolism was estimated and Cox hazard ratios (HR [95% confidence interval]) were calculated. Areas under the receiver operating characteristic curves (AUCs) for predicting 1 year event-free survival were calculated. Results Hemolysis by INTERMACS and LDH criteria occurred in 18% (n=32) and 37% (n=68) of patients, respectively. Over a median [25th, 75th] support of 427 [245,793] days, there were 78 events. One year event-free survival following the onset of INTERMACS-defined hemolysis was 16±8.3% compared with 85±3.2% in non-hemolyzers (HR 14.7 [7.9,27], p<0.001; AUC 0.70±0.05). One year event-free survival following the onset of LDH-defined hemolysis was 32±7.2% compared with 89±3.2% in those with persistent LDH values <600 IU/L (HR 8.0 [4.4,14], p<0.001; AUC 0.87±0.04). Patients meeting the LDH hemolysis definition had longer times from hemolysis onset to clinical events and larger magnitudes of risk for embolism and device exchange for thrombosis than those with INTERMACS hemolysis. Conclusions Serum hemolysis marker elevations are associated with increased events in LVAD patients. LDH monitoring provides earlier diagnosis of adverse events than sfHg, supporting need for a new INTERMACS definition of VAD-associated hemolysis.
    The Journal of Heart and Lung Transplantation. 01/2013;
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    The Annals of thoracic surgery 12/2012; 94(6):2182. · 3.45 Impact Factor
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    ABSTRACT: Venous thromboembolism (VTE), particularly thrombi in the inferior vena cava (IVC) and pulmonary embolism, can occur after successful extracorporeal membrane oxygenation (ECMO) and can be associated with adverse outcomes including death. VTE is related to the presence of a venous cannula and in some cases inadequate anticoagulation caused by clinical bleeding. We have developed a simple method for guidewire exchange of the femoral venous ECMO cannula to a working catheter for intravascular ultrasound (IVUS) IVC filter placement, and describe the specific methodology.
    ASAIO journal (American Society for Artificial Internal Organs: 1992) 10/2012; · 1.39 Impact Factor
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    ABSTRACT: Background: Hyperglycemia is common in the post-cardiac surgery population and has been associated with increased mortality rates, surgical length of stay, and infection rates. Although hospitalized patients with diabetes are known to have more complications, recent studies in various hospital settings have reported worse outcomes in patients with stress hyperglycemia than in those with diabetes. Aim: The primary objective of this study was to analyze 30- and 90-day mortality rates in post-cardiac surgery patients with stress hyperglycemia and diabetes who were managed to achieve similar moderate blood glucose goals using the University of Michigan Hospital (Ann Arbor, MI) insulin protocol between 2005 and 2008. The secondary outcomes were rates of postoperative complications, including hypoglycemia. Methods: A standardized glucose management program was followed to treat all patients in the cardiac intensive care unit, with a blood glucose goal of 100 to 140 mg/dL. Data from 1973 patients with either diabetes or stress hyperglycemia were analyzed to identify associations between mean postoperative blood glucose levels and mortality, incidence of hypoglycemia, and complication rates. Results: Mortality rates did not differ between patients with diabetes and stress hyperglycemia (3.4 and 2.3%; P = 0.2). Rates of severe hypoglycemia were low (1%) for both groups and were not associated with an increase in mortality (P = 0.95). Other complication rates were similar between patients with diabetes and stress hyperglycemia. Conclusion: Maintaining a blood glucose range between 100 to 140 mg/dL in post-cardiac surgery patients was associated with a low mortality rate, low risk of hypoglycemia, and with complications rates that were similar in patients with diabetes and stress hyperglycemia.
    Hospital practice (1995). 04/2012; 40(2):22-30.
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    ABSTRACT: Extracorporeal blood pumps are used as temporary ventricular assist devices or for extracorporeal membrane oxygenation. The ideal pump would be intrinsically self-regulating, carry no risk of cavitation or excessive inlet suction, be afterload insensitive, and valveless thus reducing thrombogenicity. Currently used technology, including roller, centrifugal, and pneumatic pulsatile pumps, does not meet these requirements. We studied a nonocclusive peristaltic pump (M-Pump) in two mock circulatory loops and compared the performance to a frequently used centrifugal pump and a modified prototype of the M-Pump (the BioVAD). The simple resistance loop consisted of the investigated pump, a fixed height reservoir at 150 mm Hg, and a variable inflow reservoir. The pulsatile circulation used a mock patient simulator with adjustable resistance elements connected to a pneumatic pulsatile pump. The M-Pump intrinsically regulated flow with changing preload, was afterload insensitive, and did not cavitate, unlike the centrifugal pump. The BioVAD also demonstrated these features and could augment output with the use of vacuum assistance. A nonocclusive peristaltic pump may be superior for short-term extracorporeal circulatory assist by mitigating risks of excessive inlet suction, afterload sensitivity, and thrombosis.
    ASAIO journal (American Society for Artificial Internal Organs: 1992) 03/2012; 58(2):109-14. · 1.39 Impact Factor
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    ABSTRACT: Lower extremity ischemia is common when the femoral artery is used for veno-arterial extracorporeal membrane oxygenation (VA ECMO). We describe a new technique to reperfuse the extremity. The ipsilateral posterior tibial artery is exposed via a small incision behind the medial malleolus. The vessel is cannulated in a retrograde fashion and connected to the arterial limb of the ECMO circuit. Thirty-six patients received a posterior tibial reperfusion cannula: average flow was 155.8 ml/min and increased over the initial 24 hours. Fifty-eight percent received the posterior tibial cannula within 6 hours of ECMO initiation and none sustained permanent lower extremity injury. Of the remaining 42%, three required amputation or developed permanent neurologic injury. Overall survival was 41%. Cannulation of the posterior tibial artery is a simple technique to reperfuse the lower extremity during VA ECMO. The cannula should be inserted within 6 hours of ECMO initiation to avoid irreversible ischemic damage.
    Perfusion 12/2011; 27(2):141-5. · 0.94 Impact Factor
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    ABSTRACT: Blood pumps used for temporary circulatory support have limitations. We propose a novel device designed for short-term extracorporeal support that is intrinsically volume responsive, afterload insensitive, and incapable of cavitation or excessive hemolysis. After in vitro testing, we performed the initial in vivo implantations and assessments. The BioVAD prototype (MC3, Inc, Ann Arbor, MI) was implanted in 6 adult male sheep (60.2±2.8 kg) through the left ventricular apex and descending thoracic aorta. Arterial, left and right atrial, and pump inlet and outlet pressures and BioVAD flow were measured and recorded. The animals were volume loaded to assess volume responsiveness, and the inlet lines were abruptly clamped during maximum support to observe for cavitation. An acute heart failure model was created with rapid ventricular pacing, and the animals were supported for 4 hours. Peak flow was 3.19±0.56 L/min and increased to 3.71±0.53 L/min with 20 mm Hg vacuum-assisted drainage. Without manual changes in pump settings, pump flow increased 17.5% with volume loading. During acute venous line occlusion, there was no evidence of cavitation, and inlet suction was minimal. Hemodynamics were maintained for 4 hours during acute heart failure. The BioVAD provided adequate flow in an acute in vivo model. Its design may be superior for short-term extracorporeal support.
    The Annals of thoracic surgery 11/2011; 93(1):141-6. · 3.45 Impact Factor
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    ABSTRACT: Right thoracotomy using ventricular fibrillation with cooling has been used for redo mitral valve surgery. This approach avoids the complications of redo sternotomy, such as injury to prior grafts and hemorrhage. As a further refinement, we have used a beating heart technique to further minimize complications while simplifying the operation. We reviewed the outcomes of 450 patients who underwent redo mitral valve surgery via a right thoracotomy from 1996 to 2011 at the University of Michigan. Of these, 134 patients underwent redo mitral valve surgery with ventricular fibrillation, and 316 patients underwent beating heart surgery. Although operative eras were consecutive, patients' age, risk factors, New York Heart Association, and preoperative left ventricular ejection fraction were not significantly different. Core temperature on cardiopulmonary bypass for beating heart surgery was 32°C versus 26°C for ventricular fibrillation. Patients undergoing beating heart surgery had shorter periods of cardiopulmonary bypass: 81±9 minutes versus 113±36 minutes. Beating heart surgery required less blood products than ventricular fibrillation: 1.65±2 units versus 3.8±5 units packed red blood cells, 0.6±1.2 units versus 1.8±4 units fresh-frozen plasma, and 1.02±4 versus 7.5±17 platelet packs (all P<.01). Conversely, patients receiving ventricular fibrillation required longer postoperative ventilation: 34±101 hours versus 15.5±27 hours (P<.01). The 30-day mortality was similar for both (6.5% for beating heart and 7.4% for ventricular fibrillation), and postoperative length of stay was the same at 7 days. Stroke rate was 2.6% for patients undergoing beating heart surgery and 3% for patients receiving ventricular fibrillation. Significant operative complications were uncommon; there was no catastrophic hemorrhage, and only 2 patients receiving ventricular fibrillation and 2 patients undergoing beating heart surgery required reexploration. As reoperative cardiac surgery continues to increase, techniques that safely facilitate operation while improving outcome should be adopted. As an operative alternative, redo right thoracotomy mitral valve surgery on the beating heart is associated with shorter bypass time, less transfusion requirements, shorter postoperative ventilation, and lower mortality. This safe and effective approach should be considered for this complex operation.
    The Journal of thoracic and cardiovascular surgery 11/2011; 144(2):334-9. · 3.41 Impact Factor
  • Jonathan W Haft
    The Annals of thoracic surgery 10/2011; 92(4):1427. · 3.45 Impact Factor