Ashkan Karimi

Midterm Cost and Effectiveness of Thoracic Endovascular Aortic Repair Versus Open Repair

BACKGROUND Thoracic endovascular aneurysm repair (TEVAR) has been rapidly introduced as a primary treatment modality for thoracic aortic diseases with limited data available on midterm to late-term outcomes. METHODS A retrospective single institution study comparing hospital and midterm outcomes and costs for TEVAR versus open elective repair of descending thoracic aneurysms was conducted. Fifty-seven patients were included between 2005 and 2007 (TEVAR=28; open=29) and were followed until May 2010. RESULTS Patients in the TEVAR group were older (73.2 versus 62.3 years; p<0.001). Hospital mortality was higher in the open repair group (10.3% versus 3.6%; p=0.611). There was no statistical difference in stroke, paraparesis or paralysis, sepsis, or renal failure; however, a composite major adverse event variable showed a higher complication with open repair versus TEVAR (37.9% versus 14.3%; p=0.043). Mean follow-up was 42.6 months for open repair versus 26.9 for TEVAR (p=0.002). Kaplan-Meier survival analysis showed the initial survival benefit for TEVAR was lost in less than 6 months; however, the difference did not reach statistical significance during follow-up (log-rank test p=0.232). Mean surveillance imaging costs for a TEVAR patient were

Outcomes for Acute Type A Aortic Dissection: Effects of Previous Cardiac Surgery

1,800.38 higher than for an open patient at 2 years. Compliance of TEVAR patients with follow-up imaging was 78%, 64%, 50%, and 42% at 1, 6, 12, and 24 months, respectively, and was even lower in those not registered in device trials. CONCLUSIONS Patients in the TEVAR group had favorable early outcomes; however, midterm survival was reduced secondary to comorbidities. This study raises concern for the ongoing costs of surveillance imaging in TEVAR as well as patient compliance with follow-up.

Close antiplatelet therapy monitoring and adjustment based upon thrombelastography may reduce late-onset bleeding in HeartMate II ecipients

BACKGROUND The standard of performing emergent surgical repair for acute aortic dissection type A has been questioned in patients with previous cardiac surgery. The effects of previous cardiac surgery on the presentation and operative outcome of these patients is understudied. METHODS Between 1998 and 2010, 190 patients were operated on for acute type A aortic dissection; there were 159 first cardiac operations (FCO) and 31 redo operations (REDO). Stepwise logistic regression analysis identified independent predictors of hospital mortality. Propensity score-matching yielded 31 FCOs who matched the REDOs with respect to age, sex, hypertension history, chronic obstructive pulmonary disease, and renal failure. The presentation, operative outcome, and complications were compared between the two groups. RESULTS Hospital mortality rate was 16.8% (32 of 190). Regression analysis identified mental status change (odds ratio [OR] = 5.9), hypertension (OR = 4.6), concomitant coronary artery bypass grafting (OR = 3), reoperation (OR = 2.9), and age of 70 years or older (OR = 2.8) as predictors of hospital mortality. After matching there was no difference between REDO and FCO groups in the presenting symptoms, but REDOs had a higher incidence of aortic rupture (29% [9 of 31] versus 3.2% [1 of 31]; p = 0.012). Cardiac tamponade was present in 3.2% (1 of 31) of REDOs versus 16.1% of FCOs (5 of 31; p = 0.195). Patients in the REDO group required more intraoperative blood transfusion, and had longer cardiopulmonary bypass time. Major complications occurred similarly between the two groups, except REDOs had worse renal function and a higher rate of sudden cardiac arrest (14.3% [4 of 28] versus 0; p = 0.045). CONCLUSIONS Although hospital mortality is higher among REDOs, it is still lower than the reported mortality for medical management, and major complications occurred at a rate similar to that of FCOs; hence, emergent surgery remains the prudent treatment.

Speckle tracking echocardiography-determined measures of global and regional left ventricular function correlate with functional capacity in patients with and without preserved ejection fraction

OBJECTIVES Bleeding is the most common complication of HeartMate II and is partially attributable to platelet dysfunction; however, antiplatelet therapy is arbitrary in most centres. We investigated how antiplatelet therapy adjustment with thrombelastography affects late-onset bleeding. METHODS Thrombelastography was used to adjust antiplatelet therapy in 57 HeartMate II recipients. Kaplan-Meier survival curves and Cox proportional hazard ratio model were used to identify predictors of late-onset bleeding in univariate and multivariate analysis. Finally, late-onset bleeding rate in our study was compared with the reported rates in other studies in the literature, all of which did not use any test to monitor or adjust antiplatelet therapy. RESULTS Mean follow-up was 347 days. Eighteen late-onset bleeding events occurred in 12 patients, a late-onset bleeding rate of 12/57 (21%) or 0.21 events/patient-year. The Kaplan-Meier survival curves demonstrated that late-onset bleeding was more common in the destination therapy cohort (P = 0.02), in patients older than 60 years (P = 0.04) and in females (P = 0.01), none of which was significant in multivariate analysis at a significance level of 0.05. To further investigate the higher bleeding rate in elderly patients, thrombelastography parameters were compared between younger and older patients at the age cut-off of 60 years which demonstrated a prothrombotic change the day after device implantation in younger patients that was absent in the elderly. There was also a trend towards higher requirement for antiplatelet therapy in younger patients while on device support, but the difference did not reach statistical significance. The average late-onset or gastrointestinal bleeding rate among seven comparable studies in the literature that did not use any monitoring test to adjust antiplatelet therapy was 0.49 events/patient-year. CONCLUSIONS Our study implicates that antiplatelet therapy adjustment with thrombelastography may reduce late-onset bleeding rate in HeartMate II recipients. Bleeding was more common in the elderly recipients and analysis of thrombelastography data suggests that a less aggressive antiplatelet therapy regimen could potentially lower bleeding rate in this vulnerable population.

Technical Pearls for Swine Lung Transplantation

BackgroundStandard measures of left ventricular systolic and diastolic function often fail to identify left ventricular dysfunction in patients with heart failure and do not correlate with measures of functional capacity.AimTo determine if speckle tracking echocardiography (STE)–determined measures of global and regional myocardial contractility have a linear association with functional capacity in patients with and without preserved ejection fraction.MethodsIn 68 adult patients, functional status was estimated with the Duke Activity Status Index (DASI), left ventricular ejection fraction was determined with Simpson’s biplane method, and QLAB advanced quantification software (Philips, The Netherlands) was used to determine peak measures of strain.ResultsGlobal and regional measures of longitudinal, circumferential, and radial strain had a strong linear association with the DASI score. Longitudinal strain in the inferolateral segments had the strongest correlation with DASI (r = −0.72, P < 0.001). In patients with an ejection fraction ≥45%, ejection fraction and E/e’ had no correlation with DASI, whereas longitudinal strain in the inferolateral segments had significant correlation with DASI (r = −0.53, P = 0.03, n = 16).ConclusionsSTE–determined measures of global and regional left ventricular function have a strong linear association with estimates of functional capacity in patients with and without preserved ejection fraction. STE–determined measures of strain, especially longitudinal strain, are likely to be important targets for therapy and should be considered in future studies aimed at improving our diagnosis of left ventricular inadequacy in patients with heart failure, especially those with preserved ejection fraction.

Brucellosis Relapse Causing Prosthetic Valve Endocarditis and Aortic Root Infective Pseudoaneurysm

BACKGROUND Since the advent of ex vivo lung perfusion (EVLP), there has been increased focus on swine models of lung transplantation; however, the anatomic differences between human and swine lungs and the technical challenges in performing porcine lung transplantation are not well described in the surgical literature. METHODS Surgically important anatomic variations are described, and the technical measures taken to address them during harvest and transplantation are introduced. RESULTS There are three surgically important anatomic variations in pigs. First, the right cranial lobe bronchus arises directly from the trachea, which makes right lung transplantation technically challenging if not prohibitive. Second, the left hemi-azygos vein is fully developed and courses upward through the posterior mediastinum, where it crosses the left pulmonary hilum and drains directly into the coronary sinus. During transplantation, this vein is ligated and dissected away to expose the underlying left pulmonary hilar structures. Third, the right inferior pulmonary vein crosses the midline to drain into the left atrium immediately adjacent to the left inferior pulmonary vein. During donor lung preparation, the right inferior pulmonary vein is ligated distally from the left atrium, which leaves an adequate atrial cuff around the left sided pulmonary veins for later anastomosis. CONCLUSION Experimental porcine lung transplantation is technically demanding. We have found recognition of the above described anatomical differences and technical nuances facilitate transplantation and provide reproducible results.

Implantation of a cardiac resynchronization therapy defibrillator in a patient with bilateral deep brain stimulator: feasibility and technique

We report a previously treated case of brucellosis and aortic root replacement, which became complicated by prosthetic valve endocarditis and a massive aortic root pseudoaneurysm. Preoperative blood and intraoperative pseudoaneurysm wall cultures were positive for Brucella, and the patient was managed successfully with a combination of surgical and medical treatment. Brucella endocarditis is further discussed.

The importance of localizing pulmonary veins in atrial septal defect closure

Uncommonly, a patient with a NeuroStimulator Device (NSD) for a neurologic indication requires a cardiovascular implantable electronic device (CIED) for a cardiac indication. Typically in those with a unilateral pectoral NSD, the contralateral pectoral space is used for CIED implantation; however, in very rare occasions the patient has bilateral pectoral NSDs which makes subsequent implantation of a CIED challenging both because of placement and device interaction. Herein, we introduce the case of a 68-year-old gentleman with bilateral pectoral deep brain stimulators for Parkinsonism who received cardiac resynchronization therapy-defibrillator (CRT-D) for advanced heart failure. The CRT-D generator was implanted in the abdomen and the CRT-D leads were placed through a minimally invasive epicardial approach. Both devices were tested without any evidence of device interaction.

Early and midterm outcomes of transcatheter aortic valve replacement in patients with bicuspid aortic valves

An 8-year-old girl was admitted for a simple closure of echocardiographically diagnosed Atrial Septal Defect (ASD). During the operation the right pulmonary veins orifices were not detected in the left atrium and attempt to localize them led to the discovery of three additional anomalies, namely Interrupted Inferior Vena Cava (IIVC), Scimitar syndrome, and systemic arterial supply of the lung. Postoperatively these finding were confirmed by CT angiography. This case report emphasizes the need for adequate preoperative diagnosis and presents a very rare constellation of four congenital anomalies that to the best of our knowledge is not reported before.

Pulmonary and tricuspid valvuloplasty in carcinoid heart disease

Bicuspid aortic valve (BAV) stenosis has been considered a relative contraindication to transcatheter aortic valve replacement (TAVR). We compared the outcomes of TAVR in patients with BAV stenosis versus patients with trileaflet aortic valve stenosis.