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Jeffrey L Anderson,
Jonathan L Halperin,
Nancy M Albert,
Biykem Bozkurt,
Ralph G Brindis,
Lesley H Curtis,
David Demets, Robert A Guyton,
Judith S Hochman,
Richard J Kovacs,
E Magnus Ohman,
Susan J Pressler,
Frank W Sellke,
Win-Kuang Shen
Circulation 04/2013; · 14.74 Impact Factor
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Jeffrey L Anderson,
Jonathan L Halperin,
Nancy M Albert,
Biykem Bozkurt,
Ralph G Brindis,
Lesley H Curtis,
David Demets, Robert A Guyton,
Judith S Hochman,
Richard J Kovacs,
E Magnus Ohman,
Susan J Pressler,
Frank W Sellke,
Win-Kuang Shen
Journal of the American College of Cardiology 03/2013; · 14.16 Impact Factor
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ABSTRACT: OBJECTIVE: The purpose of the present study was to determine the effect of different clamping strategies during coronary artery bypass grafting on the incidence of postoperative stroke. METHODS: In the present case-control study, all patients at Emory hospitals from 2002 to 2009 with postoperative stroke after isolated coronary artery bypass grafting (n = 141) were matched 1:4 to a contemporaneous cohort of patients without postoperative stroke (n = 565). The patients were matched according to the Society of Thoracic Surgeons' predicted risk of postoperative stroke score, which is based on 26 variables. The patients who received on-pump and off-pump coronary artery bypass grafting were matched separately. Multiple logistic regression analysis with adjusted odds ratios was performed to identify the operative variables associated with postoperative stroke. RESULTS: Among the on-pump cohort, the single crossclamp technique was associated with a decreased risk of stroke compared with the double clamp (crossclamp plus partial clamp) technique (odds ratio, 0.385; P = .044). Within the on-pump cohort, no significant difference was seen in the incidence of stroke according to clamp use. Epiaortic ultrasound of the ascending aorta increased from 45.3% in 2002 to 89.4% in 2009. From 2002 to 2009, clamp use decreased from 97.7% of cases to 72.7%. CONCLUSIONS: During on-pump coronary artery bypass grafting, the use of a single crossclamp compared with the double clamp technique decreased the risk of postoperative stroke. The use of any aortic clamp decreased and epiaortic ultrasound use increased from 2002 to 2009, indicating a change in the operative technique and surgeon awareness of the potential complications associated with manipulation of the aorta.
The Journal of thoracic and cardiovascular surgery 03/2013; · 3.41 Impact Factor
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Jeffrey L Anderson,
Jonathan L Halperin,
Nancy M Albert,
Biykem Bozkurt,
Ralph G Brindis,
Lesley H Curtis,
David Demets, Robert A Guyton,
Judith S Hochman,
Richard J Kovacs,
E Magnus Ohman,
Susan J Pressler,
Frank W Sellke,
Win-Kuang Shen
Circulation 03/2013; · 14.74 Impact Factor
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Jeffrey L Anderson,
Jonathan L Halperin,
Nancy Albert,
Biykem Bozkurt,
Ralph G Brindis,
Lesley H Curtis,
David Demets, Robert A Guyton,
Judith S Hochman,
Richard J Kovacs,
E Magnus Ohman,
Susan J Pressler,
Frank W Sellke,
Win-Kuang Shen
Journal of the American College of Cardiology 02/2013; · 14.16 Impact Factor
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Thomas G Brott,
Jonathan L Halperin,
Suhny Abbara,
J Michael Bacharach,
John D Barr,
Ruth L Bush,
Christopher U Cates,
Mark A Creager,
Susan B Fowler,
Gary Friday, [......],
Harlan M Krumholz,
Frederick G Kushner,
Bruce W Lytle,
Rick A Nishimura,
E Magnus Ohman,
Richard L Page,
Barbara Riegel,
William G Stevenson,
Lynn G Tarkington,
Clyde W Yancy
Catheterization and Cardiovascular Interventions 01/2013; 81(1):E76-E123. · 2.29 Impact Factor
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ABSTRACT: BACKGROUND: Optimizing treatment strategies to risk profile patients undergoing aortic valve replacement remains a priority. The role that specific and combinations of preoperative organ dysfunction (OD) plays in informing these decisions remains uncertain. This study sought to determine the relative effect that OD in particular systems has on short- and long-term outcomes. METHODS: A total of 1,759 aortic valve replacement cases with and without coronary artery bypass grafting performed from January 2002 to June 2010 at Emory University are the basis for this retrospective analysis. Patients were classified by the presence or absence of preoperative OD: (1) cardiac: congestive heart failure (ejection fraction <0.35), (2) pulmonary: forced expiratory volume in 1 second less than 50% predicted, (3) neurologic (prior stroke), and (4) renal: chronic renal failure. The impact of individual and combined OD on outcomes was evaluated. Kaplan-Meier survival estimates and Cox regression models were used to assess the relationship between OD and long-term survival. RESULTS: A total of 513 patients (29.2%) had at least one OD, including 95 patients (5.4%) with more than one OD. Organ dysfunction in each organ system was associated with poorer survival. Renal (hazard ratio, 3.90) and pulmonary (hazard ratio, 2.40) OD patients had poorer long-term survival, including 30-day mortality. Seven-year survival for OD patients is as follows: prior stroke, 48.6%; severe chronic obstructive pulmonary disease, 30.8%; congestive heart failure, 55.9%; and chronic renal failure, 11.7%. The sequential addition of OD systems was a powerful predictor of poorer long-term survival. CONCLUSIONS: The presence of chronic renal failure most profoundly decreases survival, followed by severe chronic obstructive pulmonary disease and prior stroke. Furthermore, multiple OD systems significantly decrease short- and long-term survival.
The Annals of thoracic surgery 12/2012; · 3.74 Impact Factor
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Alice K Jacobs,
Frederick G Kushner,
Steven M Ettinger, Robert A Guyton,
Jeffrey L Anderson,
E Magnus Ohman,
Nancy M Albert,
Elliott M Antman,
Donna K Arnett,
Marnie Bertolet, [......],
Sharon-Lise T Normand,
Eduardo Ortiz,
Eric D Peterson,
William H Roach,
Ralph L Sacco,
Sidney C Smith,
William G Stevenson,
Gordon F Tomaselli,
Clyde W Yancy,
William A Zoghbi
Circulation 12/2012; · 14.74 Impact Factor
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Alice K Jacobs,
Frederick G Kushner,
Steven M Ettinger, Robert A Guyton,
Jeffrey L Anderson,
E Magnus Ohman,
Nancy M Albert,
Elliott M Antman,
Donna K Arnett,
Marnie Bertolet, [......],
William G Stevenson,
Gordon F Tomaselli,
Clyde W Yancy,
William A Zoghbi,
John G Harold,
Yulei He,
Pamela B Mangu,
Amir Qaseem,
Michael R Sayre,
Mark R Somerfield
Journal of the American College of Cardiology 12/2012; · 14.16 Impact Factor
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Cynthia M Tracy,
Andrew E Epstein,
Dawood Darbar,
John P Dimarco,
Sandra B Dunbar,
N A Mark Estes,
T Bruce Ferguson,
Stephen C Hammill,
Pamela E Karasik,
Mark S Link, [......],
Nancy M Albert,
Mark A Creager,
David Demets,
Steven M Ettinger, Robert A Guyton,
Judith S Hochman,
Frederick G Kushner,
E Magnus Ohman,
William Stevenson,
Clyde W Yancy
The Journal of thoracic and cardiovascular surgery 12/2012; 144(6):e127-45. · 3.41 Impact Factor
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Mikhael F El-Chami,
Fadi J Sawaya,
Patrick Kilgo,
William Stein,
Michael Halkos,
Vinod Thourani,
Omar M Lattouf,
David B Delurgio, Robert A Guyton,
John D Puskas,
Angel R Leon
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ABSTRACT: OBJECTIVES: This study sought to investigate the prevalence, predictors, and outcomes of patients with postoperative ventricular arrhythmia (POVA) in a large cohort of patients. BACKGROUND: New-onset POVA after cardiac surgery (CS) is uncommon and has controversial prognostic value. METHODS: A total of 14,720 consecutive patients undergoing CS at Emory University between January 2004 and July 2010 were included in the study. Data on all-cause mortality were obtained from Social Security Administration death records. Multivariable regression models were constructed to determine the risk factors for POVA and to estimate the independent impact of POVA on long-term survival after adjusting for 40 different covariates. RESULTS: POVA occurred in 248 patients (1.7%). Patients with POVA were older (63.5 vs. 61.6 years), had lower left ventricular ejection fraction (EF) (43.7 vs. 51.3), and had greater comorbidities (Society of Thoracic Surgeons mortality risk score of 7.2% vs. 3.1%, p < 0.001). Multivariable analysis showed that older age (odds ratio [OR]: 1.018 per 1-year increase, p < 0.001), emergent surgery (OR: 1.77, p = 0.019), and the presence of PVD (OR: 1.41, p = 0.049) were associated with a higher incidence of POVA, whereas higher left ventricular EF (OR: 0.97 per 1% increase, p < 0.001), mild chronic obstructive pulmonary disease (OR: 0.37, p < 0.001), and off-pump surgery (OR: O.41, p < 0.001) were associated with a lower incidence of POVA. POVA was associated with substantially increased adjusted long-term mortality (hazard rate: 2.53, p < 0.001) over 3.5 years of follow-up. CONCLUSIONS: POVA is associated with increased long-term mortality after CS. Older age, PVD, lower EF, and emergent surgery are associated with a higher risk of POVA, whereas off-pump surgery seems to be protective.
Journal of the American College of Cardiology 11/2012; · 14.16 Impact Factor
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ABSTRACT: BACKGROUND: Patients at high and low body mass index have been shown to experience higher morbidity and mortality when undergoing coronary artery bypass grafting. The purpose of this research was to compare outcomes of patients at body mass index extremes who underwent coronary artery bypass grafting with or without cardiopulmonary bypass. METHODS: A retrospective review of 6801 patients with a body mass index <25 or >35 undergoing isolated, primary coronary artery bypass grafting from 1996 to 2009 at Emory Healthcare Hospitals was performed. Patients were compared by therapy either on-pump coronary artery bypass grafting (n = 3210) or off-pump coronary artery bypass grafting (n = 3591). Salvage patients or those with concomitant operations were excluded. Comparisons were made using multivariable regression analysis, using a propensity score covariate calculated from 41 preoperative risk factors. RESULTS: A total of 6801 patients, including 4312 with a body mass index <25 (off-pump coronary artery bypass grafting, n = 2083; on-pump coronary artery bypass grafting, n = 2229) and 2489 with a body mass index >35 (off-pump coronary artery bypass grafting, n = 1127; on-pump coronary artery bypass grafting, n = 1362) were included for analysis. Society of Thoracic Surgeons predicted risk of mortality was significantly higher for both body mass index strata in patients undergoing off-pump coronary artery bypass grafting (2.8% vs 3.1% for body mass index <25 [P = .043] and 1.7% vs 1.8% for body mass index >35 [P = .049]). For patients with a body mass index <25, multivariable analysis of outcomes showed a significant decrease in in-hospital mortality (adjusted odds ratio, 0.48; 95% confidence interval, 0.28-0.82), stroke (adjusted odds ratio, 0.31; 95% confidence interval, 0.18-0.56), new-onset renal failure (adjusted odds ratio, 0.59; 95% confidence interval, 0.36-0.96), and prolonged ventilation (adjusted odds ratio, 0.50; 95% confidence interval, 0.38-0.64). Long-term survival was unaffected by method of revascularization for either body mass index strata (P > .05). CONCLUSIONS: Patients with high and low body mass indices experience reduced morbidity and in-hospital mortality when undergoing off-pump coronary artery bypass grafting. Despite a higher risk profile, patients with a body mass index <25 who underwent off-pump coronary artery bypass grafting experienced a significant reduction in in-hospital mortality.
The Journal of thoracic and cardiovascular surgery 10/2012; · 3.41 Impact Factor
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ABSTRACT: Single-vessel disease of the left anterior descending (LAD) coronary artery may be surgically revascularized by left internal mammary artery (LIMA) grafting either through a sternotomy or a nonsternotomy approach. Nonsternotomy approaches are used in the hope of achieving a less invasive operation. It is unknown whether nonsternotomy approaches impact in-hospital or midterm outcomes.
The institutional Society of Thoracic Surgeons (STS) database at a single US academic center was reviewed for 597 consecutive patients treated surgically for single-vessel LAD disease from January 1, 2002 to June 30, 2011. In-hospital adverse events and length of stay (LOS) were compared between patients who had LIMA-LAD grafting performed through a sternotomy (sternotomy patients) versus patients who had this procedure performed through a nonsternotomy approach (nonsternotomy patients), adjusted for propensity score (likelihood of receiving sternotomy, calculated on 33 variables). Midterm survival between groups was compared using Kaplan-Meier and Cox regression analysis by referencing the National Social Security Death Index.
There were 597 consecutive patients who underwent single-vessel grafting by LIMA-LAD coronary artery grafting. Of these patients, 234 underwent sternotomy, whereas 363 patients had nonsternotomy procedures: 239 patients had endoscopic LIMA harvest and left anterolateral thoracotomy, 106 patients had robot LIMA harvest and left anterolateral thoracotomy, and 18 patients had minimally invasive direct coronary artery bypass. There were no strokes in the nonsternotomy group and 3 (1.3%) in the sternotomy group (p = 0.031). Thirty-day mortality, incidence of myocardial infarction, hospital LOS, and midterm survival were similar between groups. Operative time was significantly longer in the nonsternotomy group (1.8 hours, 95% confidence interval [CI], 1.5-2.1).
In this propensity-adjusted comparison, sternal-sparing incisions were associated with similar 30-day adverse events and midterm survival compared with sternotomy for single-vessel LIMA-LAD artery grafting.
The Annals of thoracic surgery 07/2012; 94(5):1469-77. · 3.74 Impact Factor
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Vinod H Thourani,
Colleen M Smith, Robert A Guyton,
Peter Block,
David Liff,
Patrick Willis,
Stamatios Lerakis,
Chesnal D Arepalli,
Sharon Howell,
Bryon J Boulton,
James Stewart,
Vasilis Babaliaros
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ABSTRACT: Patients who present with significant paravalvular regurgitation after mitral valve replacement remain a difficult patient population and high-risk surgical candidates. We present 3 cases of transapical closure of mitral valve paravalvular leak (PVL) after mitral valve replacement using Amplatzer closure devices (AGA Medical Corp, Plymouth, MN). All 3 patients experienced decreased regurgitation at the site of the closure as well as symptomatic improvement in their heart failure.
The Annals of thoracic surgery 07/2012; 94(1):275-8. · 3.74 Impact Factor
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ABSTRACT: The aim of this study was to create a simple risk index to predict new-onset atrial fibrillation (AF) after coronary artery bypass grafting in patients with histories of AF. AF after coronary artery bypass grafting (referred to here as AF) is associated with increased morbidity and mortality. Identifying patients at high risk for developing AF may help identify a group of patients who might benefit from strategies to prevent postoperative AF. A cohort of 18,517 patients enrolled from January 1, 1996, to December 31, 2009, was used to derive a risk index for AF prediction. A multivariate logistic regression model determined the independent predictive impact of clinical and demographic characteristics on the occurrence of AF. A subset of these variables was used to construct a risk index to predict AF. This risk index was validated in a sequential cohort of 1,378 consecutive patients who underwent coronary artery bypass grafting from January 1, 2010, to June 30, 2011. AF occurred in 3,486 patients in the calibration cohort (18.83%) and in 269 patients in the validation cohort (19.52%). After considering patients' demographics, co-morbid conditions, and severity of illness, advanced age appeared as the most powerful predictor of AF (odds ratio 1.059/year, 95% confidence interval 1.055 to 1.063). Age, height, weight, and the presence of peripheral vascular disease contributed most to the prediction model. An AF risk index including these variables had adequate discriminatory power, with a concordance index of 0.68. In conclusion, using a large cohort of patients, a simple risk index relying only on preoperative clinical variables was developed, which will help predict AF. This risk index can be used clinically to identify patients at high risk for the development of AF.
The American journal of cardiology 05/2012; 110(5):649-54. · 3.58 Impact Factor
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ABSTRACT: For the past few decades, coronary artery bypass grafting (CABG) using cardiopulmonary bypass (CPB) and cardioplegic arrest has been considered the standard for surgical coronary revascularization. Since the mid-1990s, there has been increased interest in avoiding the use of extracorporeal circulation and the bypass circuit during construction of the distal anastomoses. This interest in off-pump coronary artery bypass grafting (OPCAB) has, in large part, been because of the detrimental effects of CPB; specifically the inflammation response, adverse neurologic outcomes, and the multi-system organ injury that may occur. Importantly, OPCAB has been associated with reduced myocardial enzyme release, lower transfusion requirement, reduced pulmonary and renal complications, shorter length of stay, and lower cost.(1,2) (SELECT FULL TEXT TO CONTINUE).
Circulation 05/2012; 125(23):2806-8. · 14.74 Impact Factor
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ABSTRACT: Senile aortic stenosis (AS), the narrowing and progressive dysfunction of the valve between the heart and the aorta, is the
most common structural heart disease in the elderly, with an estimated increase in prevalence from approximately 38.7 million
in 2008 to 88.5 million by 2050. The indications for conventional open aortic valve replacement (AVR) utilizing cardiopulmonary
bypass remains the standard of care with excellent results. However, physicians remain reluctant to recommend AVR for elderly
patients or those considered very high risk. The advent of transcatheter aortic valve intervention (TAVI, transfemoral, and
transapical) represents a tremendous advance in our ability to treat high-risk patients with severe AS. By avoiding the risks
associated with aortic cross-clamping and cardiopulmonary bypass, it provides a treatment alternative for patients deemed
too high risk for conventional AVR. However, this technology is still in the initial stages of clinical use and thus several
design challenges and opportunities for improvements in the engineering concepts exist. This paper reviews the outcomes of
the two TAVI technologies currently in wide clinical use, the Edwards Sapien® Valve (ESV) and the Medtronic CoreValve® (MCV) and discusses potential improvements in the current design.
KeywordsAortic valve-Aortic stenosis-Transcatheter aortic valve technologies-Heart valve hemodynamics
04/2012; 1(1):77-87.
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Ritam Chowdhury,
Darcy White,
Patrick Kilgo,
John D Puskas,
Vinod H Thourani,
Edward P Chen,
Omar M Lattouf,
William A Cooper,
Richard J Myung, Robert A Guyton,
Michael E Halkos
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ABSTRACT: Off-pump coronary artery bypass graft (OPCAB) may be associated with improved hospital outcomes compared with on-pump coronary artery bypass graft. However, intraoperative conversion to on-pump coronary artery bypass graft has been associated with adverse outcomes. The purpose of this study was to identify preoperative risk factors for intraoperative conversion in nonemergent patients undergoing isolated OPCAB.
From 2002 to 2010, 8,077 consecutive OPCAB cases were performed at a single US academic center. Of these, 200 (2.5%) required intraoperative conversion. Standard variables from The Society of Thoracic Surgeons database were analyzed. A multivariable logistic model with adjusted odds ratios (OR) and 95% confidence intervals was used to identify independent risk factors for conversion. Adjusted in-hospital and long-term survival between converted and nonconverted patients were determined using multiple logistic regression and Cox proportional hazards regression, respectively.
Converted patients had a higher Society of Thoracic Surgeons predicted risk of mortality (2.8% versus 2.1%; p<0.001). Surgeon identity was the most significant multivariable predictor of conversion. After adjustment for surgeon identity, the following independent risk factors were associated with intraoperative conversion: previous coronary artery bypass graft (OR, 3.43; p=0.018), congestive heart failure (OR, 1.51), myocardial infarction (OR, 1.86), number of grafts (OR, 1.45), left main disease (OR 1.41), and urgent status (OR, 1.77; all p<0.05). Conversion to on-pump coronary artery bypass graft was associated with increased in-hospital (OR, 4.8; p<0.001) and long-term mortality (hazard ratio, 1.65; p<0.001).
Conversion to cardiopulmonary bypass during OPCAB is associated with increased in-hospital and long-term mortality and may be related to surgeon experience. Recognition of the preoperative risk factors associated with an increased risk of conversion may allow for better patient selection and reduce the incidence of intraoperative conversion during OPCAB.
The Annals of thoracic surgery 04/2012; 93(6):1936-41; discussion 1942. · 3.74 Impact Factor
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Glenn N Levine,
Eric R Bates,
James C Blankenship,
Steven R Bailey,
John A Bittl,
Bojan Cercek,
Charles E Chambers,
Stephen G Ellis, Robert A Guyton,
Steven M Hollenberg,
Umesh N Khot,
Richard A Lange,
Laura Mauri,
Roxana Mehran,
Issam D Moussa,
Debabrata Mukherjee,
Brahmajee K Nallamothu,
Henry H Ting
Catheterization and Cardiovascular Interventions 02/2012; 79(3):453-95. · 2.29 Impact Factor
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ABSTRACT: To examine the early results of the David V valve-sparing aortic root replacement procedure in expanded, higher risk clinical scenarios with appropriately selected patients.
From 2005 to 2011, 150 David V valve-sparing aortic root replacements were performed within Emory Healthcare. A total of 78 patients (expanded group) had undergone the David V in expanded, difficult clinical settings such as emergent type A dissection (n = 29), grade 3+ or greater aortic insufficiency (AI) (n = 53), or reoperative cardiac surgery (n = 14). These patients were evaluated and compared with a group of 72 patients (traditional group) with less than grade 3+ AI who underwent a David V in a traditional, elective setting. The mean follow-up was 19 months (range, 1-72), and the follow-up data were 88% complete.
There were 3 operative deaths (2.2%), all occurring in the expanded group. The overall patient survival at 6 years was 95%. Three patients required aortic valve replacement: two for severe AI and one for fungal endocarditis. Both groups had concomitant cusp repairs performed in conjunction with the David V (traditional, n = 10; and expanded, n = 16; P = .27). At follow-up, freedom from moderate AI was 93%, and the freedom from aortic valve replacement was 98%. No significant difference was observed in the freedom from moderate AI between the expanded and traditional groups (91% vs 95%, respectively; P = .16).
In selected patients possessing appropriate aortic cusp anatomy, the David V can be safely and effectively performed for the expanded indications of aortic dissection, severe AI, and reoperative cardiac surgery with low operative risk. Valve function has remained excellent in the short term, providing evidence of durability and a low rate of valve-related complications.
The Journal of thoracic and cardiovascular surgery 02/2012; 143(4):879-84. · 3.41 Impact Factor
