Levi Watkins

Johns Hopkins Medicine, Baltimore, Maryland, United States

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Publications (57)346.22 Total impact

  • Annals of the New York Academy of Sciences 12/2006; 382(1):371 - 380. DOI:10.1111/j.1749-6632.1982.tb55231.x · 4.31 Impact Factor
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    ABSTRACT: L'expérience acquise lors des essais cliniques avec le défibrillateur implantable souligne l'importance d'un bilan physiopathologique précis dans la période préopératoire. Cette évaluation demande une documentation précise de la tachyarrythmie ventriculaire, une évaluation de la possibilité d'autres interventions éventuelles aussi bien que la considération de l'intéraction entre stimulateurs et médicamments antiarrythmiques.The experience obtained from the clinical trials with the automatic implantable cardioverter-defibrillator have reemphasized the need for a detailed pathophysiologic evaluation of the patient preoperatively. This evaluation requires careful documentation of the probable cause of the ventricular tachyarrhythmia and evaluation of other surgical needs of the patient, as well as consideration of the interactive effects of pacemakers and concurrent pharmacologic therapy post-operatively.
    Pacing and Clinical Electrophysiology 06/2006; 7(6):1338 - 1344. DOI:10.1111/j.1540-8159.1984.tb05705.x · 1.25 Impact Factor
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    ABSTRACT: The current study was undertaken to determine long-term results of aortic valve replacement (AVR) in the elderly, to ascertain predictors of poor outcome, and to assess quality of life. Aortic valve replacement is the procedure of choice for elderly patients with aortic valve disease. The number of patients aged 70 and older requiring AVR continues to increase. However, controversy exists as to whether surgery devoted to this subset reflect a cost-effective approach to attaining a meaningful quality of life. This study reviews data on 247 patients aged 70 to 89 years who underwent isolated AVR between 1980 and 1995; there were 126 men (51%) and 121 women (49%). Follow-up was 97% complete (239/247 patients) for a total of 974.9 patient-years. Mean age was 76.2 +/- 4.8 years. Operative mortality and actuarial survival were determined. Patient age, gender, symptoms, associated diseases, prior conditions, New York Health Association class congestive heart failure, native valve disease, prosthetic valve type, preoperative catheterization data, and early postoperative conditions were analyzed as possible predictors of outcome. Functional recovery was evaluated using the SF-36 quality assessment tool. Operative mortality was 6.1% (15/247). Multivariate logistic regression showed that poor left ventricular function and preoperative pacemaker insertion were independent predictors of early mortality. After surgery, infection was predictive of early mortality. Overall actuarial survival at 1, 5, and 10 years was 89.5 +/- 2% (198 patients at risk), 69.3 +/- 3.4% (89 patients at risk), and 41.2 +/- 6% (13 patients at risk), respectively. Cox proportional hazards model showed that chronic obstructive pulmonary disease and urgency of operation were independent predictors of poor long-term survival. Postoperative renal failure also was predictive of poor outcome. Using the SF-36 quality assessment tool, elderly patients who underwent AVR scored comparably to their age-matched population norms in seven of eight dimensions of overall health. The exception is mental health. Aortic valve replacement in the elderly can be performed with acceptable mortality. Significant preoperative risk factors for early mortality include poor left ventricular function and preoperative pacemaker insertion. Predictors of late mortality include chronic obstructive pulmonary disease and urgency of operation. These results stress the importance of operating on the elderly with aortic valve disease; both long-term survival and functional recovery are excellent.
    Annals of Surgery 07/1997; 225(6):793-802; discussion 802-4. · 7.19 Impact Factor
  • Annals of Surgery 01/1997; 225(6):793-804. DOI:10.1097/00000658-199706000-00017 · 7.19 Impact Factor
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    ABSTRACT: Many centers advocate bioprosthetic valves in the elderly to avoid anticoagulation, in particular when patient survival is less than the expected valve durability. Because expected survival in the elderly is increasing and age-specific risk of anticoagulation in the elderly is not known, we examined valve- and anticoagulation-related morbidity in elderly patients after aortic valve replacement (AVR) with bioprostheses or mechanical prostheses. Between January 1980 and June 1994, 211 patients age > or = 70 years underwent isolated AVR; there were 109 men (52%) and 102 women (48%). Mean age was 75.9 +/- 4.8 years. Aortic stenosis was present in 194 (92%) patients. Bioprostheses were used in 145 (69%) and mechanical prostheses were used in 66 (31%). Chronic anticoagulation was maintained in all patients with a mechanical valve and in 18 patients (12%) with a bioprosthetic valve. Follow-up data were obtained for 98% (194 of 197) of hospital survivors at a mean follow-up of 3.8 years. Operative mortality was 6.6%; survival at 3 and 5 years was 75.3 +/- 3% and 64.6 +/- 4%, respectively. There was no significant difference in operative or late mortality between patient groups. Rates of freedom from thromboembolic events, endocarditis and anticoagulant-related hemorrhage for bioprosthetic and mechanical valve patients were similar. Prosthetic failure was identified in three bioprosthetic valves (2%); furthermore, the 4 patients in the series who required reoperation had received bioprostheses at the first operation. In conclusion, (1) elderly patients undergoing isolated AVR can be managed with either mechanical or bioprosthetic valves with similar early and late risk, as long as there are no specific contraindications to anticoagulation; (2) anticoagulation-related risk of hemorrhage is low in this group of elderly patients; and (3) the low but significant risk of reoperation following the use of bioprostheses suggests that mechanical valves may be underused in the elderly.
    Circulation 11/1996; 94(9 Suppl):II121-5. · 14.95 Impact Factor
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    ABSTRACT: Background.Controversy still exists as to whether patients with previous stroke are at increased risk for neurologic complications after heart operations.Methods.We performed a prospective analysis of 1,000 consecutive patients undergoing cardiac operations requiring cardiopulmonary bypass, without hypothermic circulatory arrest. Of the 1,000 patients, 71 had previously documented stroke (study group); 2 control patients with no history of stroke were selected for each of these patients (control group, n = 142). There were no significant differences between the study and control patients with respect to established risk factors for neurologic complications.Results.Compared with controls, study patients took longer to awaken (12.6 ± 10.9 versus 3.5 ± 2.1 hours; p < 0.001) and longer to extubate (29.5 ± 29.3 versus 9.1 ± 5.2 hours; p < 0.001), and had a greater incidence of reintubation (7 of 71, 9.9% versus 2 of 142, 1.4%; p < 0.01) and postoperative confusion (26 of 71, 36.6% versus 7 of 142, 4.9%; p < 0.001). There was a higher incidence of focal neurologic deficit among study patients (31 of 71, 43.7% versus 2 of 142, 1.4%; p < 0.001). These deficits included new stroke (6 of 71, 8.5%) as well as the reappearance of previous deficits (19 of 71, 26.8%) or worsening of previous deficits (6 of 71, 8.5%), without new abnormalities on head computed tomography or magnetic resonance imaging. Study patients with neurologic deficit had longer cardiopulmonary bypass times than did study patients without deficit (146 ± 48.5 versus 110 ± 43.3 minutes; p < 0.001). The 30-day mortality rate was greater in study patients than in controls (5 of 71, 7% versus 1 of 142, 0.7%; p < 0.02), with four deaths among the 6 study patients with a new stroke (66.7%).Conclusion.This analysis identifies a group of patients at high risk for neurologic sequelae and confirms the vulnerability of the previously injured brain to cardiopulmonary bypass, as evidenced by reappearance or exacerbation of focal deficits in such patients.
    The Annals of Thoracic Surgery 01/1996; DOI:10.1016/0003-4975(95)00903-5 · 3.63 Impact Factor
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    ABSTRACT: To determine the morbidity and mortality associated with use of centrifugal ventricular assist devices for postcardiotomy cardiogenic shock and to determine factors that might influence outcome and thus, aid in patient selection. A retrospective study. Surgical intensive care unit in a university hospital. During a 6-yr period, a total of 7,385 adult patients underwent cardiac operations requiring cardiopulmonary bypass. Myocardial protection consisted of single-dose cold crystalloid cardioplegia and continuous topical hypothermia by saline lavage. A total of 72 (1%) patients developed postcardiotomy cardiogenic shock. Of 72 patients, 28 met the institutional criteria and were placed on centrifugal ventricular assist devices. Twenty-eight adult patients with postcardiotomy cardiogenic shock were supported with centrifugal ventricular assist devices. A total of 15 patients received left ventricular assist devices, five received right ventricular assist devices, and eight received both right and left ventricular assist devices. Mean age of ventricular assistance patients was 50.8 +/- 12.9 yrs (range 22 to 72), and mean duration of ventricular assistance was 2.8 +/- 2.5 days (range 4 hrs to 10 days; median 2 days). Twenty-five complications occurred in 16 patients and included bleeding (13), tamponade (2), systemic embolism (6), seizures (2), and sepsis (2). Nine patients required reexploration for bleeding or tamponade. Nine (32%) of 28 patients were discharged from the hospital. Ventricular assistance for cardiac failure after transplantation was associated with improved survival (p < .10), while age > 50 yrs and postoperative tamponade each showed trends toward association with mortality (p = .10). Survival was not predicted by gender, weight, time on cardiopulmonary bypass, aortic cross-clamp time, urgency of operation, or preoperative congestive heart failure. At 27 +/- 20 months follow-up, all survivors were alive and New York Heart Association functional class I or II. These results document a low incidence of ventricular assist device use in a surgical practice that employs a relatively simple method of myocardial protection. When postcardiotomy ventricular assistance was necessary, a centrifugal pump was used and successful outcome and satisfactory long-term results were possible in nearly one third of patients. Ventricular assistance for cardiac failure after transplantation was associated with improved survival. Older age is a relative contraindication to mechanical ventricular assistance.
    Critical Care Medicine 08/1993; 21(8):1186-91. DOI:10.1097/00003246-199308000-00019 · 6.15 Impact Factor
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    ABSTRACT: Aortic valve disease in the elderly is primarily calcific stenosis with preservation of left ventricular function. In contrast, mitral valve disease in the elderly often is ischemic in nature with damage occurring to both valve and myocardium. The present study was undertaken to compare results of aortic (AVR) and mitral valve replacement (MVR) in the elderly and to ascertain predictors of poor outcome. Because patients who had concomitant coronary artery bypass grafting (CABG) are included (51% for AVR, 55% for MVR), patients who had isolated CABG were used as a comparison group. Between January 1, 1984, and June 30, 1991, 1,386 patients aged 70 years and older underwent CABG (n = 1,043), AVR (n = 245), or MVR (n = 98). The operative mortality rates were 5.3% for AVR, 20.4% for MVR, and 5.8% for CABG. Late follow-up of patients undergoing operation in 1984 and 1985 was available for 98% (231/237). Overall survival was comparable for all three groups through the first 5 years of follow-up (AVR, 68% +/- 8%; MVR, 73% +/- 8%; CABG, 78% +/- 3%). After 5 years, survival for patients having AVR and MVR was less than that for those having CABG. Patient age, sex, New York Heart Association functional class, concomitant CABG, prosthetic valve type, native valve pathology, and preoperative catheterization data were examined as possible predictors of outcome by multivariate logistic regression.(ABSTRACT TRUNCATED AT 250 WORDS)
    The Annals of Thoracic Surgery 03/1993; 55(2):333-7; discussion 337-8. DOI:10.1016/0003-4975(93)90993-R · 3.63 Impact Factor
  • Journal of Thoracic and Cardiovascular Surgery 01/1993; 104(6):1756-7. · 3.99 Impact Factor
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    ABSTRACT: Surgical approaches for implantation of the automatic cardioverter defibrillator are sternotomy, left thoracotomy, subxiphoid, and subcostal. Although any one of these may be combined with insertion of one or more of the electrodes transvenously, surgical entry into the chest is required for every noninvestigational defibrillator implantation operation. The approaches differ in exposure provided for selecting electrode sites and for handling untoward events, in amount and location of tissue that must be divided or dissected, and in average time required. The operation is an electrical one. Its purpose is to obtain reliable rhythm sensing so that defibrillation or cardioversion shocks will occur only when necessary, and to obtain low enough defibrillation thresholds for shocks of 30 joules or less to have a 10-joule defibrillation safety margin. Many of the patients have had previous cardiac operations. They usually have low or very low ejection fractions. Intraoperative electrophysiological testing with often multiple defibrillation episodes is required. The choice of approach varies with the state of the patient, the institutional experience, and the surgeon. This article describes technique, and the advantages and disadvantages of the four approaches as used by four surgeons in four different institutions.
    Journal of Cardiac Surgery 10/1992; 7(3):208-24. DOI:10.1111/j.1540-8191.1992.tb00804.x · 0.89 Impact Factor
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    ABSTRACT: A retrospective analysis of the records of 60 patients who underwent pericardiectomy over a 10-year period (1980 to 1990) at The Johns Hopkins Hospital was performed. Indications for operation were effusive disease in 24 patients and constriction in 36 patients. Six patients (10%) with pericardial effusion had pain as the primary symptom necessitating intervention. The operative approach for pericardiectomy was median sternotomy in 52 patients (4 patients required cardiopulmonary bypass) and left anterior thoracotomy in 8 patients. Nine patients (5 with constriction and 4 with effusion) with a prior limited pericardial procedure required formal pericardiectomy. The operative mortality rate for pericardial effusion and constriction was 4.2% and 5.6%, respectively. Follow-up (median follow-up, 56.9 +/- 38.2 months) was obtained on 56 patients (93.3%). Actuarial survival at 1 year, 5 years, and 10 years for all patients was 82.1% +/- 5.1%, 71.7% +/- 6.7%, and 59.8% +/- 12.2%, respectively. A Cox proportional hazards regression analysis was performed using 20 clinical variables. A history of malignancy, previous pericardial procedure, and preoperative New York Heart Association class IV were found to be predictors of poor survival. All patients who underwent operation primarily for effusion with associated pain are alive and have improved functional capacity without steroid use. We conclude that pericardiectomy can be performed with low mortality and can result in good long-term survival and improved functional capacity. Patients who are seen primarily with pain refractory to steroid therapy can be relieved of symptoms with operation.
    The Annals of Thoracic Surgery 09/1991; 52(2):219-24. DOI:10.1016/0003-4975(91)91339-W · 3.63 Impact Factor
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    ABSTRACT: Left internal mammary artery (LIMA) grafts have better long-term patency rates than do saphenous vein grafts and result in improved late survival. The present study was undertaken to assess the results of LIMA grafting in the elderly. From 1980 through 1988, 723 patients 70 years of age or older had isolated coronary artery bypass grafting performed. During the first 5 years, only 11% of the elderly patients received LIMA grafts, whereas 86% having coronary artery bypass grafting since 1985 had LIMA grafts. Since 1986, LIMA use in the elderly has become routine, with 92% of patients receiving internal mammary artery grafts. During the first 5 years, elderly patients had a hospital mortality rate of 9.3%. Since 1985, the hospital mortality rate fell to 5.5%. In addition, the occurrence of major surgical complications was either unchanged or reduced in patients receiving LIMA grafts. Furthermore, late follow-up indicates a significantly improved 4-year survival rate in patients with internal mammary artery grafts compared with those without: 86 ± 0.02% versus 77 ± 0.03% (p < 0.01). Analysis of multiple potential risk factors for early mortality was performed using multiple logistic regression and late survival wing the Cox proportional hazards model. Although unmeasured predictor variables may confound retrospective analyses, LIMA grafting appears to be an independent predictor both of improved early and late survival.
    The Annals of Thoracic Surgery 03/1990; DOI:10.1016/0003-4975(90)90137-U · 3.63 Impact Factor
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    ABSTRACT: To determine the influence of valve selection on valve-related morbidity and mortality and patient survival, comparative long-term performance characteristics of mechanical (N = 68) and bioprosthetic (N = 73) heart valves were analyzed for 141 patients more than 70 years old who underwent isolated aortic valve replacement between 1970 and 1985. Cumulative patient follow-up was 491 patient-years (average, 4.3 years per patient). Hospital mortality was 18% and 19% for patients with mechanical valves and bioprosthetic valves, respectively. Survival at 5 years was 61 +/- 7% (+/- the standard error) and 67 +/- 10% for recipients of mechanical valves and bioprosthetic valves, respectively. Male sex (p = 0.014) and urgency of operation (p = 0.006) were independent risk factors for hospital mortality. Atrial fibrillation increased valve-related mortality (p = 0.01). No patient required reoperation or experienced structural valve failure. While anticoagulant-related hemorrhage was increased in recipients of mechanical valves (9.2 +/- 2.1%/patient-year) compared with recipients of bioprosthetic valves (2.3 +/- 1.1%/patient-year), it did not result in a death or lead to permanent disability. There was no difference in freedom from any valve-related complication at 5 years. However, when all morbid events are considered, recipients of bioprosthetic valves experienced fewer valve-related complications than patients receiving mechanical valves (10.7 +/- 2.3%/patient-year versus 17.6 +/- 2.5%/patient-year, respectively; p less than 0.05). The reduced incidence of anticoagulant-related hemorrhage and the infrequent need for warfarin sodium anticoagulation favor selection of a bioprosthetic heart valve in patients older than 70 years.
    The Annals of Thoracic Surgery 10/1988; 46(3):270-7. DOI:10.1016/S0003-4975(10)65924-3 · 3.63 Impact Factor
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    ABSTRACT: Factors associated with increased operative mortality in patients with postinfarction angina have not been defined. Two hundred twenty-five patients underwent urgent coronary artery bypass grafting from 1982 through 1986. One hundred sixty-two men and 63 women averaged 62 years of age (range, 35-87 years). Operative mortality was 5.3%. To assess the predictors of perioperative mortality, 16 variables were evaluated by univariate and multivariate analyses. Significant independent predictors of perioperative mortality were the presence of a transmural anterior myocardial infarction (p less than 0.0005) and the need for preoperative intra-aortic balloon pumping for angina or congestive heart failure (p = 0.009). All perioperative mortalities (12 patients) occurred in this subset (anterior myocardial infarction, intra-aortic balloon pumping, or both) that included 101 patients. The mean follow-up period was 27.8 months (range, 1-69 months). There were 11 late deaths, resulting in an actuarial survival of 92 +/- 2%, 91 +/- 2%, 88 +/- 2.6%, and 88 +/- 4% at 1,2,3, and 4 years, respectively. Ninety-six percent of survivors were assigned to New York Heart Association Class I or II for congestive heart failure, and 96% were assigned to Class I or II for angina. Urgent coronary artery bypass grafting can be performed in patients with unstable postinfarction angina with acceptable mortality, although a significant increase in risk exists for patients with preoperative transmural anterior myocardial infarction, intra-aortic balloon pumping, or both.
    Circulation 10/1988; 78(3 Pt 2):I163-5. · 14.95 Impact Factor
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    ABSTRACT: Myocardial revascularization and implantation of the automatic implantable cardioverter defibrillator (AICD) have individually been shown to improve survival in patients after sudden cardiac death. Their combined role has not been well defined. Twenty-three survivors of sudden death underwent revascularization and AICD implantation at an average age of 59 years. The initial arrest was caused by ventricular fibrillation in 15 and ventricular tachycardia in 8. Exercise stress tests, ambulatory ECGs, and electrophysiological monitoring with programmed electrical stimulation were done preoperatively and postoperatively. Follow-up averaged 24 months with a two-year survival of 91%. Eight patients (35%) required AICD resuscitation an average of 8 months postoperatively, and electrophysiological testing did not accurately predict arrhythmia recurrence. The addition of AICD implantation to revascularization substantially improves survival of patients with sudden cardiac death.
    The Annals of Thoracic Surgery 08/1988; 46(1):13-9. DOI:10.1016/S0003-4975(10)65843-2 · 3.63 Impact Factor
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    ABSTRACT: Since February 1980 the automatic implantable cardioverter defibrillator has been implanted in over 1,500 patients. Sudden death rates have been reduced to 2%-4% annually. This report reviews the implantation techniques, their indications, and our clinical experience in 200 patients.
    Journal of Cardiac Surgery 04/1988; 3(1):1-7. · 0.89 Impact Factor
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    ABSTRACT: Because the automatic internal cardioverter defibrillator's long-term ability to reduce arrhythmic mortality in patients with ventricular tachycardia/fibrillation is unknown, it is important to determine whether the threshold for defibrillation changes over time. Serial defibrillation thresholds were measured in 23 patients over a mean replacement time of 24.8 +/- 7.5 months. In all cases the lead system was a superior vena cava coil to a left ventricular epicardial patch. The defibrillation threshold for the entire group increased from 12.3 +/- 4.7 J to 16.9 +/- 5.9 J (p less than 0.05). Striking increases in the defibrillation threshold were seen in the subgroup of patients taking amiodarone (from 10.9 +/- 4.3 J at implantation to 20.0 +/- 4.7 J at replacement, p less than 0.05). Defibrillation threshold decreased in patients taking no antiarrhythmic drugs or taking class I agents. Thus, the increase in mean defibrillation threshold was the result of an increase in the patients taking amiodarone. These data suggest that at initial implantation lead systems associated with the lowest defibrillation threshold should be used and the defibrillation threshold should be measured at generator change to guarantee an adequate margin of safety.
    The American Journal of Cardiology 12/1987; 60(13):1061-4. DOI:10.1016/0002-9149(87)90352-3 · 3.43 Impact Factor
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    ABSTRACT: To study the effects of increasing age on outcome after coronary artery bypass grafting (CABG), 684 patients who underwent CABG from 1980 to 1985 were entered into a noncurrent prospective study. Patients were matched by date of operation and placed into three groups according to age: (1) 70 and older, (2) 55 to 69, or (3) less than 55. In addition to intraoperative and postoperative data collected on all patients, follow-up was obtained on 97% of the patients at a mean of 30 +/- 16 months. Older patients were more often female (p less than .002), and white (p less than .001) and had more preexisting cerebrovascular disease (p less than .0001), peripheral vascular disease (p less than .001), unstable angina (p less than .0001), and longer mean bypass pump times (p less than .001). Older patients had a higher hospital mortality (9.3% vs 2.2%), suffered more complications, including stroke, wound infection, reoperation for bleeding, need for intropic drug support, and prolonged ventilation, and had longer mean postoperative hospital stays (14 vs 9 days, p less than .0001). After discharge, mortality rates were similar in all groups, as was recurrence of symptoms and degree of rehabilitation. While patient age at operation significantly influenced hospital mortality and morbidity, this appeared to be a consequence of the greater frequency of risk factors in patients over 70 years of age. In addition, late follow-up failed to demonstrate any significant differences based on age alone in survival or functional status among patients undergoing CABG.
    Circulation 12/1987; 76(5 Pt 2):V6-12. · 14.95 Impact Factor
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    ABSTRACT: A 78-year-old man treated with amiodaronce for recurrent ventricular tachycardia, had soquential placement of a bipolar VVI pacemaker and an automatic implantable cardioverter defibrillator (AICD). During defibrillation threshold testing, there was failure to capture of the pacer in the post-shock period. The time of failure to capture appeared energy-related: the greater the energy delivered, the longer the failure to capture. Careful attention will be necessary in constructing combined AICD/pacemaker units.
    Pacing and Clinical Electrophysiology 08/1987; 10(5):1194 - 1197. DOI:10.1111/j.1540-8159.1987.tb06140.x · 1.25 Impact Factor
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    ABSTRACT: Comparative long-term performance characteristics of Björk-Shiley mechanical and bioprosthetic valves were analyzed for patients undergoing aortic valve replacement between 1976 and 1981. A total of 419 patients received either a standard Björk-Shiley (n = 266) or bioprosthetic (porcine, n = 126, or pericardial, n = 27) aortic valve. Cumulative patient follow-up was 1,705 patient-years; the average patient follow-up was 4.1 +/- 2.7 years. Survival data were obtained for all but 11 patients (97% complete follow-up) up to 9 years after operation. Survival at 5 years was 81% +/- 4% (+/- standard error) for Björk-Shiley and for bioprosthetic valve recipients. Valve failure in the Björk-Shiley group was predominantly due to valve-related mortality and did not result from structural failure. Patients with bioprosthetic valves experienced valve failure as a result of prosthetic valve endocarditis and intrinsic valve degeneration. Although patients with bioprostheses experienced a lower incidence of valve-related morbidity than Björk-Shiley valve recipients (p less than 0.03), no difference could be demonstrated in the incidence of valve-related mortality or valve failure at 5 years between bioprosthetic and Björk-Shiley valves. Mortality rate from valve failure was higher for Björk-Shiley (86%, 12/14) than bioprosthetic valves (36%, 5/14) (p less than 0.01).
    Journal of Thoracic and Cardiovascular Surgery 08/1987; 94(1):20-33. · 3.99 Impact Factor

Publication Stats

2k Citations
346.22 Total Impact Points

Institutions

  • 1984–2006
    • Johns Hopkins Medicine
      • • Department of Medicine
      • • Division of Cardiac Surgery
      • • Department of Surgery
      Baltimore, Maryland, United States
  • 1978–1987
    • Johns Hopkins University
      • Division of Cardiac Surgery
      Baltimore, Maryland, United States
  • 1982–1984
    • Sinai Hospital
      • Department of Medicine
      Baltimore, Maryland, United States