Vaughn A Starnes

Keck School of Medicine USC, Los Ángeles, California, United States

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Publications (168)621.56 Total impact

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    ABSTRACT: Right anterior minithoracotomy with central arterial cannulation is our preferred technique of minimally invasive aortic valve replacement (AVR). We compared perioperative outcomes with this technique to those via sternotomy. Between March 1999 and December 2013, 492 patients underwent isolated AVR via either sternotomy (SAVR, n = 198) or minimally invasive right anterior thoracotomy (MIAVR, n = 294) in our institution. Univariate comparisons between groups were made to evaluate overall outcomes and adverse events. To control treatment selection bias, propensity scores were constructed from core patient characteristics. A propensity score-stratified analysis of outcome and adverse events was then performed. Overall mortality was 2.5 and 1.0% in the SAVR and MIAVR groups, respectively. Hospital and ICU stays were shorter, there was less intraoperative blood product usage, and fewer wound infections in the MIAVR group. There were no differences in other adverse events, including strokes. The composite end-point of alive and adverse event-free was significantly more common in the MIAVR group (83 vs 74%, P = 0.002). After adjusting for the propensity score, hospital and ICU stays remained shorter and intraoperative blood product usage remained less in the MIAVR group. There was no difference in mortality, stroke or other adverse events between groups. Minimally invasive AVR via an anterior right thoracotomy with predominately central cannulation can be performed with morbidity and mortality similar to that of a sternotomy approach. There appear to be advantages to this minimally invasive approach when compared with sternotomy in terms of less intraoperative blood product usage, lower wound infection rates and decreased hospital stays. If mortality and the occurrence of adverse events are taken together, MIAVR may be associated with better outcomes. As minimally invasive AVR becomes more common, further long-term follow-up is needed and a prospective multicentre randomized trial would be warranted. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
    European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery 03/2015; DOI:10.1093/ejcts/ezv038 · 2.81 Impact Factor
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    ABSTRACT: Pulmonary sequestration refers to segmental lung tissue that has no connection with the bronchial tree or pulmonary arteries. In adults, the clinical sequelae are usually related to infection. Patients are typically referred for sequestrectomy even when they are asymptomatic. There are no guidelines for treating patients who have pulmonary sequestration and coexisting cardiac valvular disease, in which case the venous drainage patterns of sequestra pose the additional risks of infective endocarditis and volume overload. We present the cases of 2 adult patients-one symptomatic and one asymptomatic-who had concurrent aortic valvular disease and pulmonary sequestration, and we discuss the factors involved in our evaluation of their cardiac risk and our treatment decisions. In view of the sparse data to predict cardiac risks, we think that pulmonary sequestrectomy in adult patients with concurrent valvular conditions should be considered on a case-by-case basis.
    Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital 12/2014; DOI:10.14503/THIJ-13-3907 · 0.63 Impact Factor
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    ABSTRACT: Background and Aim. While aortic valve replacement for aortic stenosis can be performed safely in elderly patients, there is a need for hemodynamic and quality of life evaluation to determine the value of aortic valve replacement in older patients who may have age-related activity limitation. Materials and Methods. We conducted a prospective evaluation of patients who underwent aortic valve replacement for aortic stenosis with the Hancock II porcine bioprosthesis. All patients underwent transthoracic echocardiography (TTE) and completed the RAND 36-Item Health Survey (SF-36) preoperatively and six months postoperatively. Results. From 2004 to 2007, 33 patients were enrolled with an average age of 75.3 ± 5.3 years (24 men and 9 women). Preoperatively, 27/33 (82%) were New York Heart Association (NYHA) Functional Classification 3, and postoperatively 27/33 (82%) were NYHA Functional Classification 1. Patients had a mean predicted maximum V O2 (mL/kg/min) of 19.5 ± 4.3 and an actual max V O2 of 15.5 ± 3.9, which was 80% of the predicted V O2 . Patients were found to have significant improvements (P ≤ 0.01) in six of the nine SF-36 health parameters. Conclusions. In our sample of elderly patients with aortic stenosis, replacing the aortic valve with a Hancock II bioprosthesis resulted in improved hemodynamics and quality of life.
    12/2014; 2014:151282. DOI:10.1155/2014/151282
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    ABSTRACT: The development of transcatheter aortic valve implantation (TAVI) has increased the use of balloon aortic valvuloplasty (BAV) in treating aortic stenosis. We evaluated our use of BAV in an academic tertiary referral center with a developing TAVI program. We reviewed 69 consecutive stand-alone BAV procedures that were performed in 62 patients (mean age, 77 ± 10 yr; 62% men; baseline mean New York Heart Association functional class, 3 ± 1) from January 2009 through December 2012. Enrollment for the CoreValve(®) clinical trial began in January 2011. We divided the study cohort into 2 distinct periods, defined as pre-TAVI (2009-2010) and TAVI (2011-2012). We reviewed clinical, hemodynamic, and follow-up data, calculating each BAV procedure as a separate case. Stand-alone BAV use increased 145% from the pre-TAVI period to the TAVI period. The mean aortic gradient reduction was 13 ± 10 mmHg. Patients were successfully bridged as intended to cardiac or noncardiac surgery in 100% of instances and to TAVI in 60%. Five patients stabilized with BAV subsequently underwent surgical aortic valve replacement with no operative deaths. The overall in-hospital mortality rate (17.4%) was highest in emergent patients (61%). The implementation of a TAVI program was associated with a significant change in BAV volumes and indications. Balloon aortic valvuloplasty can successfully bridge patients to surgery or TAVI, although least successfully in patients nearer death. As TAVI expands to more centers and higher-risk patient groups, BAV might become integral to collaborative treatment decisions by surgeons and interventional cardiologists.
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    ABSTRACT: Pregnancy after lung transplantation has been described, but pregnancy after living donor lobar lung transplantation (LDLT) has not been reported. The aim of this study was to evaluate outcomes after pregnancy with LDLT and discuss current recommendations regarding pregnancy and lung transplantation. A total of four LDLT patients and five pregnancies were identified, all from our institution. No patient has developed worsening pulmonary function or acute or chronic rejection. The complications of pulmonary hypertension and rejection may be overestimated in this population, and recommendations for preventive sterilization at transplantation or abortion at the time of conception are likely unwarranted and unnecessary.
    Transplantation 08/2014; 98(7). DOI:10.1097/TP.0000000000000363 · 3.78 Impact Factor
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    ABSTRACT: Cardiovascular computed tomographic angiography (CCTA) provides an understanding of the three-dimensional (3D) coronary artery anatomy in relation to cardiovascular thoracic structures important to the surgical management of anomalous coronary arteries (ACAs). Although some ACA variants are not clinically significant, others can lead to ischemia/infarction, related acute ventricular dysfunction, ventricular arrhythmias, and sudden cardiac death. The CCTA is important to surgical decision making, as it provides noninvasive visualization of the coronary arteries with (1) assessment of origin, course, and termination of coronary artery anomalies in the context of 3D thoracic anatomy, (2) characterization of anatomy helpful for differentiation of benign versus hemodynamically significant variants, (3) identification of other cardiothoracic anomalies, and (4) detection of coronary artery disease. High-risk ACA anatomy in the appropriate clinical setting can require surgical intervention with decisions including minimally invasive versus open sternotomy approach, correction via reimplantation of a coronary artery, alteration of the ACA course without reimplantation, or bypass of an ACA. Given the rarity of ACA, there is limited data in the literature, and significant controversy related to the management issues. The management of ACA requires comprehensive clinical history, thorough assessment of cardiac function, and detailed anatomic imaging. Future studies will need to address the long-term outcome based on detailed assessment of original anatomy and surgical approach.
    04/2013; 4(2):142-154. DOI:10.1177/2150135112474027
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    ABSTRACT: Cardiovascular disease is the leading cause of death in the US and worldwide. Failure to properly repair or regenerate damaged cardiac tissues after myocardial infarction is a major cause of heart failure. In contrast to humans and other mammals, zebrafish hearts regenerate after substantial injury or tissue damage. Here, we review recent progress in studying zebrafish heart regeneration, addressing the molecular and cellular responses in the three tissue layers of the heart: myocardium, epicardium, and endocardium. We also compare different injury models utilized to study zebrafish heart regeneration and discuss the differences in responses to injury between mammalian and zebrafish hearts. By learning how zebrafish hearts regenerate naturally, we can better design therapeutic strategies for repairing human hearts after myocardial infarction.
    Wound Repair and Regeneration 07/2012; 20(5):638-46. DOI:10.1111/j.1524-475X.2012.00814.x · 2.77 Impact Factor
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    ABSTRACT: We report a modification of the Starnes technique for palliating severe tricuspid regurgitation associated with a dysplastic right ventricle in a neonate, using a fenestrated pericardial patch allowing for unidirectional flow. The patient eventually underwent a successful Glenn shunt construction with a persistent reduction in right ventricle size at 1 year follow-up.
    The Annals of thoracic surgery 02/2012; 93(2):658-9. DOI:10.1016/j.athoracsur.2011.07.021 · 3.65 Impact Factor
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    ABSTRACT: Submitted May 6, 2011; Accepted August 3, 2011. The survival into adulthood of patients with unoperated complex congenital heart disease with anomalies often considered life threatening in infancy and childhood requires a complex interplay of "balanced" defects allowing for cardiovascular physiology compatible with long-term survival. We report on a series of three cases from our advanced imaging database of middle-aged adults presenting with multiple similar defects providing a hemodynamically balanced circulation. The constellation of defects seen in each of these patients included congenitally corrected transposition of the great arteries, a large nonrestrictive ventricular septal defect, valvular pulmonary stenosis, and in two cases anomalous coronary arteries. Cardiovascular computed tomographic angiography (CCTA) and cardiovascular magnetic resonance imaging (CMR) were important to the characterization of the multiple defects and their three-dimensional relationships in these cases. Treatment decisions in patients with this constellation of findings are challenging, given the limited data due to the rarity of survival of patients with these defects into middle adulthood and the paucity of data related to decisions and approaches to medical management, surgical correction, or transplantation.
    01/2012; 3(1):123-129. DOI:10.1177/2150135111421625
  • Lauren C Kane, Winfield J Wells, Vaughn A Starnes
    The Journal of thoracic and cardiovascular surgery 11/2011; 143(4):981-2. DOI:10.1016/j.jtcvs.2011.10.058 · 3.99 Impact Factor
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    ABSTRACT: The number of women affected by valvular heart disease and the number of women with breast implants are both on the rise. Minimally invasive heart surgery using a limited thoracotomy offers many potential benefits including reduction in blood loss, shorter hospital stay, faster recovery time, decreased pain, and improved cosmesis. Minimally invasive heart surgery often requires access to the second, third, or fourth intercostal space of the anterior chest wall. The presence of a breast implant may interfere with the surgeon's ability to gain adequate exposure for entry to the appropriate intercostal space. We present a case series of 5 women with breast implants who successfully underwent minimally invasive cardiac valve surgery. A retrospective review was conducted of all patients with breast implants who underwent minimally invasive cardiac valve surgery at the University of Southern California University Hospital. In each patient, an inframammary incision was performed, facilitating removal of the implant, performance of the cardiac operation, and reimplantation of the implant. Five women with breast implants who underwent minimally invasive cardiac valve surgery were identified; of these, 4 (80%) patients underwent repair of the mitral valve for mitral regurgitation, whereas 1 (20%) underwent an aortic valve replacement for aortic stenosis. Two patients underwent a concomitant maze procedure for atrial fibrillation during the same operation. The median follow-up time was 7.4 months, and the follow-up period ranged from 2 to 12 months. There were no significant postoperative complications such as infection, hematoma, or need for reoperation. Our series of 5 patients demonstrates that minimally invasive heart surgery performed through an inframammary incision can be safely performed in those with breast implants.
    Annals of plastic surgery 06/2011; 69(1):10-3. DOI:10.1097/SAP.0b013e318221b54b · 1.46 Impact Factor
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    ABSTRACT: : Transthoracic minimally invasive aortic valve replacement (TMI-AVR) is gaining popularity despite criticism that time from incision to the initiation of cardiopulmonary bypass (exposure time, ET), cardiopulmonary bypass time (CPBT), and cross-clamp time (XCT) is excessive. Database analysis was used to characterize these parameters and their associated learning curves. : From 2004 to 2008, 101 patients underwent TMI-AVR at a single institution. Of them, 54 were men (53%) and 47 were women (47%). Mean age was 70 years (range, 24-90 years). ET includes 6-cm incision, second intercostals anterior thoracotomy, medial transection of the third rib, opening pericardial sac, retracing pericardium with stay sutures, placing aortic arterial, and right arterial venous bypass cannulae. ET, CPBT, XCT, and operating room times were calculated. Logarithmic trend analysis established associated learning curves. : ET steadily improved over time. ET decreased from an average of 51 minutes for the first 25 patients to 39 minutes for the most recent 25 patients. When surgeon experience reached 10 procedures, the ET trend line began to decline steadily and plateaued by 55 cases. Cross-clamp (55 ± 21 minutes), cardiopulmonary bypass (77 ± 31 minutes), and operating room times (304 ± 67 minutes) all remained constant. There were no early deaths or conversions to sternotomy. : ET learning curve for TMI-AVR was reflected after 10 procedures with continued gradual improvement. Reliability of TMI-AVR was observed in the absence of a learning curve for XCT, CPBT, and operating room times. A sternal-sparing transthoracic approach for AVR can be performed safely, with expected operative times equivalent to sternotomy.
    Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery 01/2011; 6(1):10-4. DOI:10.1097/IMI.0b013e31820bc462
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    ABSTRACT: A zebrafish heart can fully regenerate after amputation of up to 20% of its ventricle. During this process, newly formed coronary blood vessels revascularize the regenerating tissue. The formation of coronary blood vessels during zebrafish heart regeneration likely recapitulates embryonic coronary vessel development, which involves the activation and proliferation of the epicardium, followed by an epithelial-to-mesenchymal transition. The molecular and cellular mechanisms underlying these processes are not well understood. We examined the role of PDGF signaling in explant-derived primary cultured epicardial cells in vitro and in regenerating zebrafish hearts in vivo. We observed that mural and mesenchymal cell markers, including pdgfrβ, are up-regulated in the regenerating hearts. Using a primary culture of epicardial cells derived from heart explants, we found that PDGF signaling is essential for epicardial cell proliferation. PDGF also induces stress fibers and loss of cell-cell contacts of epicardial cells in explant culture. This effect is mediated by Rho-associated protein kinase. Inhibition of PDGF signaling in vivo impairs epicardial cell proliferation, expression of mesenchymal and mural cell markers, and coronary blood vessel formation. Our data suggest that PDGF signaling plays important roles in epicardial function and coronary vessel formation during heart regeneration in zebrafish.
    Proceedings of the National Academy of Sciences 10/2010; 107(40):17206-10. DOI:10.1073/pnas.0915016107 · 9.81 Impact Factor
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    ABSTRACT: Purpose: Improvement in the management of patients with congenital cardiac disease (CHD) has resulted in improved survival of children undergoing early palliation and subsequent definitive repair. Despite advances in staged management, mortality in patients with complex lesions remains high, particularly because of intractable gastro-esophageal reflux disease (GERD). We sought to define the morbidity and mortality of laparoscopic and open gastrostomy, fundoplication, nasojejunal access, and gastrojejunal access in patients with complex CHD. Methods: A total of 812 patients with CHD (excluding ASD and PDA) were identified at our institute between July 2004 and July 2009. Demographic variables, cardiovascular parameters, co-morbid conditions, and interventions were analyzed within the first 502 consecutive patients. For each surgical procedure, preoperative cardiac status, operative management, and postoperative complications were analyzed. Results: 127 had a clinical GERD; 84 patients had radiographic evidence of GERD. 150 patients underwent feeding access procedures: nasojejunal or gastrojejunal tubes in 27, gastrostomy in 86, and fundoplication with gastrostomy in 37. Additional morbidities included airway problems (aspiration, vocal cord paralysis, cleft lip and palate), genetic disease, heterotaxy, and renal insufficiency. 57% of patients were placed on the single ventricle pathway with goal of Fontan. The remainder were amenable to complete repair. Among those undergoing procedures for feeding access, there were 21 deaths, 5 of which occurred within 30 days of procedure: two associated with gastrostomy and three with fundoplication, one of which was intraoperative. Four of five perioperative deaths occurred in single ventricles, all before Glenn palliation. There were no airway emergencies or aspiration on induction. 3 patients did demonstrate hypoxia or hypotension on induction, and 11 patients had sustained hypotension intraoperatively. Sepsis was the most common postoperative complication in 14 patients, with pneumonia in 8. In patients without GERD, gastrostomy tube placement was associated with improved survival (p=0.044). However, fundoplication does not improve survival to two ventricle repair (p=0.47) or Fontan completion (p= 0.11). The perioperative mortality of fundoplication was 11% in single ventricle patients. Conclusion: Our analysis suggests that in patients with complex CHD, feeding access can improve survival to definitive repair. Intraoperative events are common, and postoperative complications are more frequent than in patients without cardiac disease. While the operative procedures appear to carry significant risk, the interstage risk of death in patients with feeding difficulties and reflux is also quite high. Further work to identify appropriate operative or nasojejunal candidates may provide opportunities for reduced mortality.
    2010 American Academy of Pediatrics National Conference and Exhibition; 10/2010
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    ABSTRACT: Purpose: Improvement in the management of patients with single ventricle disease has resulted in increasing numbers of children surviving to Fontan palliation. A high risk time for these patients remains prior to stage two palliation (bidirectional cavopulmonary shunt), with interstage mortality of 15-20% and overall mortality before stage two of 30-50%. Studies considering anatomic, physiologic, and technical factors have resulted in refined Fontan criteria that guide the cardiovascular management of these patients. We hypothesize that some of the excess mortality is associated with management of airway, feeding access, reflux, and infection. Methods: A total of 396 patients with single ventricle physiology were identified at our institute between July 2004 and July 2009 . Demographic variables, cardiovascular parameters, co-morbid conditions, and interventions were analyzed to date for the first 211 consecutive patients. Presence of non-cardiac pathology included neurologic, airway (including primary aspiration and vocal cord paralysis), pulmonary, gastrointestinal, hepatobiliary, endocrine, renal, hematologic, infectious and genetic diseases. We also recorded interventions for each of these illnesses, including airway reconstruction, tracheostomy, diaphragm plication, thoracic duct ligation, feeding access, anti-reflux procedures, other gastrointestinal procedures and dialysis. Results: There were 66.8% right ventricles, 23.4% left ventricles, and 9.7% indeterminate or complex ventricles. Of these, 5.3% died at our institute prior to initial palliation, 85.6% underwent a primary palliation, and 9.1% had balanced pulmonary circulation and did not require initial palliation. Primary palliation included arch reconstruction with shunt in 51.6%, shunt without arch augmentation in 30%, and PA banding of unbalanced pulmonary overcirculation in 5.2%. Excluding the 11 patients who died prior to initial palliation, there was 77.5% survival to stage two, with 2.4% in-hospital death following stage-one palliation, and 19% interstage mortality. Vocal Cord Paralysis with aspiration Dialysis Acute Liver Injury Genetic Disease Survival to stage 2 when present 50% 50% 53.8% 50% Survival to stage 2 when not present 72% 75.8% 77.7% 82.9% Interestingly, while survival to 6 months is greater in patients without radiologic reflux (80% versus 73%), survival to stage two is greater in patients with radiologic reflux (81% versus 75%). Radiologic reflux correlates with earlier performance of Glenn (p=0.03). Preliminary analysis suggests cyanosis leading to urgent Glenn may be due to pulmonary disease (several pulmonary venous saturations 90-95%). Conclusion: Our analysis suggests that in single ventricle patients, vocal cord paralysis with documented aspiration, renal failure requiring dialysis, acute liver injury, and genetic disease are associated with failure to survive to stage two. The strongest predictor of failure is vocal cord paralysis with evidence of aspiration (Odds ratio 1.94, p=0.013). Other co-morbidities did not correlate with survival. Radiologic evidence of reflux is associated with progressive cyanosis, pulmonary disease, earlier Glenn, and worse survival. The role of anti-reflux procedures in reducing this mortality requires further investigation.
    2010 American Academy of Pediatrics National Conference and Exhibition; 10/2010
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    ABSTRACT: There is limited information on longer-term outcomes of pulmonary homograft monocusp (PHM) reconstruction of the right ventricular outflow tract (RVOT). A retrospective review of 131 consecutive patients undergoing RVOT reconstruction with PHM was completed. Median age was 7.6 months (range, 1 day to 14 years) and weight was 7.3 kg (range, 2 to 65 kg). Most patients (108 of 131; 82%) underwent repair for Tetralogy. After PHM, median duration of mechanical ventilation was 1 day (range, 0 to 89) and hospital stay was 6.5 days (range, 2 to 137). Hospital mortality was 2% (3 of 131) with 1 patient undergoing early replacement of PHM. Echocardiogram at hospital discharge demonstrated peak RVOT gradient of 16 mm Hg (range, 4 to 64 mm Hg); and pulmonary insufficiency was absent/trivial in 40%, mild in 42%, moderate in 16%, and severe in 2%. Follow-up is completed in 91% of hospital survivors at a median of 5 years (range, 1 to 12). There were 5 late deaths, with an actuarial survival of 96% +/- 3.7%, 94% +/- 4.6%, and 89% +/- 9.2% at 1 year, 5 years, and 10 years, respectively. There were 24 reinterventions, including 10 pulmonary valve replacements. Median time to valve replacement was 1.9 years (range, 0.4 to 4.6). Actuarial freedom from pulmonary valve replacement was 97% +/- 3.0%, 90% +/- 6.1%, and 85% +/- 10.3% at 1 year, 5 years, and 10 years, respectively. Echocardiogram at last follow-up demonstrated no increase in RVOT gradient compared with hospital discharge (16 mm Hg), but there was significant increase in pulmonary insufficiency (mild 27%, moderate 39%, severe 34%). Pulmonary homograft monocusp reconstruction is an alternative strategy for RVOT reconstruction and provides early but gradually diminishing protection against pulmonary insufficiency without a risk of stenosis. As expected, PHM function decreases over time as the RVOT grows and the homograft tissue undergoes structural deterioration.
    The Annals of thoracic surgery 07/2010; 90(1):42-9. DOI:10.1016/j.athoracsur.2010.03.045 · 3.65 Impact Factor
  • The Journal of thoracic and cardiovascular surgery 04/2010; 139(4):e90-1. DOI:10.1016/j.jtcvs.2009.04.030 · 3.99 Impact Factor
  • Journal of the American College of Cardiology 03/2010; 55(10). DOI:10.1016/S0735-1097(10)61365-4 · 15.34 Impact Factor
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    ABSTRACT: Cardiovascular computed tomographic angiography (CCTA) has great relevance for cardiothoracic surgical procedures, providing information essential to decisions regarding proceeding with surgical intervention, presurgical planning, as well as assessment for surgical efficacy and complications. In addition to visualization cardiovascular anatomy, CCTA provides a 3-D view of the relationships between thoracic skeletal, vascular, visceral, and cardiac structures (Figure 24.1). The spectrum of approaches to cardiovascular surgery has expanded to minimally invasively procedures [1, 2]. CCTA 3-D full field of view images with use of editing software enables visualization of multidimensional planes important to achieving access to target structures while avoiding important vascular and visceral thoracic structures for planning of these minimally invasive procedures.
    12/2009: pages 321-332;
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    ABSTRACT: Innovative ways of adjusting Fontan fenestrations have been developed over the last two decades. Long-term complications have not been described. We successfully treated one such complication of Fontan conduit obstruction due to an adjustable occluder device.
    Journal of Cardiac Surgery 11/2009; 24(6):750-2. DOI:10.1111/j.1540-8191.2009.00918.x · 0.89 Impact Factor

Publication Stats

3k Citations
621.56 Total Impact Points

Institutions

  • 2001–2015
    • Keck School of Medicine USC
      Los Ángeles, California, United States
  • 1995–2014
    • University of Southern California
      • • Department of Cardiothoracic Surgery
      • • Department of Surgery
      • • Keck School of Medicine
      Los Ángeles, California, United States
    • Kaiser Permanente
      Oakland, California, United States
  • 1994–2011
    • University of California, Los Angeles
      • • Department of Surgery
      • • Division of Cardiothoracic Surgery
      Los Ángeles, California, United States
  • 1994–2010
    • Children's Hospital Los Angeles
      • • Division of Cardiothoracic Surgery
      • • Division of Critical Care Medicine
      • • Department of Surgery
      Los Ángeles, California, United States
  • 2005
    • Indiana University-Purdue University Indianapolis
      Indianapolis, Indiana, United States