Vaughn A Starnes

Keck School of Medicine USC, Los Ángeles, California, United States

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Publications (267)1154.83 Total impact

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    ABSTRACT: Persistent pleural effusions after the Fontan procedure contribute to prolonged hospitalization and increased costs. We report our experience using a modified Wisconsin Fontan protocol to reduce chest tube drainage and hospital length of stay (LOS). Single institutional retrospective chart review of 120 consecutive patients (60 before and 60 after initiation of our protocol) undergoing an extracardiac Fontan procedure from January 2004 to February 2007. Protocol influence was assessed by comparing group differences on duration of pleural drainage, requirement for nothing by mouth/total parenteral nutrition, hospital LOS, readmission for pleural effusion, and total hospital costs. Groups were similar in demographic characteristics, single ventricle morphology, preoperative hemodynamic parameters, and operative and immediate postoperative management. Median duration of pleural drainage and hospital LOS was reduced in the post- versus preprotocol groups: 4 days (interquartile range [IQR], 4-5 days) pre versus 6 days (IQR, 5-10 days) (P < .0001) and 6 days (IQR, 5-9 days) versus 8 days (IQR, 6-13 days) (P = .005), respectively. Pleural drainage lasting >1 week was also less common postprotocol: 23 (38%) before versus 7 (12%) after (P = .001). Fewer postprotocol patients required nothing by mouth/total parenteral nutrition to control effusions: 5 pre versus 0 post (P = .06), and fewer readmissions for effusions (14 before vs 7 after [P = .1]). An average total cost savings of 22% and readmissions savings of 29% resulted in nearly $500,000 in institutional savings over the study period. A modified Fontan protocol resulted in reduced time to chest tube removal, hospital LOS, and chest tube drainage lasting >1 week. There was a strong trend toward avoiding nothing by mouth/total parenteral nutrition to control pleural effusion and lower hospital costs. Copyright © 2015 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Jun 2015 · The Journal of thoracic and cardiovascular surgery
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    ABSTRACT: The Ross procedure is an alternative for patients with aortic valve disease not amenable to repair. Long-term follow-up after a Ross has demonstrated the need for autograft (left ventricular outflow tract [LVOT]) and homograft (right ventricular outflow tract [RVOT]) reinterventions. We assessed the age-stratified outcomes of the LVOT and RVOT after the Ross procedure performed by a single surgeon during a 20-year period. We retrospectively reviewed 305 consecutive patients aged 4 days to 70 years, stratified by age younger than than 1 (n = 41), 1 to 10 (n = 85), 10 to 20 (n = 84), 20 to 40 (n = 59), and older than 40 years (n = 36). Median follow-up was 8.2 years (interquartile range, 1 month to 19.2 years). Primary end points were survival and freedom from reintervention on the LVOT and RVOT. Outcomes were compared by Kaplan-Meier analysis. A total of 173 patients (57%) had prior intervention on their aortic valve, 95 (31%) had isolated regurgitation, 91 (30%) had stenosis, and 119 (39%) had mixed pathology. There were 92 concomitant procedures (43 congenital lesions, 18 aorta, 9 mitral valve). In-hospital morbidity was 11.5% (35 of 305); mortality was 3.6% (11 of 305) and highest in infants. Need for an emergency operation (p < 0.05) predicted mortality in infants. The LVOT reintervention rate was lowest in infants compared with older patients (p < 0.05); conversely, age was directly related to RVOT reintervention (p < 0.01). Autograft encasement in a Hemashield (Atrium, Hudson, NH) tube in patients aged older than 10 years improved 5-year freedom from reintervention on the LVOT from 81% to 91% (p < 0.001). At last follow-up, aortic insufficiency was mild or less in 290 (95%) patients, and heart function was normal in 285 (93%). The Ross procedure is a safe, effective, and anti-coagulation-free alternative for aortic valve replacement across all age groups. Long-term survival and preservation of heart function are highly favorable. Surgical mortality is related to salvage procedures in infants. When feasible, autograft durability can be improved by using a Hemashield graft for support. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Apr 2015 · The Annals of thoracic surgery
  • Luke M. Wiggins · S. Ram Kumar · Vaughn A. Starnes · Winfield J. Wells
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    ABSTRACT: Right ventricular outflow tract obstruction (RVOT) is the most common late complication requiring intervention after arterial switch operation (ASO). The durability of surgical management of this complication has not been well established. We retrospectively reviewed the charts of 38 consecutive patients who underwent RVOT reconstruction after ASO at our institution between 2004 and 2013. During the same time period, 223 consecutive patients underwent ASO for transposition of the great arteries at our institution. Thirty-five (16%) of the 223 patients developed RVOT obstruction, and 3 additional patients who had ASO done elsewhere presented to us with RVOT obstruction. Patient characteristics, site of stenosis, type of intervention, and outcomes were analyzed. Data are presented as median with interquartile ranges. The time interval between ASO and echocardiographic diagnosis of significant RVOT obstruction was 12.5 (3 to 23.7) months. After echocardiographic diagnosis, 33 (87%) children underwent cardiac catheterization. Obstruction involved the supravalvar main pulmonary artery (PA) in 21 (64%), branch PA in 14 (42%), pulmonary valve in 4 (12%), and sub-valvar area in 1 (3%). Ten of 33 patients who underwent catheterization had attempted percutaneous intervention, with 4 (40%) demonstrating significant response. Surgical intervention was performed at a median of 4 months in responders compared with 2.3 months in non-responders. Surgical repair included main PA plasty (36), extended to 1 or both branch PAs (26), or crossed the RVOT annulus (7). Surgical morbidity was 13% and there was no hospital or late mortality. At last follow-up, 41.2 months (21.4 to 81) after RVOT reconstruction, all patients had New York Heart Association grade 0 or 1 symptoms, and RV pressure was a median 36% of systemic pressure. Five (13%) patients underwent catheterization 26 months after surgery, with 2 requiring dilation at site of arterioplasty and 3 requiring distal branch PA intervention. One patient required reoperation for main PA stenosis. Freedom from re-intervention after surgery is 89%, 86%, and 86% at 2, 3, and 5 years, respectively. Surgical management of RVOT obstruction after ASO is an effective and durable intervention in the intermediate term. Our results serve as a benchmark for expected outcomes in this disease process. Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Apr 2015 · The Annals of thoracic surgery
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    ABSTRACT: Right anterior minithoracotomy with central arterial cannulation is our preferred technique of minimally invasive aortic valve replacement (AVR). We compared perioperative outcomes with this technique to those via sternotomy. Between March 1999 and December 2013, 492 patients underwent isolated AVR via either sternotomy (SAVR, n = 198) or minimally invasive right anterior thoracotomy (MIAVR, n = 294) in our institution. Univariate comparisons between groups were made to evaluate overall outcomes and adverse events. To control treatment selection bias, propensity scores were constructed from core patient characteristics. A propensity score-stratified analysis of outcome and adverse events was then performed. Overall mortality was 2.5 and 1.0% in the SAVR and MIAVR groups, respectively. Hospital and ICU stays were shorter, there was less intraoperative blood product usage, and fewer wound infections in the MIAVR group. There were no differences in other adverse events, including strokes. The composite end-point of alive and adverse event-free was significantly more common in the MIAVR group (83 vs 74%, P = 0.002). After adjusting for the propensity score, hospital and ICU stays remained shorter and intraoperative blood product usage remained less in the MIAVR group. There was no difference in mortality, stroke or other adverse events between groups. Minimally invasive AVR via an anterior right thoracotomy with predominately central cannulation can be performed with morbidity and mortality similar to that of a sternotomy approach. There appear to be advantages to this minimally invasive approach when compared with sternotomy in terms of less intraoperative blood product usage, lower wound infection rates and decreased hospital stays. If mortality and the occurrence of adverse events are taken together, MIAVR may be associated with better outcomes. As minimally invasive AVR becomes more common, further long-term follow-up is needed and a prospective multicentre randomized trial would be warranted. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
    No preview · Article · Mar 2015 · European journal of cardio-thoracic surgery: official journal of the European Association for Cardio-thoracic Surgery

  • No preview · Article · Mar 2015 · Journal of the American College of Cardiology
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    ABSTRACT: Some pediatric patients referred for heart transplant (HTx) are sub-optimal candidates. Their outcomes without HTx are presumed to be dismal, but have not been well described. Knowledge about their outcomes is critical when weighing the risks between a high-risk transplant and "terminal" palliation. We retrospectively reviewed all HTx referrals from January 2005 to July 2013. We excluded those who were listed for HTx, or who were denied HTx due to being "too well," seeking only those who were in need of but not suitable for HTx. End-points included mortality and length of survival. Of 212 referrals, 39 (19%) (age 0 to 19 years, median 3.5 years) were denied HTx for reasons other than being too well. Twenty-eight (72%) had palliated congenital heart disease. Overall mortality during the follow-up period was 38% (n = 15) with a median follow-up time of 195 days (8 to 2,832 days). Ten patients received subsequent cardiac surgery with 1 death (10%) and median follow-up of 2.6 years. Mortality risk was not influenced by age, weight, growth failure, congenital heart disease or single-ventricle physiology. Mechanical ventilation (hazard ratio 6.31, p = 0.001) and inotrope dependence (hazard ratio 4.79, p = 0.006) were associated with the highest risk of mortality. Quality of life was measured with the PedsQL cardiac module and completed by 11 of 16 eligible patients with an overall average score of 70.2 ± 23.9. An advanced heart failure program can achieve satisfactory results for pediatric patients who are not suitable candidates for HTx. For some children, high-risk palliative surgery can result in better outcome than high-risk HTx. Mortality was related to the degree of heart failure at presentation rather than underlying heart disease. Copyright © 2015 International Society for Heart and Lung Transplantation. Published by Elsevier Inc. All rights reserved.
    No preview · Article · Jan 2015 · The Journal of Heart and Lung Transplantation
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    ABSTRACT: Background and Aim. While aortic valve replacement for aortic stenosis can be performed safely in elderly patients, there is a need for hemodynamic and quality of life evaluation to determine the value of aortic valve replacement in older patients who may have age-related activity limitation. Materials and Methods. We conducted a prospective evaluation of patients who underwent aortic valve replacement for aortic stenosis with the Hancock II porcine bioprosthesis. All patients underwent transthoracic echocardiography (TTE) and completed the RAND 36-Item Health Survey (SF-36) preoperatively and six months postoperatively. Results. From 2004 to 2007, 33 patients were enrolled with an average age of 75.3 ± 5.3 years (24 men and 9 women). Preoperatively, 27/33 (82%) were New York Heart Association (NYHA) Functional Classification 3, and postoperatively 27/33 (82%) were NYHA Functional Classification 1. Patients had a mean predicted maximum V O2 (mL/kg/min) of 19.5 ± 4.3 and an actual max V O2 of 15.5 ± 3.9, which was 80% of the predicted V O2 . Patients were found to have significant improvements (P ≤ 0.01) in six of the nine SF-36 health parameters. Conclusions. In our sample of elderly patients with aortic stenosis, replacing the aortic valve with a Hancock II bioprosthesis resulted in improved hemodynamics and quality of life.
    Preview · Article · Dec 2014
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    ABSTRACT: Pulmonary sequestration refers to segmental lung tissue that has no connection with the bronchial tree or pulmonary arteries. In adults, the clinical sequelae are usually related to infection. Patients are typically referred for sequestrectomy even when they are asymptomatic. There are no guidelines for treating patients who have pulmonary sequestration and coexisting cardiac valvular disease, in which case the venous drainage patterns of sequestra pose the additional risks of infective endocarditis and volume overload. We present the cases of 2 adult patients-one symptomatic and one asymptomatic-who had concurrent aortic valvular disease and pulmonary sequestration, and we discuss the factors involved in our evaluation of their cardiac risk and our treatment decisions. In view of the sparse data to predict cardiac risks, we think that pulmonary sequestrectomy in adult patients with concurrent valvular conditions should be considered on a case-by-case basis.
    Full-text · Article · Dec 2014 · Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital
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    ABSTRACT: Objectives: Sternotomy is the standard approach to aortic valve replacement. We have adopted an approach of minimally invasive aortic valve replacement (AVR) via a right anterior mini-thoracotomy with central arterial cannulation (MIAVR). We compared perioperative outcomes with this technique to those via sternotomy (SAVR). Methods: A prospective observational study of 492 patients who underwent isolated AVR (294 MIAVR, 198 SAVR) between March 1999 and December 2013. Univariate comparisons between groups were made using t-tests or Mann-Whitney U (non-normally distributed), and c2 tests (Fisher's exact or Pearson) for categorical outcomes; a = 0.05 Results: The groups did not differ in age, BMI, creatinine, sex, diabetes, COPD, atrial fibrillation, history of myocardial infarction, or stroke. MIAVR patients were more likely to have a bicuspid valve (35% vs 18%, P = 0.03). In MIAVR patients, central aortic cannulation was utilized in 92% (n = 273). Venous cannulation was central in 86% (n = 255). Conversion to sternotomy was required in 6 patients (2%). Aortic cross-clamp and cardiopulmonary bypass times were similar. MIAVR patients had shorter ICU (2.8 vs 3.2 days, P < 0.01) and hospital stays (8.2 vs 9.7 days, P < 0.01), shorter time to extubation, reduced transfusions, and fewer wound infections (6.6% vs 1%, P < 0.001). Perioperative stroke (1.7% vs 2.5%) and mortality rates (1% vs 2.5%) were similar [see Table 1]. View this table: In this window In a new window
    Preview · Article · Oct 2014 · Interactive Cardiovascular and Thoracic Surgery
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    ABSTRACT: The development of transcatheter aortic valve implantation (TAVI) has increased the use of balloon aortic valvuloplasty (BAV) in treating aortic stenosis. We evaluated our use of BAV in an academic tertiary referral center with a developing TAVI program. We reviewed 69 consecutive stand-alone BAV procedures that were performed in 62 patients (mean age, 77 ± 10 yr; 62% men; baseline mean New York Heart Association functional class, 3 ± 1) from January 2009 through December 2012. Enrollment for the CoreValve(®) clinical trial began in January 2011. We divided the study cohort into 2 distinct periods, defined as pre-TAVI (2009-2010) and TAVI (2011-2012). We reviewed clinical, hemodynamic, and follow-up data, calculating each BAV procedure as a separate case. Stand-alone BAV use increased 145% from the pre-TAVI period to the TAVI period. The mean aortic gradient reduction was 13 ± 10 mmHg. Patients were successfully bridged as intended to cardiac or noncardiac surgery in 100% of instances and to TAVI in 60%. Five patients stabilized with BAV subsequently underwent surgical aortic valve replacement with no operative deaths. The overall in-hospital mortality rate (17.4%) was highest in emergent patients (61%). The implementation of a TAVI program was associated with a significant change in BAV volumes and indications. Balloon aortic valvuloplasty can successfully bridge patients to surgery or TAVI, although least successfully in patients nearer death. As TAVI expands to more centers and higher-risk patient groups, BAV might become integral to collaborative treatment decisions by surgeons and interventional cardiologists.
    No preview · Article · Sep 2014 · Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital
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    ABSTRACT: Pregnancy after lung transplantation has been described, but pregnancy after living donor lobar lung transplantation (LDLT) has not been reported. The aim of this study was to evaluate outcomes after pregnancy with LDLT and discuss current recommendations regarding pregnancy and lung transplantation. A total of four LDLT patients and five pregnancies were identified, all from our institution. No patient has developed worsening pulmonary function or acute or chronic rejection. The complications of pulmonary hypertension and rejection may be overestimated in this population, and recommendations for preventive sterilization at transplantation or abortion at the time of conception are likely unwarranted and unnecessary.
    No preview · Article · Aug 2014 · Transplantation
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    Full-text · Article · Apr 2014 · Journal of the American College of Cardiology

  • No preview · Article · Jan 2014 · Cardiology
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    ABSTRACT: Cardiovascular computed tomographic angiography (CCTA) provides an understanding of the three-dimensional (3D) coronary artery anatomy in relation to cardiovascular thoracic structures important to the surgical management of anomalous coronary arteries (ACAs). Although some ACA variants are not clinically significant, others can lead to ischemia/infarction, related acute ventricular dysfunction, ventricular arrhythmias, and sudden cardiac death. The CCTA is important to surgical decision making, as it provides noninvasive visualization of the coronary arteries with (1) assessment of origin, course, and termination of coronary artery anomalies in the context of 3D thoracic anatomy, (2) characterization of anatomy helpful for differentiation of benign versus hemodynamically significant variants, (3) identification of other cardiothoracic anomalies, and (4) detection of coronary artery disease. High-risk ACA anatomy in the appropriate clinical setting can require surgical intervention with decisions including minimally invasive versus open sternotomy approach, correction via reimplantation of a coronary artery, alteration of the ACA course without reimplantation, or bypass of an ACA. Given the rarity of ACA, there is limited data in the literature, and significant controversy related to the management issues. The management of ACA requires comprehensive clinical history, thorough assessment of cardiac function, and detailed anatomic imaging. Future studies will need to address the long-term outcome based on detailed assessment of original anatomy and surgical approach.
    No preview · Article · Apr 2013 · World Journal for Pediatric and Congenital Hearth Surgery
  • Ching-Ling Lien · Michael R Harrison · Tai-Lan Tuan · Vaughn A Starnes
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    ABSTRACT: Cardiovascular disease is the leading cause of death in the US and worldwide. Failure to properly repair or regenerate damaged cardiac tissues after myocardial infarction is a major cause of heart failure. In contrast to humans and other mammals, zebrafish hearts regenerate after substantial injury or tissue damage. Here, we review recent progress in studying zebrafish heart regeneration, addressing the molecular and cellular responses in the three tissue layers of the heart: myocardium, epicardium, and endocardium. We also compare different injury models utilized to study zebrafish heart regeneration and discuss the differences in responses to injury between mammalian and zebrafish hearts. By learning how zebrafish hearts regenerate naturally, we can better design therapeutic strategies for repairing human hearts after myocardial infarction.
    No preview · Article · Jul 2012 · Wound Repair and Regeneration
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    ABSTRACT: We report a modification of the Starnes technique for palliating severe tricuspid regurgitation associated with a dysplastic right ventricle in a neonate, using a fenestrated pericardial patch allowing for unidirectional flow. The patient eventually underwent a successful Glenn shunt construction with a persistent reduction in right ventricle size at 1 year follow-up.
    Full-text · Article · Feb 2012 · The Annals of thoracic surgery
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    ABSTRACT: Submitted May 6, 2011; Accepted August 3, 2011. The survival into adulthood of patients with unoperated complex congenital heart disease with anomalies often considered life threatening in infancy and childhood requires a complex interplay of "balanced" defects allowing for cardiovascular physiology compatible with long-term survival. We report on a series of three cases from our advanced imaging database of middle-aged adults presenting with multiple similar defects providing a hemodynamically balanced circulation. The constellation of defects seen in each of these patients included congenitally corrected transposition of the great arteries, a large nonrestrictive ventricular septal defect, valvular pulmonary stenosis, and in two cases anomalous coronary arteries. Cardiovascular computed tomographic angiography (CCTA) and cardiovascular magnetic resonance imaging (CMR) were important to the characterization of the multiple defects and their three-dimensional relationships in these cases. Treatment decisions in patients with this constellation of findings are challenging, given the limited data due to the rarity of survival of patients with these defects into middle adulthood and the paucity of data related to decisions and approaches to medical management, surgical correction, or transplantation.
    Full-text · Article · Jan 2012 · World Journal for Pediatric and Congenital Hearth Surgery
  • Lauren C Kane · Winfield J Wells · Vaughn A Starnes

    No preview · Article · Nov 2011 · The Journal of thoracic and cardiovascular surgery
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    ABSTRACT: The number of women affected by valvular heart disease and the number of women with breast implants are both on the rise. Minimally invasive heart surgery using a limited thoracotomy offers many potential benefits including reduction in blood loss, shorter hospital stay, faster recovery time, decreased pain, and improved cosmesis. Minimally invasive heart surgery often requires access to the second, third, or fourth intercostal space of the anterior chest wall. The presence of a breast implant may interfere with the surgeon's ability to gain adequate exposure for entry to the appropriate intercostal space. We present a case series of 5 women with breast implants who successfully underwent minimally invasive cardiac valve surgery. A retrospective review was conducted of all patients with breast implants who underwent minimally invasive cardiac valve surgery at the University of Southern California University Hospital. In each patient, an inframammary incision was performed, facilitating removal of the implant, performance of the cardiac operation, and reimplantation of the implant. Five women with breast implants who underwent minimally invasive cardiac valve surgery were identified; of these, 4 (80%) patients underwent repair of the mitral valve for mitral regurgitation, whereas 1 (20%) underwent an aortic valve replacement for aortic stenosis. Two patients underwent a concomitant maze procedure for atrial fibrillation during the same operation. The median follow-up time was 7.4 months, and the follow-up period ranged from 2 to 12 months. There were no significant postoperative complications such as infection, hematoma, or need for reoperation. Our series of 5 patients demonstrates that minimally invasive heart surgery performed through an inframammary incision can be safely performed in those with breast implants.
    Full-text · Article · Jun 2011 · Annals of plastic surgery
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    ABSTRACT: : Transthoracic minimally invasive aortic valve replacement (TMI-AVR) is gaining popularity despite criticism that time from incision to the initiation of cardiopulmonary bypass (exposure time, ET), cardiopulmonary bypass time (CPBT), and cross-clamp time (XCT) is excessive. Database analysis was used to characterize these parameters and their associated learning curves. : From 2004 to 2008, 101 patients underwent TMI-AVR at a single institution. Of them, 54 were men (53%) and 47 were women (47%). Mean age was 70 years (range, 24-90 years). ET includes 6-cm incision, second intercostals anterior thoracotomy, medial transection of the third rib, opening pericardial sac, retracing pericardium with stay sutures, placing aortic arterial, and right arterial venous bypass cannulae. ET, CPBT, XCT, and operating room times were calculated. Logarithmic trend analysis established associated learning curves. : ET steadily improved over time. ET decreased from an average of 51 minutes for the first 25 patients to 39 minutes for the most recent 25 patients. When surgeon experience reached 10 procedures, the ET trend line began to decline steadily and plateaued by 55 cases. Cross-clamp (55 ± 21 minutes), cardiopulmonary bypass (77 ± 31 minutes), and operating room times (304 ± 67 minutes) all remained constant. There were no early deaths or conversions to sternotomy. : ET learning curve for TMI-AVR was reflected after 10 procedures with continued gradual improvement. Reliability of TMI-AVR was observed in the absence of a learning curve for XCT, CPBT, and operating room times. A sternal-sparing transthoracic approach for AVR can be performed safely, with expected operative times equivalent to sternotomy.
    No preview · Article · Jan 2011 · Innovations Technology and Techniques in Cardiothoracic and Vascular Surgery

Publication Stats

7k Citations
1,154.83 Total Impact Points

Institutions

  • 1997-2015
    • Keck School of Medicine USC
      Los Ángeles, California, United States
  • 1995-2015
    • Children's Hospital Los Angeles
      • • Division of Cardiothoracic Surgery
      • • The Heart Institute
      • • Division of Critical Care Medicine
      • • Department of Surgery
      Los Ángeles, California, United States
    • Kaiser Permanente
      Oakland, California, United States
  • 1994-2015
    • University of California, Los Angeles
      • • Department of Surgery
      • • Division of Cardiothoracic Surgery
      Los Ángeles, California, United States
  • 1995-2014
    • University of Southern California
      • • Department of Cardiothoracic Surgery
      • • Keck School of Medicine
      • • Department of Surgery
      • • Department of Molecular Microbiology and Immunology
      Los Ángeles, California, United States
  • 1997-1998
    • University of Verona
      Verona, Veneto, Italy
  • 1987-1995
    • Stanford University
      • • Department of Cardiothoracic Surgery
      • • Division of Vascular Surgery
      Palo Alto, California, United States
  • 1993
    • Great Ormond Street Hospital for Children NHS Foundation Trust
      Londinium, England, United Kingdom
  • 1988-1993
    • Stanford Medicine
      • • Division of Pulmonary and Critical Care Medicine
      • • Division of Vascular and Endovascular Surgery
      Stanford, California, United States
  • 1990
    • University of Iowa Children's Hospital
      Iowa City, Iowa, United States
    • Lucile Packard Children’s Hospital at Stanford
      Palo Alto, California, United States