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ABSTRACT: OBJECTIVE:: To evaluate whether transfusion of cell saver salvaged, stored at the bedside for up to 24 hrs, would decrease the number of postoperative allogeneic RBC transfusions and donor exposures, and possibly improve clinical outcomes. DESIGN:: Prospective, randomized, controlled, clinical trial. SETTING:: Pediatric cardiac intensive care unit. PATIENTS:: Infants weighing less than 20 kg (n = 106) presenting for cardiac surgery with cardiopulmonary bypass. INTERVENTIONS:: Subjects were randomized to a cell saver transfusion group where cell saver blood was available for transfusion up to 24 hrs after collection, or to a control group. Cell saver subjects received cell saver blood for volume replacement and/or RBC transfusions. Control subjects received crystalloid or albumin for volume replacement and RBCs for anemia. Blood product transfusions, donor exposures, and clinical outcomes were compared between groups. MEASUREMENTS AND MAIN RESULTS:: Children randomized to the cell saver group had significantly fewer RBC transfusions (cell saver: 0.19 ± 0.44 vs. control: 0.75 ± 1.2; p = 0.003) and coagulant product transfusions in the first 48 hrs post-op (cell saver: 0.09 ± 0.45 vs. control: 0.62 ± 1.4; p = 0.013), and significantly fewer donor exposures (cell saver: 0.60 ± 1.4 vs. control: 2.3 ± 4.8; p = 0.019). This difference persisted over the first week post-op, but did not reach statistical significance (cell saver: 0.64 ± 1.24 vs. control: 1.1 ± 1.4; p = 0.07). There were no significant clinical outcome differences. CONCLUSION:: Cell saver blood can be safely stored at the bedside for immediate transfusion for 24 hrs after collection. Administration of cell saver blood significantly reduces the number of RBC and coagulant product transfusions and donor exposures in the immediate postoperative period. Reduction of blood product transfusions has the potential to reduce transfusion-associated complications and decrease postoperative morbidity. Larger studies are needed to determine whether this transfusion strategy will improve clinical outcomes.
Pediatric Critical Care Medicine 01/2013; · 3.13 Impact Factor
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ABSTRACT: This study sought to determine if serum markers for collagen I and III synthesis, the carboxyl terminal peptide from pro-collagen I (PICP) and the amino terminal peptide from pro-collagen III (PIIINP), correlate with left atrial (LA) fibrosis and post-operative atrial fibrillation (AF).
AF after cardiac surgery is associated with adverse outcomes. We recently demonstrated that LA fibrosis is associated with post-operative AF in patients with no previous history of AF.
Fifty-four patients having cardiac surgery without a history of AF consented to left and right atrial biopsies and a pre-operative peripheral blood draw. Picrosirius red staining quantified the percentage of fibrosis, and reverse transcriptase polymerase chain reaction assessed atrial tissue messenger ribonucleic acid transcripts involved in the fibrosis pathway. PICP and PIIINP levels were measured using an enzyme immunosorbent assay.
Eighteen patients developed AF, whereas 36 remained in normal sinus rhythm. LA fibrosis was higher in patients who developed AF versus normal sinus rhythm (6.13 ± 2.9% vs. 2.03 ± 1.9%, p = 0.03). LA messenger ribonucleic acid transcripts for collagen I, III, transforming growth factor, and angiotensin were 1.5- to 2.0-fold higher in AF patients. Serum PICP and PIIINP levels were highest in AF versus normal sinus rhythm (PICP: 451.7 ± 200 ng/ml vs. 293.3 ± 114 ng/ml, p = 0.006; PIIINP: 379 ± 286 pg/ml vs. 191.6 ± 162 pg/ml, p = 0.01). Furthermore, there was a linear correlation between LA fibrosis and serum PICP levels (R(2) = 0.2; p = 0.01), and of the markers, only PICP was independently associated with AF.
This demonstrates that serum PICP and PIIINP levels correlate with the presence of LA fibrosis and may act as predictors for post-operative AF even in the absence of previous history of AF.
Journal of the American College of Cardiology 09/2012; 60(18):1799-806. · 14.16 Impact Factor
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ABSTRACT: Supravalvar pulmonary stenosis (SVPS) is frequently observed after arterial switch. Traditionally the coronary arteries are removed from the neopulmonic root by excising the entire sinus of Valsalva. As a result, reconstruction of the neopulmonic root requires a pericardial patch encompassing two-thirds of the anastomosis between the neopulmonic root and pulmonary artery. We present a technique where the coronary arteries are removed as limited buttons of sinus tissue, leaving the transected edge of the neopulmonic root intact. We hypothesize that maintaining native arterial tissue in the anastomosis between the neopulmonic root and the pulmonary artery bifurcation reduces postoperative SVPS.
We performed a retrospective review of neonates with D-transposition of the great arteries undergoing arterial switch procedure from 1996 to 2009. Charts were reviewed, and clinical outcomes recorded for each patient. Most recent echocardiograms were evaluated for right ventricular outflow tract obstruction. A total of 120 patients received arterial switch using this technique. There was 99% survival and no injuries to the coronary arteries regardless of anatomy. Total follow-up was 564 patient-years. Mean follow-up at last clinical visit was 66±46 months. Evaluation of the most recent outpatient echocardiogram revealed an average peak instantaneous gradient across the neopulmonic root of 22.5±5 mm Hg. Only 7 (5%) patients required reintervention (balloon dilation, n=5; surgery, n=2).
Our technique of removing the coronary arteries as limited buttons, and anastomosis of the pulmonary artery using only native arterial tissue provides excellent midterm results with minimal SVPS.
Circulation 09/2012; 126(11 Suppl 1):S118-22. · 14.74 Impact Factor
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ABSTRACT: OBJECTIVE: Right ventricular outflow tract (RVOT) reconstruction necessitates frequent reoperation. To understand the early outcomes, we analyzed our results to provide the intra- and postoperative morbidity and mortality. We hypothesized that multiple previous sternotomies do not influence the morbidity, mortality, or survival. DESIGN: We performed a retrospective review of patients who underwent reoperative RVOT reconstruction at the University of Rochester Medical Center and SUNY Upstate Medical Center from January 1, 2000 to December 31, 2009. Patients were divided into three groups based upon the number of previous sternotomies: Group 1 with one, Group 2 with two, and Group 3 with three or more previous sternotomies. RESULTS: 220 patients had reoperative RVOT reconstruction, 103 in Group 1, 71 in Group 2, and 46 in Group 3. There was no difference in the percentage of inadvertent cardiotomy between groups (Group 1: 2%, Group 2: 1%, Group 3: 2%; P =.9) The number of previous sternotomies had no effect upon infection, arrhythmia, or the percentage of patients who received a red blood cell transfusion (Group 1: 56%, Group 2: 49% Group 3: 43%; P =.3). Perioperative mortality for the entire group was 3/220 (1.4%), with no difference between groups. At a mean follow-up of 39 months, there was a survival of 98% for Groups 1 and 3 and 97% for Group 2 (P =.7). CONCLUSION: Reoperative RVOT reconstruction can safely be performed with limited morbidity and mortality. The number of previous sternotomies does not influence the rate of cardiotomy, red blood cell transfusion, or early outcome.
Congenital Heart Disease 06/2012; · 0.90 Impact Factor
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ABSTRACT: Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) can result in left-ventricular distension and the development of pulmonary edema. We present the case of a 13-year-old girl who presented with cardiogenic shock. VA-ECMO was initiated, but after 6 days, severe left-ventricular distension resulted in decreased VA-ECMO flows. With guidance by bedside transesophageal echocardiography, a percutaneous atrial transseptal cannula was placed and connected to the venous circuit, thus decompressing the left ventricle. The patient improved, was weaned from VA-ECMO 5 days later, and was discharged from the hospital. Bedside transseptal catheter insertion is an effective method of left-ventricular decompression.
Pediatric Cardiology 01/2012; 33(1):185-7. · 1.30 Impact Factor
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ABSTRACT: The goal of aortic coarctation repair is laminar aortic blood flow resulting in a negative or absent arm:leg blood pressure (BP) gradient. Despite satisfactory relief of coarctation, associated arch hypoplasia can result in residual obstruction and postoperative upper body hypertension.
We devised a surgical strategy to create a tension-free anastomosis with a diameter as large as both the adjacent proximal and distal aorta using a radically extended end-to-end anastomosis via sternotomy and/or thoracotomy. Sternotomy is chosen when there is significant transverse arch hypoplasia defined as a distal transverse arch ≤ diameter of the left carotid artery, presence of a common brachiocephalic trunk, or coexisting intracardiac lesion requiring repair. Thoracotomy is used in all other cases.
From 2000 to 2008, 95 consecutive patients were repaired using this approach, 35 with sternotomy and 60 with thoracotomy. At a mean follow-up of 50 ± 23 months, mean systolic BP was 94 ± 10 mm Hg, and 84% of patients had no residual arm:leg BP gradient. Mean arm:leg BP gradient was not statistically different between groups (-8.5 ± 15 sternotomy and -7.0 ± 10 mm Hg thoracotomy, P= .7). With Doppler echocardiography, 96% of patients demonstrated normal early diastolic reversal of blood flow in the descending thoracic aorta.
For aortic coarctation repair in infancy, a strategy designed to directly address aortic arch hypoplasia results in excellent intermediate-term results with normal BP, physiologic arm:leg BP relationship, and near normal descending aortic blood flow velocities by Doppler.
Congenital Heart Disease 11/2011; 6(6):583-91. · 0.90 Impact Factor
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ABSTRACT: The optimal conduit for right ventricular outflow tract (RVOT) reconstruction is uncertain, with varying degrees of longevity reported for pericardial, homograft, and xenograft valves utilized in this position.
A retrospective review of children and adults with congenital heart disease who underwent RVOT reconstruction with the Carpentier Edwards™ (CE) porcine valved conduit was conducted from 2001 to 2009 at the University of Rochester and SUNY Upstate Medical Centers. Clinical data were analyzed for each subject according to conduit size, and all of the Doppler derived transconduit gradients from postoperative echocardiograms were analyzed.
Two hundred and eighteen patients received a single CE conduit for RVOT reconstruction with conduit size ranging from 12 to 30 mm. Perioperative mortality was 1.8% (4/218). Follow-up data were available for 95% of subjects with duration of follow-up ranging from 1 to 9 years. The increase in transconduit gradient over time was inversely proportional to conduit size. For the entire series, freedom from reoperation was 70.3% at 8.2 years. Patients receiving 25 and 30 mm conduits demonstrated no gradient development over this period of follow-up.
In this series, the CE conduit showed excellent longevity at intermediate term follow-up, with slower progression of conduit stenosis as measured by RVOT gradient change compared with previous reports.
Journal of Cardiac Surgery 09/2011; 26(6):643-9. · 0.87 Impact Factor
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Pediatric Cardiology 10/2010; 31(7):1118. · 1.30 Impact Factor
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ABSTRACT: Neonatal surgical repair for truncus arteriosus historically involves removing the pulmonary arteries from the truncal root, closing the ventricular septal defect, and creating right ventricular to pulmonary artery continuity. Unfortunately, early reintervention is frequently required for conduit failure and proximal branch pulmonary artery stenosis. We present a technique that preserves the pulmonary artery architecture, keeping the pulmonary arteries in their native position. This technique has been applied to 16 patients and appears to decrease proximal branch pulmonary artery stenosis, thereby extending conduit longevity and increasing the freedom from early reintervention.
The Annals of thoracic surgery 09/2010; 90(3):1038-9. · 3.74 Impact Factor
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Michael F Swartz,
Gregory W Fink,
Charles J Lutz,
Steven M Taffet,
Omer Berenfeld,
Karen L Vikstrom,
Kimberly Kasprowicz,
Luna Bhatta,
Ferenc Puskas,
Jérôme Kalifa,
José Jalife
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ABSTRACT: The development of atrial fibrillation (AF) after cardiac surgery is associated with adverse outcomes; however, the mechanism(s) that trigger and maintain AF in these patients are unknown.
The purpose of this study was to test our hypothesis that postoperative AF is maintained by high-frequency sources in the left atrium (LA) resulting from ion channel and structural features that differ from the right atrium (RA).
Forty-four patients with no previous history of AF who underwent cardiac surgery consented to LA and RA biopsies. Histologic sections evaluated fatty infiltration, fibrosis, and iron deposition; quantitative reverse transcription-polymerase chain reaction (RT-PCR) assessed ion channel expression. In a subset of 27 patients, LA and RA unipolar recording leads were also placed. In patients who developed AF, the dominant frequency (DF) for each lead was calculated using fast Fourier transform.
DFs during AF were LA 6.26 +/- 0.8 Hz, RA 4.56 +/- 0.7 Hz (P <.01). RT-PCR revealed LA-to-RA differences in mRNA abundance for Kir2.3 (1.8:1) and Kir3.4 (2.3:1). While LA fibrosis was greater in patients developing AF compared with those remaining in normal sinus rhythm (10.8% +/- 11% vs. 3.8% +/- 3.5%; P = .03), the amount of LA fibrosis inversely correlated with the LA DF.
This is the first demonstration of LA-to-RA frequency differences during postoperative AF, which are associated with LA-to-RA differences in mRNA levels for potassium channel proteins and LA fibrosis. These results strongly suggest that sources of AF after cardiac surgery are located in the LA and are stabilized by LA fibrosis.
Heart rhythm: the official journal of the Heart Rhythm Society 06/2009; 6(10):1415-22. · 4.56 Impact Factor
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ABSTRACT: Saphenous vein graft pseudoaneurysms are rare and potentially fatal complications after coronary artery bypass graft surgery. Here we present an 11-cm saphenous vein graft pseudoaneurysm from a 20-year-old vein graft to the obtuse marginal artery. The pseudoaneurysm was directly located beneath the sternum and adjacent to two patent grafts. Therefore, we used a novel approach to access the aorta through a right thoracotomy, and using a pericardial patch, we closed the ostia to the pseudoaneurysm. Postoperatively there was no longer flow into the aneurysm, and at 1-year follow-up the patient is doing well.
The Annals of thoracic surgery 05/2009; 87(4):1291-2. · 3.74 Impact Factor
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ABSTRACT: Raynaud's phenomenon is characterized by episodes of arterial vasospasm precipitated by cold stress, usually affecting the digits of the hands. There is controversy about the occurrence of vasospasm in internal organ systems. In this report, we present a case of Raynaud's peripheral vasospasm accompanied by cerebral oxygen desaturation as detected by near infrared cerebral oximetry after separation from cardiopulmonary bypass.
Anesthesia and analgesia 06/2007; 104(5):1034-6, tables of contents. · 3.08 Impact Factor
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ABSTRACT: Aprotinin (Trasylol) is a serine protease inhibitor, isolated from bovine lung that initially was marketed for the treatment of pancreatitis. In the mid 1980s, reports of its ability to decrease hemorrhaging after cardiopulmonary bypass surgery introduced the drug to the realm of cardiac surgery. Unfortunately, its introduction into this arena was followed by the publication of multiple studies and case reports that blamed aprotinin for poor outcomes in the form of early graft closure. More than 17 years have passed since the initial article describing the use of aprotinin during cardiopulmonary bypass, and with time there has been a significant increase in scientific knowledge and clinical experience. Interestingly, modern literature does not support the dogma that aprotinin is a procoagulant. Aprotinin increases the activated partial thromboplastin time (aPTT), as well as the kaolin- and celite-activated clotting time (ACT), regardless of heparin. Aprotinin, because of its ability to inhibit kallikrein, has been found to decrease thrombin antithrombin III complexes, fibrin-split products, fibrinopeptide 1+2, prothrombin fragments, and all markers of thrombin formation. Some authors have suggested that it may have a synergistic effect with heparin to ensure graft patency. Anticoagulation monitoring during the use of aprotinin also has been developed based on early studies. Aprotinin administration does influence the results of various ACT tests, and consequently different methods of testing anticoagulation have been developed. Researchers have demonstrated that the celite ACT is not "artificially" prolonged in the presence of heparin and aprotinin, rather the kaolin ACT is "artificially" shortened. This article will review the scientific literature with regard to aprotinin's anticoagulatory effects and review the current recommendations for hemostasis monitoring during the use of aprotinin.
The Journal of extra-corporeal technology 01/2005; 36(4):375-83.
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Michael F Swartz,
Jeffrey M Halter,
Gregory W Fink,
Lucio Pavone,
Alexey Zaitsev,
Hsi-Ming Lee,
Jay M Steinberg,
Charles J Lutz,
Timo Sorsa,
Louis A Gatto,
Steve Landas,
Christopher Hare,
Gary F Nieman
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ABSTRACT: Reperfusion of ischemic myocardium has been implicated in extension of infarct size and deleterious clinical outcomes. Anti-inflammatory agents reduce this reperfusion injury. Chemically modified tetracycline-3 (CMT-3) (Collagenex Pharmaceuticals, Newtown, PA, USA) lacks antimicrobial properties yet retains anti-inflammatory activity. We examined infarct size and myocardial function in a porcine coronary artery occlusion/reperfusion model in CMT-3-treated and control animals.
Yorkshire pigs (n = 8) underwent median sternotomy, pretreatment with heparin (300 U/kg and 67 U/kg/hr IV) and lidocaine (1 mg/kg IV) and were divided into two groups. Group one (n = 4) had the left anterior descending artery (LAD) occluded for 1 hour, after which it was reperfused for 2 hours. Group two (n = 4) had an identical protocol to group one except CMT-3 (2 mg/kg IV) was administered prior to occlusion of the LAD.
Animals receiving CMT-3 had significantly decreased infarct size in relation to the ventricular area-at-risk (AAR) (28 +/- 9% vs. 64 +/- 8%; p < 0.05). Myocardial contractile function was superior in the CMT-3 treatment, indicated by a higher cardiac index (2.9 +/- 0.3 vs. 2.0 +/- 0.3 L/min/m(2); p < 0.05) and stroke volume index (22 +/- 2 vs. 17 +/- 1 L/m(2)/beat; p < 0.05).
CMT-3 decreased infarct size in relation to the AAR resulting in relative preservation of contractility, suggesting CMT-3 may improve outcomes during myocardial ischemia reperfusion.
Journal of Cardiac Surgery 21(3):254-60. · 0.87 Impact Factor
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ABSTRACT: Enteric cysts result from an anomaly of embryonic foregut development. In adults, these are frequently asymptomatic. The following is a case of an enteric cyst identified during routine coronary artery bypass attached directly to the epicardium of the left ventricle, a finding not previously reported. Approaches to the treatment of this rare lesion vary. Due to the patient's history of breast cancer, the lesion was excised for histopathological diagnosis.
Cardiovascular Pathology 15(2):113-5. · 2.07 Impact Factor
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ABSTRACT: This report describes a patient treated for metastatic leiomyosarcoma, who acutely developed doxorubicin-induced cardiotoxicity, and consequently developed heart failure. Medical therapy was initiated; however, her condition deteriorated and a surgical alternative was proposed. A biventricular assist device was implanted, allowing her multisystem organ failure to improve. During the next 9 days while on the assist device, her heart failure resolved, her organs were well perfused, and her heart entered a recovery period. After 9 days of mechanical support with the biventricular assist device, she was explanted from the assist device, and with inotropic support and an intra-aortic balloon pump, she maintained adequate hemodynamics. Eighteen days after implantation of the assist device, she was discharged from the hospital with hospice care, where she later died. Although the patient's cardiac function did not have long-term recovery, short-term recovery after doxorubicin toxicity was achieved. The authors maintain that the use of a biventricular assist device in the treatment of acute heart failure resulting from doxorubicin-induced cardiomyopathy is an effective way to manage this patient population.
Congestive Heart Failure 10(4):197-9.
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ABSTRACT: Atrial myxoma is the most common cardiac neoplasm. Although not widely reported, two anatomic types have been observed: solid and papillary. We examined whether differences in gross or microscopic appearance and location correlated with symptomatology, specifically congestive heart failure (CHF), neurologic symptoms, and embolic events.
We performed a retrospective review of atrial myxomas removed from 1972 to 2002, recording the clinical presentation, diagnostic modality, tumor location, gross, and microscopic features for each patient. Twenty-six patients (16 females and 10 males) had atrial myxomas excised. Two patients (one female and one male) were excluded due to unavailable pathologic slides.
In 24 patients there were 15 solid and 9 papillary tumors. CHF was more prevalent in solid myxomas, while neurologic symptoms and embolic events were more common in papillary tumors. Tumor location further correlated with presenting symptoms. Ninety-two percent of patients presenting with CHF had tumors attached to the atrial septum. Extraseptal myxomas more frequently presented with neurologic (80% vs. 29%) and embolic features (50% vs. 25%). All patients exhibiting clefted tumor surface had a history of embolization. A higher percentage of solid myxomas (93%) showed hemorrhage within the tumor than with papillary (56%).
CHF was more common with solid myxomas, and neurologic and embolization events were more common in the papillary type. Septal tumor location showed strong association with CHF, while extraseptal location correlated with neurologic events. We speculate that the various gross and microscopic patterns reflect secondary changes within these neoplasms over the course of their natural history.
Journal of Cardiac Surgery 21(4):435-40. · 0.87 Impact Factor
