Alexander J C Mittnacht

Icahn School of Medicine at Mount Sinai, Borough of Manhattan, New York, United States

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Publications (41)101.58 Total impact

  • Alexander J C Mittnacht · Srinivas Dukkipati · Aman Mahajan
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    ABSTRACT: Percutaneous catheter ablation is being increasingly performed in patients with recurrent ventricular tachycardia (VT) unresponsive to medical treatment. Optimal management of patients requires careful consideration of the severity of the underlying cardiac disease, the anesthetic drug interactions, and the procedural technique during VT mapping and ablation. The goal is to choose an anesthetic technique that has the least effect on arrhythmogenicity, allowing reproducibility of the VT in the electrophysiology laboratory. Anesthetics can alter action potential and ventricular depolarization directly through their effects on ion channels and gap junctions, as well as indirectly via their effects on the autonomic nervous system. Furthermore, maintaining hemodynamic stability and monitoring for adequate end-organ perfusion are additional challenges. In this review, we provide a comprehensive update on the currently performed VT ablation procedures and their anesthetic considerations.
    Anesthesia and analgesia 04/2015; 120(4):737-48. DOI:10.1213/ANE.0000000000000556 · 3.47 Impact Factor
  • Alexander C Egbe · Alexander J Mittnacht · Khanh Nguyen · Umesh Joashi
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    ABSTRACT: Primary repair of tetralogy of Fallot (TOF) has low surgical mortality, but some patients still experience significant postoperative morbidity. To review our institutional experience with primary TOF repair, and identify predictors of intensive care unit (ICU) morbidity. Medium-sized pediatric cardiology program. Retrospective study. We retrospectively reviewed all the patients with TOF and pulmonic stenosis who underwent primary repair in infancy at our institution from January 2001 to December 2012. Preoperative, operative, and postoperative demographic and morphologic data were analyzed. ICU morbidity was defined as prolonged ICU stay (≥7 days), and/or prolonged duration of mechanical ventilation (≥48 h). Multiple logistic regression analysis. Ninety-seven patients underwent primary surgical repair during the study period. The median age was 4.9 months (1-9 months) and the median weight was 5.3 kg (3.1-9.8 kg). There was no early surgical mortality. Incidence of junctional ectopic tachycardia (JET) and persistent complete heart block was 2 and 1%, respectively. The median length of ICU stay was 6 days (2-21 days) and median duration of mechanical ventilation was 19 h (0-136 h). By multiple regression analysis, age and weight were independent predictors of length of ICU stay, while surgical era was an independent predictor of duration of mechanical ventilation. Primary TOF repair is a safe procedure with low mortality and morbidity in a medium-sized program with outcomes comparable to national standards. Age and weight at the time of surgery remain significant predictors of morbidity.
    Annals of Pediatric Cardiology 03/2014; 7(1):13-8. DOI:10.4103/0974-2069.126539
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    Alexander J C Mittnacht · Partho P Sengupta
    Journal of cardiothoracic and vascular anesthesia 02/2014; 28(1):8-10. DOI:10.1053/j.jvca.2013.11.008 · 1.46 Impact Factor
  • Menachem M. Weiner · Michael Greco · Wenchi Kevin Tsai · Alexander J.C. Mittnacht
    Journal of cardiothoracic and vascular anesthesia 02/2014; 29(4). DOI:10.1053/j.jvca.2013.11.004 · 1.46 Impact Factor
  • Alexander J C Mittnacht · Cesar Rodriguez-Diaz
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    ABSTRACT: Despite significant improvements in overall outcome, neurological injury remains a feared complication following pediatric congenital heart surgery (CHS). Only if adverse events are detected early enough, can effective actions be initiated preventing potentially serious injury. The multifactorial etiology of neurological injury in CHS patients makes it unlikely that one single monitoring modality will be effective in capturing all possible threats. Improving current and developing new technologies and combining them according to the concept of multimodal monitoring may allow for early detection and possible intervention with the goal to further improve neurological outcome in children undergoing CHS.
    Annals of Cardiac Anaesthesia 01/2014; 17(1):25-32. DOI:10.4103/0971-9784.124130
  • Amit Pawale · Aaron Weiss · Alexander Mittnacht · Paul Stelzer
    The Journal of thoracic and cardiovascular surgery 12/2013; 147(3). DOI:10.1016/j.jtcvs.2013.10.045 · 4.17 Impact Factor
  • Matthew A Levin · Anelechi C Anyanwu · Charles A Eggert · Alexander J.C. Mittnacht
    The Journal of thoracic and cardiovascular surgery 11/2013; 147(3). DOI:10.1016/j.jtcvs.2013.10.042 · 4.17 Impact Factor
  • Alexander J C Mittnacht
    Annals of Cardiac Anaesthesia 04/2013; 16(2):107-8.
  • Journal of cardiothoracic and vascular anesthesia 04/2013; 27(3). DOI:10.1053/j.jvca.2012.11.015 · 1.46 Impact Factor
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    ABSTRACT: Background: The feasibility of fast-tracking children undergoing congenital heart disease surgery has not been assessed adequately. Current knowledge is based on limited single-center experiences without contemporaneous control groups. Methods and results: We compared administrative data for atrial septal defect (ASD) and ventricular septal defect (VSD) surgeries in children 2 months to 19 years of age at the Mount Sinai Medical Center (MSMC) with data from comparable patients at 40 centers contributing to the Pediatric Health Information System. Three-year blocks, early in and after fast tracking had been implemented at the MSMC, were examined. Seventy-seven and 89 children at MSMC undergoing ASD and VSD closure, respectively, were compared with 3103 ASD and 4180 VSD patients nationally. With fast tracking fully implemented, median length of stay at the MSMC decreased by 1 day compared with the earlier era (length of stay, 1 and 3 days for ASD and VSD, respectively). Nationally, median length of stay remained unchanged (3 days for ASD and 4 days for VSD) in the observed time periods. Hospitalization costs fell by 33% and 35% at MSMC (ASD and VSD, respectively), whereas they rose by 16% to 17% nationally. When analyzed in multiple regression models, the decrease in both length of stay and cost remained significantly greater at MSMC compared with nationally (P<0.0001 for all). Hospital mortality and 2-week readmission rates were unchanged at MSMC between the 2 time periods and were not different from the national rates. Conclusion: Shorter length of stay and cost savings compared with national data were observed after implementation of fast tracking.
    Circulation Cardiovascular Quality and Outcomes 02/2013; 6(2). DOI:10.1161/CIRCOUTCOMES.111.000066 · 5.66 Impact Factor
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    ABSTRACT: Background: Percutaneous left ventricular assist devices (pLVADs) are increasingly being used to facilitate ablation of unstable ventricular tachycardia (VT), but the safety profile and hemodynamic benefits of these devices have not been described in a systematic, prospective manner. Methods and results: Twenty patients with scar VT underwent ablation with a pLVAD. Neuromonitoring using cerebral oximetry was performed to evaluate a cerebral desaturation threshold to guide the duration of activation/entrainment mapping. The efficacy of pLVAD support was tested in a controlled manner with simulated VT. Complete procedural success was achieved in 50% (n=8) of patients, who were initially inducible for sustained VT, and partial procedural success in 37% (n=6). Using a cerebral desaturation level of 55% as a lower safety limit to guide the duration of sustained VT, 3 patients (15%) developed mild acute kidney injury (all resolved), and 1 (5%) patient developed mild cognitive dysfunction. During fast simulated VT (300 ms), cerebral desaturation to ≤55% occurred in more than half (53%) of patients tested without pLVAD support, compared with only 5% with full pLVAD support (P=0.003). Conclusions: In a consecutive series of patients with severe left ventricular dysfunction, pLVAD-supported scar VT ablation was safe and feasible. During fast simulated VT, a miniaturized axial flow pump imparted a more favorable hemodynamic profile compared with pharmacological agents alone. Cerebral oximetry is a complimentary monitoring modality during scar VT ablation, and avoidance of cerebral desaturations below a threshold of 55% may safely guide the duration of mapping during unstable VT.
    Circulation Arrhythmia and Electrophysiology 12/2012; 6(1). DOI:10.1161/CIRCEP.112.975888 · 4.51 Impact Factor
  • Menachem M Weiner · Paul Geldard · Alexander J.C. Mittnacht
    Journal of cardiothoracic and vascular anesthesia 09/2012; 27(2). DOI:10.1053/j.jvca.2012.07.007 · 1.46 Impact Factor
  • Ralph Dilisio · Alexander J C Mittnacht
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    ABSTRACT: Carotid puncture and insertion of a large-bore catheter into the carotid artery is a feared complication associated with internal jugular vein (IJV) cannulation. The use of ultrasound with real-time imaging of the neck vessels during needle insertion has the potential to decrease the incidence of serious complications associated with central venous access. The authors describe a new technique for ultrasound-guided IJV cannulation. The suggested "medial-oblique" approach allows for optimal imaging of the IJV and the carotid artery side by side and following the needle throughout the insertion from skin to vessel penetration in a medial-cephalad to lateral-caudad direction. This technique combines the advantages of the short-axis and long-axis approaches and minimizes the risk of carotid puncture from a medial-to-lateral needle direction.
    Journal of cardiothoracic and vascular anesthesia 06/2012; 26(6). DOI:10.1053/j.jvca.2012.04.013 · 1.46 Impact Factor
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    ABSTRACT: Early extubation in adults undergoing surgery for congenital heart disease has not been described. The authors report their experience with extubation in the operating room (OR), including factors associated with the decision to defer extubation to a later time. A retrospective chart review. A tertiary-care teaching hospital. This study included adults undergoing surgery for congenital heart disease using cardiopulmonary bypass. Exclusion criteria were as follows: preoperative mechanical ventilation, age >70 years, inotrope score >20 after surgery, and surgical risk (Risk Adjustment for Congenital Heart Surgery [RACHS] score ≥4). A stepwise logistic regression model was used to test for the independent influence of the various factors on extubation in the OR. Sixty-seven patients (age 18-59 years, median = 32 years) were included. Overall, 79% of patients were extubated in the OR. The RACHS score was the strongest predictor of deferring extubation (RACHS 3 v 1 or 2: odds ratio = 16.7; 95% confidence interval, 3.3-84.2; p = 0.0006). Further exploration of the high-risk group (RACHS 3) showed that 75% of the RACHS 3 patients with a body mass index <25 were extubated compared with only 20% of patients who had a body mass index ≥25 (p = 0.01). Other factors included in the analysis did not contribute any additional independent information. Extubation of adult patients in the OR after surgery for congenital heart disease is feasible in most cases. Surgical risk (RACHS score) and body mass index predict the decision for OR extubation in this patient population.
    Journal of cardiothoracic and vascular anesthesia 05/2012; 26(5):773-6. DOI:10.1053/j.jvca.2012.04.009 · 1.46 Impact Factor
  • M M Weiner · A J C Mittnacht
    Minerva anestesiologica 02/2012; 78(5):519-20. · 2.13 Impact Factor
  • Menachem M Weiner · Meg A Rosenblatt · Alexander J C Mittnacht
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    ABSTRACT: The goal of this review was to add to the existing literature documenting the safety of performing neuraxial techniques in patients who are subsequently fully heparinized, with particular emphasis on the timing of heparin administration. This will help improve risk estimation and possibly lead to a more widespread use of neuraxial anesthesia in patients undergoing cardiac surgery. Retrospective chart review. Single tertiary-care university hospital. All patients undergoing surgery for congenital heart diseases during a 5-year period. The medical records of all patients undergoing surgery for congenital heart diseases during a 5-year period were reviewed for any complications related to the use of neuraxial anesthesia. Furthermore, the interval from neuraxial anesthesia to heparinization for cardiopulmonary bypass was examined. In total, 714 patients were identified who had neuraxial anesthesia administered before full heparinization for cardiopulmonary bypass. No cases of symptomatic spinal or epidural hematomas occurred. Further analysis showed that the interval from neuraxial anesthesia to full heparinization was <1 hour in 466 patients. No complications related to neuraxial anesthesia were found in a series of 714 patients undergoing surgery for congenital heart disease using cardiopulmonary bypass, including 466 patients in whom the interval from neuraxial anesthesia to full heparinization was <1 hour.
    Journal of cardiothoracic and vascular anesthesia 12/2011; 26(4):581-4. DOI:10.1053/j.jvca.2011.10.010 · 1.46 Impact Factor
  • Alexander J.C. Mittnacht
    Journal of cardiothoracic and vascular anesthesia 10/2011; 25(5):874-6. DOI:10.1053/j.jvca.2011.06.025 · 1.46 Impact Factor
  • Journal of cardiothoracic and vascular anesthesia 10/2011; 25(5):867-73. DOI:10.1053/j.jvca.2011.06.005 · 1.46 Impact Factor
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    ABSTRACT: Our goal was to investigate the effects of percutaneous left ventricular assist device (pLVAD) support during catheter ablation of unstable ventricular tachycardia (VT). Mechanical cardiac support during ablation of unstable VT is being increasingly used, but there is little available information on the potential hemodynamic benefits. Twenty-three consecutive procedures in 22 patients (ischemic, n = 11) with structural heart disease and hemodynamically unstable VT were performed with either pLVAD support (n = 10) or no pLVAD support (intra-aortic balloon pump counterpulsation, n = 6; no support, n = 7). Procedural monitoring included vital signs, left atrial pressure, arterial blood pressure, cerebral perfusion/oximetry, VT characteristics, and ablation outcomes. The pLVAD group was maintained in VT significantly longer than the non-pLVAD group (66.7 min vs. 27.5 min; p = 0.03) and required fewer early terminations of sustained VT for hemodynamic instability (1.0 vs. 4.0; p = 0.001). More patients in the pLVAD group had at least 1 VT termination during ablation than non-pLVAD patients (9 of 10 [90%] vs. 5 of 13 [38%]; p = 0.03). There were no differences between groups in duration of cerebral deoxygenation, hypotension or perioperative changes in left atrial pressure, brain natriuretic peptide levels, lactic acid, or renal function. In patients with scar-related VT undergoing catheter ablation, pLVAD support was able to safely maintain end-organ perfusion despite extended periods of hemodynamically unstable VT. Randomized studies are necessary to determine whether this enhanced ability to perform entrainment and activation mapping will translate into a higher rate of clinical success.
    Journal of the American College of Cardiology 09/2011; 58(13):1363-71. DOI:10.1016/j.jacc.2011.06.022 · 16.50 Impact Factor
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    ABSTRACT: To determine the feasibility and safety of esophageal displacement during atrial fibrillation (AF) ablation, to prevent thermal injury. Patients undergoing AF ablation are at risk of esophageal thermal injury, which ranges from superficial ulceration, to gastroparesis, to the rare but catastrophic atrioesophageal fistula. A common approach to avoid damage is luminal esophageal temperature (LET) monitoring; however, (1) temperature rises mandate interruptions in energy delivery that interrupt workflow and potentially decrease procedural efficacy, and (2) esophageal fistulas have been reported even with LET monitoring. A cohort of 20 consecutive patients undergoing radiofrequency (RF) (16 patients) or laser balloon (4 patients) ablation of AF under general anesthesia. After barium instillation, the esophagus was deviated using an endotracheal stylet placed within a thoracic chest tube. LET monitoring was used during catheter ablation. Upper GI endoscopy was performed prior to discharge. At the pulmonary vein level, leftward deviation measured 2.8 ± 1.6 cm (range: 0.4-5.7) and rightward deviation 2.8 ± 1.8 cm (range: 0.5-4.9). The temperature rose to >38.5 °C in 3/20 (15%) patients. In these 3 patients, there was an average of 2 applications/patient that recorded temperatures >38.5 °C. No patient had a temperature rise > 40 °C. Endoscopy revealed no esophageal ulceration from thermal injury in 18/19 (95%) patients; the sole patient with a thermally mediated ulceration had an unusual esophageal diverticulum fully across the posterior left atrium. Twelve patients (63%) exhibited trauma related to instrumentation with no clinical sequelae. Mechanical esophageal deviation is feasible and allows for uninterrupted energy delivery along the posterior wall during catheter ablation of AF.
    Journal of Cardiovascular Electrophysiology 09/2011; 23(2):147-54. DOI:10.1111/j.1540-8167.2011.02162.x · 2.96 Impact Factor

Publication Stats

271 Citations
101.58 Total Impact Points


  • 2009–2015
    • Icahn School of Medicine at Mount Sinai
      • • Division of Cardiology
      • • Department of Anesthesiology
      Borough of Manhattan, New York, United States
  • 2010–2014
    • Mount Sinai Hospital
      New York, New York, United States
  • 2006–2013
    • Mount Sinai Medical Center
      New York City, New York, United States
  • 2011
    • Sinai Hospital
      New York, New York, United States