Hersh S Maniar

Washington University in St. Louis, San Luis, Missouri, United States

Are you Hersh S Maniar?

Claim your profile

Publications (44)207.83 Total impact

  • [Show abstract] [Hide abstract]
    ABSTRACT: An inflammatory response after cardiac surgery is associated with worse clinical outcomes, but recent trials to attenuate it have been neutral. We evaluated the association between systemic inflammatory response syndrome (SIRS) and mortality after transcatheter (TAVR) and surgical aortic valve replacement (SAVR) for aortic stenosis (AS) and evaluated whether diabetes influenced this relationship. Patients (n=747) with severe AS treated with TAVR (n=264) or SAVR (n=483) between January 2008 and December 2013 were included and 37% had diabetes mellitus. SIRS was defined by four criteria 12-48 h after aortic valve replacement (AVR): (1) white blood cell count <4 or >12; (2) heart rate >90; (3) temperature <36 or >38°C; or (4) respiratory rate >20. Severe SIRS was defined as meeting all four criteria. The primary endpoint was 6-month all-cause mortality (60 deaths occurred by 6 months). Inverse probability weighting (IPW) was performed on 44 baseline and procedural variables to minimise confounding. Severe SIRS developed in 6% of TAVR patients and 11% of SAVR patients (p=0.02). Six-month mortality tended to be higher in those with severe SIRS (15.5%) versus those without (7.4%) (p=0.07). After adjustment, severe SIRS was associated with higher 6-month mortality (IPW adjusted HR 2.77, 95% CI 2.04 to 3.76, p<0.001). Moreover, severe SIRS was more strongly associated with increased mortality in diabetic (IPW adjusted HR 4.12, 95% CI 2.69 to 6.31, p<0.001) than non-diabetic patients (IPW adjusted HR 1.74, 95% CI 1.10 to 2.73, p=0.02) (interaction p=0.007). The adverse effect of severe SIRS on mortality was similar after TAVR and SAVR. Severe SIRS was associated with a higher mortality after SAVR or TAVR. It occurred more commonly after SAVR and had a greater effect on mortality in diabetic patients. These findings may have implications for treatment decisions in patients with AS, may help explain differences in outcomes between different AVR approaches and identify diabetic patients as a high-risk subgroup to target in clinical trials with therapies to attenuate SIRS. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
    Heart (British Cardiac Society) 01/2015; · 6.02 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The clinical guidelines for asymptomatic patients with chronic mitral regurgitation (MR) use the ejection fraction (EF) to trigger surgical referral. We hypothesized that the EF is not sensitive enough to detect the earliest contractile injury in chronic MR and that the injury associated with chronic MR is not global but heterogeneous, occurring regionally and predictably, before the onset of global left ventricular (LV) dysfunction.
    Journal of Thoracic and Cardiovascular Surgery 10/2014; 148(4):1694-9. · 3.99 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Background and Aim of the StudyWe studied patients presenting for coronary artery bypass grafting (CABG) with significant left main coronary artery disease (LMD) despite previously documented minimal or no LMD at percutaneous coronary intervention (PCI) for left-sided branch coronary artery disease.Methods Patients undergoing CABG for LMD with previous PCI were separated into fast or slow stenosis progression using percent change in LMD from first PCI to CABG divided by time (progression velocity). Outcomes and Kaplan–Meier survival were compared between the two groups.ResultsBetween September 1997 and June 2010, 4837 patients underwent CABG with 1235 of them having previous PCI of which 118 had LMD and previous left-sided branch PCI. Using median progression velocity fast and slow progression groups were identified (0.53 ± 0.18 and 4.5 ± 4.8%/month, p < 0.001). Mean follow-up was 4.9 ± 3.6 years and 6.9 ± 3.9 years, respectively. Fast progression patients were younger (p = 0.042), with higher baseline LMD at PCI (16.4% vs. 9% stenosis, p = 0.025), and a mean of 2.5 years to LMD compared to 10.6 years for the slow group (p < 0.001). There was no difference between the groups in number or type of PCI and number or type of vessel intervened. Kaplan–Meier survival was similar at one, three, and five years.Conclusions Fast LMD progression patients were younger and made up 4.7% (59/1235) of patients undergoing CABG with a history of PCI. Rapid progression was not related to number, type of PCI, or branch vessel intervened.
    Journal of Cardiac Surgery 10/2014; · 1.35 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The impact of paravalvular regurgitation (PVR) following transcatheter aortic valve replacement (TAVR) remains uncertain. In this analysis, we sought to evaluate the impact of varying degrees of PVR on both mortality and changes in ventricular geometry and function.
    European Heart Journal 10/2014; · 14.72 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives The Cox-Maze IV has the best results for the surgical treatment of atrial fibrillation. It has been traditionally performed through sternotomy with excellent outcomes, but this has been felt to be too invasive. An alternative approach is to perform a less invasive right anterolateral mini-thoracotomy. This series compared these approaches at a single center in consecutive patients. Methods Patients receiving Cox-Maze IV (n=356) were retrospectively reviewed from January 2002 to February 2014. Patients were stratified into two groups: right mini-thoracotomy (RMT: n=104) and sternotomy (ST: n=252). Preoperative and perioperative variables were compared as well as long term outcomes. Patients were followed for up two years and rhythm was confirmed with electrocardiogram or prolonged monitoring. Results Freedom from atrial tachyarrhythmias off antiarrhythmic drugs was 81% and 74% at 1 and 2 year respectively using a RMT approach and was not significantly different from the ST group at these same time points. Overall complication rate was lower in the RMT group (6% vs. 13%, p=0.044) as was 30 day morality (0% vs. 4%, p=0.039). Median ICU length of stay was lower in the RMT group (2 days [range 0-21] vs. 3 days [range 1-61], p=0.004) as was median hospital length of stay (7 days [range 4-35] vs. 9 days [range 1-111], p<0.001). Conclusions The Cox-Maze IV performed through a right mini-thoracotomy is as effective as sternotomy in the treatment of atrial fibrillation. This approach was associated with fewer complications and decreased mortality and decreased ICU and hospital length of stays.
    Journal of Thoracic and Cardiovascular Surgery 09/2014; · 3.99 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Reducing hospital readmissions after adult cardiac surgery is necessary as part of the solution to achieving improved efficiency in health care. Patients who had undergone cardiac surgery were studied to develop strategies that may diminish the need for hospital readmission. Over a 25-month period, 2096 patients underwent cardiac surgical procedures; 102 of these patients required readmission within 30 days of discharge. Time-matched patients (n = 249), not readmitted, served as a control group. Patient demographics and perioperative variables were analyzed by univariate analyses. Logistic regression analysis identified independent risk factors for readmission. The most common diagnoses given for readmission were congestive heart failure (26 of 102, 25%), infection (23 of 102, 23%), and arrhythmias (15 of 102, 15%). The comorbidities more prevalent among readmitted patients were diminished ejection fraction (44% ± 17% vs 56% ± 13%; P < .0001), chronic obstructive pulmonary disease (23 of 102, 23% vs 23 of 249, 9%; P = .0008) and chronic renal insufficiency (26 of 102, 26% vs 24 of 249, 10%; P = .0001). Multivariate logistic regression identified chronic obstructive pulmonary disease (odds ratio [OR], 2.0; P = .05), diminished ejection fraction (OR, 0.8; P < .0001), a lower education level (OR, 0.5; P = .0001), and a prolonged length of stay (OR, 1.6; P = .009) as predictive of readmission. Failure to see a physician early in the postoperative period was associated with a 6-fold increase in the risk of readmission (P < .0001). Patients readmitted after cardiac surgery have specific comorbidities and are of lower socioeconomic status. They are admitted most commonly for exacerbation of congestive heart failure or infectious reasons. This study suggests that seeing a physician early after discharge may have an impact on reducing readmissions after cardiac surgery.
    The Journal of thoracic and cardiovascular surgery 12/2013; · 3.41 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: More than 50% of atrial fibrillation surgery occurs in the setting of mitral valve surgery. Despite this, no risk models have been validated for concomitant arrhythmia surgery. The purpose of the present study was to quantify the additional risk of performing the Cox-maze IV procedure for patients undergoing mitral valve surgery. From January 2002 to June 2011, 213 patients with mitral valve disease and preoperative atrial fibrillation underwent mitral valve surgery only (n = 109) or in conjunction with a Cox-maze IV procedure (n = 104). The operative mortality for the mitral valve procedure alone was predicted for each group using the Society of Thoracic Surgeons perioperative risk calculator. The risk attributed to the added Cox-maze IV procedure was calculated by comparing the predicted mortality rate of an isolated mitral valve procedure and the actual mortality rate of mitral valve surgery with a concomitant Cox-maze IV procedure. For patients not undergoing a Cox-maze IV procedure, the predicted and actual postoperative mortality rate was 5.5% and 4.6% (5 of 109), respectively. For patients receiving mitral valve surgery and a concomitant Cox-maze IV, the predicted and actual postoperative mortality of the mitral valve procedure was 2.5% and 2.9% (3 of 104), respectively, and not significantly different. Patients not offered a Cox-maze IV procedure had significantly more serious comorbidities. For patients with atrial fibrillation and mitral valve disease undergoing mitral valve surgery, the decision to offer a concomitant Cox-maze IV procedure will be influenced by the underlying comorbid conditions. Nonetheless, in selected lower risk patients, the addition of a Cox-maze IV procedure did not significantly affect the procedural mortality.
    The Journal of thoracic and cardiovascular surgery 08/2013; · 3.41 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Failed catheter-based ablation for the treatment of atrial fibrillation is an indication for the Cox-maze procedure. Many patients are referred for the Cox-maze IV procedure with recurrent atrial fibrillation after a previous catheter-based ablation, but the efficacy and safety of surgical management in these patients remains unclear. Data were collected prospectively on 129 consecutive patients who underwent a stand-alone Cox-maze IV procedure. Patients were grouped by the presence (n = 61; 47%) or absence (n = 68; 53%) of previous catheter ablation history. Follow-up was conducted at 3, 6, and 12 months (94% complete, mean 15.1 ± 15.6 months) with electrocardiograms and 24-hour Holter monitoring. In patients with no ablation history compared with those with, freedom from atrial tachyarrhythmias and antiarrhythmic drugs were similar at 3 months (73% versus 67%), 6 months (85% versus 83%), and 12 months (81% versus 87%; p < 0.05 for all). Those who had failed previous catheter ablation had significantly smaller left atria and longer durations of atrial fibrillation, and were more likely to have persistent atrial fibrillation compared with the group without prior ablation history. All analyzed baseline patient characteristics and comorbidities were similar between the groups. No differences were found in complication rates or surrogate measures of operative difficulty. The Cox-maze IV procedure is safe and effective in treating recurrent atrial fibrillation regardless of previous catheter ablation history. Surgical management should be considered in patients who have failed catheter ablation for the treatment of their atrial fibrillation.
    The Annals of thoracic surgery 08/2013; · 3.45 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The use of surgical lesion sets for the treatment of atrial fibrillation has been increasing, particularly in patients with complicated anatomical substrates and those undergoing concomitant surgery. Preferences in terms of lesion set, surgical approach and ablation technology vary by center. This review discusses both the surgical techniques and the outcomes for the most commonly performed procedures in the context of recent consensus guidelines. The Cox-Maze IV, pulmonary vein isolation, extended left atrial lesion sets, the hybrid approach and ganglionated plexus ablation are each reviewed in an attempt to provide insight into current clinical practice and patient selection.
    Circulation Journal 07/2013; · 3.69 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Racial disparities exist in the treatment of many cardiovascular diseases. Aortic valve replacement (AVR) is the only treatment for aortic stenosis (AS) that improves patient symptoms and survival. To date, no studies have compared the rate of AVR among different races. The records of patients with an aortic valve area <1 cm(2) by echocardiography diagnosed between January 2004 and May 2010 at Barnes-Jewish Hospital were reviewed retrospectively. Patients were stratified by race. Of the 880 patients analyzed, 10% were African American (AA), and 90% were European American (EA). AA more frequently had hypertension (82% vs 67%, p <0.01), diabetes mellitus (45% vs 32%, p = 0.02), chronic kidney disease (28% vs 17%, p = 0.01), and end stage renal disease (18% vs 2%, p <0.001). AA underwent AVR less frequently than EA (39% vs 53%, p = 0.02) and refused intervention more often (33% vs 20%, p = 0.04). When treated, AA and EA had similar 3-year survival (49% [38 to 60] vs 50% [45 to 54], p = 0.31). Identification of the factors associated with treatment refusal would further our ability to counsel patients on the decision to pursue AVR.
    The American journal of cardiology 06/2013; · 3.58 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND: The incidence of and causes for permanent pacemaker implantation (PPM) after surgical arrhythmia procedures remain poorly understood because of the varied lesion patterns and energy sources reported in small series. This study characterized the incidence, indications, and risk factors for PPM after the Cox-maze IV (CMIV) procedure when performed as either a lone or a concomitant procedure. METHODS: A retrospective analysis of 340 patients undergoing a CMIV as either a lone (n = 112) or a concomitant (n = 228) procedure was conducted. The incidence, indication, and variables associated with PPM implantation within 1 year of the operation were assessed. Follow-up was conducted at 30 days and 1 year and was 90% complete. RESULTS: The incidence of PPM after a lone CMIV procedure was 5%. Patients with concomitant cardiac operations had a nonsignificant increase in PPM insertion at 30 days (11% vs 5%, p = 0.14) and 1 year (15% vs 6%, p = 0.06) when compared with lone CMIV patients. Of patients who required pacemakers, sinus node dysfunction was present in 79% (35/44) of patients in the entire series and in 88% (8/9) after lone CMIV. After PPM, 84% (37/44) of patients remained paced at last follow-up. Multivariate analysis identified age (odds ratio = 1.10 [1.06-1.14], p < 0.001) as the only variable associated with higher risk of a PPM after any CMIV procedure. CONCLUSIONS: The risk of PPM implantation after a lone CMIV is 5% and increases with age. The need for a PPM after a CMIV is largely due to SA node dysfunction, which appears unlikely to recover. These data should help physicians counsel patients regarding the perioperative risks associated with the CMIV.
    The Annals of thoracic surgery 04/2013; · 3.45 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Background—The Placement of Aortic Transcatheter Valves (PARTNER) trial demonstrated similar survival after transcatheter and surgical aortic valve replacement (TAVR and SAVR, respectively) in high-risk patients with symptomatic, severe aortic stenosis. The aim of this study was to evaluate the effect of left ventricular (LV) dysfunction on clinical outcomes after TAVR and SAVR and the impact of aortic valve replacement technique on LV function. Methods and Results—The PARTNER trial randomized high-risk patients with severe aortic stenosis to TAVR or SAVR. Patients were stratified by the presence of LV ejection fraction (LVEF) <50%. All-cause mortality was similar for TAVR and SAVR at 30-days and 1 year regardless of baseline LV function and valve replacement technique. In patients with LV dysfunction, mean LVEF increased from 35.7±8.5% to 48.6±11.3% (P<0.0001) 1 year after TAVR and from 38.0±8.0% to 50.1±10.8% after SAVR (P<0.0001). Higher baseline LVEF (odds ratio, 0.90 [95% confidence interval, 0.86, 0.95]; P<0.0001) and previous permanent pacemaker (odds ratio, 0.34 [95% confidence interval, 0.15, 0.81]) were independently associated with reduced likelihood of ≥10% absolute LVEF improvement by 30 days; higher mean aortic valve gradient was associated with increased odds of LVEF improvement (odds ratio, 1.04 per 1 mm Hg [95% confidence interval, 1.01, 1.08]). Failure to improve LVEF by 30 days was associated with adverse 1-year outcomes after TAVR but not SAVR. Conclusions—In high-risk patients with severe aortic stenosis and LV dysfunction, mortality rates and LV functional recovery were comparable between valve replacement techniques. TAVR is a feasible alternative for patients with symptomatic severe aortic stenosis and LV dysfunction who are at high risk for SAVR. Clinical Trial Registration—URL: http://www.clinicaltrials.gov. Unique identifier: NCT00530894.
    Circulation Cardiovascular Interventions 01/2013; 6. · 6.98 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Objectives To determine whether a less invasive approach to aortic valve replacement (AVR) improves clinical outcomes in diabetic patients with aortic stenosis (AS). Background Diabetes is associated with increased morbidity and mortality after surgical AVR for AS. Methods Among treated patients with severe symptomatic AS at high-risk for surgery in the PARTNER trial, we examined outcomes stratified by diabetes status of patients randomly assigned to transcatheter or surgical AVR. The primary outcome was all-cause mortality at 1 year. Results Among 657 patients enrolled in PARTNER who underwent treatment, there were 275 patients with diabetes (145 transcatheter, 130 surgical). There was a significant interaction between diabetes and treatment group for 1-year all-cause mortality (p=0.048). Among diabetic patients, all-cause mortality at 1 year was 18.0% in the transcatheter group and 27.4% in the surgical group (HR 0.60; 95% CI, 0.36-0.99; p=0.04). Results were consistent among patients treated via transfemoral or transapical routes. In contrast, among non-diabetic patients, there was no significant difference in all-cause mortality at 1 year (p=0.48). Among diabetic patients, the 1-year rates of stroke were similar between treatment groups (3.5% transcatheter vs. 3.5% surgery, p=0.88), but the rates of renal failure requiring dialysis >30 days were lower in the transcatheter group (0% vs. 6.1%, p=0.003). Conclusions Among patients with diabetes and severe symptomatic AS at high-risk for surgery, this post-hoc stratified analysis of the PARTNER trial suggests there is a survival benefit, no increase in stroke, and less renal failure from treatment with transcatheter compared to surgical AVR. Clinical trial info NCT00530894
    Journal of the American College of Cardiology 01/2013; 63(11). · 15.34 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: OBJECTIVE: The Heart Rhythm Society, European Heart Rhythm Association, and European Cardiac Arrhythmia Society jointly recommend indefinite warfarin anticoagulation in patients with CHADS(2) (congestive heart failure, hypertension, age, diabetes, and stroke) score of at least 2 who have undergone ablation for atrial fibrillation. This study determined the impact of CHADS(2) score on risk of late stroke or transient ischemic attack after the performance of a surgical Cox maze procedure. METHODS: A retrospective review of 433 patients who underwent a Cox maze procedure at our institution was conducted. Three months after surgery, warfarin was discontinued regardless of CHADS(2) score if the patient showed no evidence of atrial fibrillation, was off antiarrhythmic medications, and had no other indication for anticoagulation. A follow-up questionnaire was used to determine whether any neurologic event had occurred since surgery. RESULTS: Follow-up was obtained for 90% of the study group (389/433) at a mean of 6.6 ± 5.0 years. Among these patients, 32% (125/389) had a CHADS(2) score of at least 2, of whom only 40% (51/125) remained on long-term warfarin after surgery. Six patients had late neurologic events (annualized risk of 0.2%). Neither CHADS(2) score nor warfarin anticoagulation was significantly associated with the occurrence of late neurologic events. Among the individual CHADS(2) criteria, both diabetes mellitus and previous stroke or transient ischemic attack were predictive of late neurologic events. CONCLUSIONS: The risk of stroke or transient ischemic attack in patients after a surgical Cox maze procedure was low and not associated with CHADS(2) score or warfarin use. Given the known risks of warfarin, we recommend discontinuation of anticoagulation 3 months after the procedure if the patient has no evidence of atrial fibrillation, has discontinued antiarrhythmic medications, and is without any other indication for systemic anticoagulation.
    The Journal of thoracic and cardiovascular surgery 07/2012; · 3.41 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Papillary fibroelastomas are rare, benign cardiac tumors. They are predominantly asymptomatic. However, they can lead to serious complications, namely thromboembolic events. Symptomatic lesions can be managed primarily with surgical excision and valvular preservation. Controversy exists as to the management of asymptomatic lesions. All patients diagnosed with cardiac papillary fibroelastoma between 1996 and 2012 at a single institution were queried for clinical and pathologic characteristics. Twenty-three patients with 29 lesions were identified. Most lesions were solitary, less than 1.0 cm in diameter, and occurred in patients greater than 60 years of age. The most common presentation was thromboembolic complication. All were managed successfully with surgical excision. One patient developed a recurrence or metachronous lesion within 3 months of initial surgical intervention. Papillary fibroelastomas are rare, benign, predominantly asymptomatic cardiac tumors that can cause potentially serious complications. The natural history and etiology of papillary fibroelastomas are largely unknown. Controversy exists over the management of asymptomatic lesions. However, there is consensus that symptomatic lesions should undergo surgical excision with valvular preservation when possible. A unique case of a possible papillary fibroelastoma recurrence is also described.
    The Annals of thoracic surgery 05/2012; 94(2):537-41. · 3.45 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: This study compared Cox-Maze IV (CMIV) outcomes for the treatment of atrial fibrillation (AF) in patients with lone AF vs those with AF and mitral valve (MV) disease. Since 2002, 200 patients have undergone a CMIV procedure for lone AF (n=101) or concomitantly with MV operations (n=99). Preoperative, perioperative, and late outcomes between these groups were compared. Data were collected prospectively and reported at 3, 6, and 12 months. Lone AF patients had AF of longer duration; patients with AF and MV disease were older, with larger left atria and worse New York Heart Association classification (p<0.05). Operative mortality (1% vs 4%, p>0.05, respectively) was similar between both groups. Perioperative atrial tachyarrhythmias were more prevalent in patients with concomitant MV operations (57% vs 41%, p=0.03); however, freedom from AF and antiarrhythmics was similar for both groups at 12 months (76% and 77%). The only predictor for atrial tachyarrhythmia recurrence or arrhythmic drug dependence was failure to isolate the posterior left atrium (p<0.01). Patients with AF and MV disease have distinct comorbidities compared with patients with lone AF. However, the CMIV is safe and effective in both groups and should be considered for patients with AF undergoing MV operations. Patients with MV disease had more atrial tachyarrhythmias at 3 months, but freedom from AF and antiarrhythmics was similar to patients with lone AF at 1 year. The posterior left atrium should be isolated in every patient, because this was the only predictor for failure of the CMIV for either group.
    The Annals of thoracic surgery 03/2012; 93(3):789-94; discussion 794-5. · 3.45 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: The Cox-Maze procedure (CMP) has achieved high success rates in the therapy of atrial fibrillation (AF) while becoming progressively less invasive. This report evaluates our experience with the CMP in the treatment of lone AF over 2 decades and compares the original cut-and-sew CMP-III to the ablation-assisted CMP-IV, which uses bipolar radiofrequency and cryoenergy to create the original lesion pattern. Data were collected prospectively on 212 consecutive patients (mean age, 53.5±10.4 years; 78% male) who underwent a stand-alone CMP from 1992 through 2010. The median duration of preoperative AF was 6 (interquartile range, 2.9-11.5) years, with 48% paroxysmal and 52% persistent or long-standing persistent AF. Univariate analysis with preoperative and perioperative variables used as covariates for the CMP-III (n=112) and the CMP-IV (n=100) was performed. Overall, 30-day mortality was 1.4%, with no intraoperative deaths. Freedom from AF was 93%, and freedom from AF off antiarrhythmics was 82%, at a mean follow-up time of 3.6±3.1 years. Freedom from symptomatic AF at 10 years was 85%. Only 1 late stroke occurred, with 80% of patients not receiving anticoagulation therapy. The less invasive CMP-IV had significantly shorter cross-clamp times (41±13 versus 92±26 minutes; P<0.001) while achieving high success rates, with 90% freedom from AF and 84% freedom from AF off antiarrhythmics at 2 years. The CMP, although simplified and shortened by alternative energy sources, has excellent results, even with improved follow-up and stricter definition of failure.
    Circulation Arrhythmia and Electrophysiology 11/2011; 5(1):8-14. · 5.95 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Increased right atrial (RA) and ventricular (RV) chamber volumes are a late maladaptive response to chronic pulmonary hypertension. The purpose of the current investigation was to characterize the early compensatory changes that occur in the right heart during chronic RV pressure overload before the development of chamber dilation. Magnetic resonance imaging with radiofrequency tissue tagging was performed on dogs at baseline and after 10 wk of pulmonary artery banding to yield either mild RV pressure overload (36% rise in RV pressure; n = 5) or severe overload (250% rise in RV pressure; n = 4). The RV free wall was divided into three segments within a midventricular plane, and circumferential myocardial strain was calculated for each segment, the septum, and the left ventricle. Chamber volumes were calculated from stacked MRI images, and RA mechanics were characterized by calculating the RA reservoir, conduit, and pump contribution to RV filling. With mild RV overload, there were no changes in RV strain or RA function. With severe RV overload, RV circumferential strain diminished by 62% anterior (P = 0.04), 42% inferior (P = 0.03), and 50% in the septum (P = 0.02), with no change in the left ventricle (P = 0.12). RV filling became more dependent on RA conduit function, which increased from 30 ± 9 to 43 ± 13% (P = 0.01), than on RA reservoir function, which decreased from 47 ± 6 to 33 ± 4% (P = 0.04), with no change in RA pump function (P = 0.94). RA and RV volumes and RV ejection fraction were unchanged from baseline during either mild (P > 0.10) or severe RV pressure overload (P > 0.53). In response to severe RV pressure overload, RV myocardial strain is segmentally diminished and RV filling becomes more dependent on RA conduit rather than reservoir function. These compensatory mechanisms of the right heart occur early in chronic RV pressure overload before chamber dilation develops.
    AJP Heart and Circulatory Physiology 09/2011; 301(6):H2362-71. · 4.01 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The Cox-maze III procedure (CMP) has achieved high success rates for the surgical treatment of atrial fibrillation (AF). In 2002, our group introduced a simplified CMP, in which most incisions were replaced with linear lines of ablation using bipolar radiofrequency and cryoenergy. This operation, termed the CMP-IV, has significantly shortened operative times and allowed for a minimally invasive approach. This report evaluates our results in 100 consecutive patients undergoing a stand-alone CMP-IV. Data were collected prospectively on 100 patients (mean age, 56 ± 10 years) who underwent a CMP-IV from January 2002 through May 2010. All patients were available for follow-up with a mean follow-up of 17 ± 10 months. Electrocardiograms or 24-h Holter monitorings were obtained at 6, 12, and 24 months. Data were analyzed using a longitudinal database containing over 380 variables. Thirty-one percent of patients had paroxysmal AF, with the remainder having persistent (6%) or longstanding persistent AF (63%). The mean preoperative duration of AF was 7.4 ± 6.7 years. The mean left atrial diameter was 4.7 ± 1.1 cm. In this group, 40 patients had failed with a mean of 2.6 ± 1.3 catheter ablations. Mean aortic cross-clamp time was 41 ± 13 min. There was one postoperative mortality. Postoperative freedom from AF was 93%, 90%, and 90% at 6, 12, and 24 months, respectively. Freedom from AF off antiarrhythmic medication was 82%, 82%, and 84% at 6, 12, and 24 months, respectively. The less invasive CMP-IV has a high single procedure success rate, even with improved follow-up and stricter definitions of failure.
    Journal of Interventional Cardiac Electrophysiology 02/2011; 31(1):47-54. · 1.39 Impact Factor
  • Journal of The American College of Cardiology - J AMER COLL CARDIOL. 01/2011; 57(14).

Publication Stats

1k Citations
207.83 Total Impact Points


  • 2002–2015
    • Washington University in St. Louis
      • • Division of Cardiothoracic Surgery
      • • Department of Surgery
      San Luis, Missouri, United States
  • 2004–2014
    • Barnes Jewish Hospital
      San Luis, Missouri, United States
    • Weill Cornell Medical College
      • Department of Surgery
      New York City, New York, United States
  • 2009
    • Christiana Care Health System
      Wilmington, Delaware, United States
  • 2002–2005
    • University of Washington Seattle
      • Division of Cardiothoracic Surgery
      Seattle, WA, United States
  • 2003
    • University of Missouri - St. Louis
      Saint Louis, Michigan, United States
  • 2000
    • Children’s Heart Institute
      Leesburg, Virginia, United States