John G. Byrne

2012 American College of Cardiology Foundation/Society for Cardiovascular Angiography and Interventions Expert Consensus Document on Cardiac Catheterization Laboratory Standards update: A report of the American College of Cardiology Foundation Task Force on Expert Consensus Documents

published online May 8, 2012; J. Am. Coll. Cardiol. L. Tommaso Carl Moliterno, John W.M. Moore, Sandra M. Oliver-McNeil, Jeffrey J. Popma, and Landzberg, Warren K. Laskey, Charles R. McKay, Julie M. Miller, David J. Cavendish, Charles E. Chambers, James Bernard Hermiller, Jr, Scott Kinlay, Joel S. M. Bashore, MD, FACC,, Stephen Balter, Ana Barac, John G. Byrne, Jeffrey J. Documents, Society of Thoracic Surgeons, Society for Vascular Medicine, Thomas American College of Cardiology Foundation Task Force on Expert Consensus Catheterization Laboratory Standards Update Angiography and Interventions Expert Consensus Document on Cardiac 2012 American College of Cardiology Foundation/Society for Cardiovascular This information is current as of May 25, 2012 http://content.onlinejacc.org/cgi/content/full/j.jacc.2012.02.010v1 located on the World Wide Web at: The online version of this article, along with updated information and services, is

Surgical management of endocarditis: the society of thoracic surgeons clinical practice guideline.

Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee; Division of Infectious Diseases, Rush University, Chicago, Illinois; Department of Surgery, Saint Mary’s Hospital, Waterbury, Connecticut; Feinberg School of Medicine of Northwestern University, Northwestern Memorial Hospital, Chicago, Illinois; Cardiac Vascular and Thoracic Surgeons, Cincinnati, Ohio; Department of Surgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania; Department of Cardiovascular-Thoracic Surgery, Rush University Medical Center, Chicago, Illinois; and Division of Cardiac Surgery, The Ohio State University Medical Center, Columbus, Ohio

High-Dose Perioperative Atorvastatin and Acute Kidney Injury Following Cardiac Surgery: A Randomized Clinical Trial

IMPORTANCE Statins affect several mechanisms underlying acute kidney injury (AKI). OBJECTIVE To test the hypothesis that short-term high-dose perioperative atorvastatin would reduce AKI following cardiac surgery. DESIGN, SETTING, AND PARTICIPANTS Double-blinded, placebo-controlled, randomized clinical trial of adult cardiac surgery patients conducted from November 2009 to October 2014 at Vanderbilt University Medical Center. INTERVENTIONS Patients naive to statin treatment (n = 199) were randomly assigned 80 mg of atorvastatin the day before surgery, 40 mg of atorvastatin the morning of surgery, and 40 mg of atorvastatin daily following surgery (n = 102) or matching placebo (n = 97). Patients already taking a statin prior to study enrollment (n = 416) continued taking the preenrollment statin until the day of surgery, were randomly assigned 80 mg of atorvastatin the morning of surgery and 40 mg of atorvastatin the morning after (n = 206) or matching placebo (n = 210), and resumed taking the previously prescribed statin on postoperative day 2. MAIN OUTCOMES AND MEASURES Acute kidney injury defined as an increase of 0.3 mg/dL in serum creatinine concentration within 48 hours of surgery (Acute Kidney Injury Network criteria). RESULTS The data and safety monitoring board recommended stopping the group naive to statin treatment due to increased AKI among these participants with chronic kidney disease (estimated glomerular filtration rate <60 mL/min/1.73 m2) receiving atorvastatin. The board later recommended stopping for futility after 615 participants (median age, 67 years; 188 [30.6%] were women; 202 [32.8%] had diabetes) completed the study. Among all participants (n = 615), AKI occurred in 64 of 308 (20.8%) in the atorvastatin group vs 60 of 307 (19.5%) in the placebo group (relative risk [RR], 1.06 [95% CI, 0.78 to 1.46]; P = .75). Among patients naive to statin treatment (n = 199), AKI occurred in 22 of 102 (21.6%) in the atorvastatin group vs 13 of 97 (13.4%) in the placebo group (RR, 1.61 [0.86 to 3.01]; P = .15) and serum creatinine concentration increased by a median of 0.11 mg/dL (10th-90th percentile, -0.11 to 0.56 mg/dL) in the atorvastatin group vs by a median of 0.05 mg/dL (10th-90th percentile, -0.12 to 0.33 mg/dL) in the placebo group (mean difference, 0.08 mg/dL [95% CI, 0.01 to 0.15 mg/dL]; P = .007). Among patients already taking a statin (n = 416), AKI occurred in 42 of 206 (20.4%) in the atorvastatin group vs 47 of 210 (22.4%) in the placebo group (RR, 0.91 [0.63 to 1.32]; P = .63). CONCLUSIONS AND RELEVANCE Among patients undergoing cardiac surgery, high-dose perioperative atorvastatin treatment compared with placebo did not reduce the risk of AKI overall, among patients naive to treatment with statins, or in patients already taking a statin. These results do not support the initiation of statin therapy to prevent AKI following cardiac surgery. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00791648.

Episodic Monoplane Transesophageal Echocardiography Impacts Postoperative Management of the Cardiac Surgery Patient

OBJECTIVE A new slender, flexible, and miniaturized disposable monoplane transesophageal TEE probe has been approved for episodic hemodynamic transesophageal echocardiographic monitoring. The authors hypothesized that episodic monoplane TEE with a limited examination would help guide the postoperative management of high-risk cardiac surgery patients. DESIGN The authors analyzed the initial consecutive observational experience with the miniaturized transesophageal echocardiography monitoring system (ClariTEE, ImaCor, Uniondale, New York). SETTING Single institution in a university setting. PARTICIPANTS Unstable cardiac surgery patients. INTERVENTIONS The authors assessed fluid responsiveness, echocardiographic data, and concordance among hemodynamic data. MEASUREMENTS AND MAIN RESULTS From June 2010 to February 2011, 21 unstable cardiac surgery patients with postoperative instability were identified. Two patients (10%) required reoperation for bleeding and tamponade physiology. Right ventricular dysfunction was diagnosed by episodic TEE monitoring in 7 patients (33%), while hypovolemia was documented in 12 patients (57%). Volume responsiveness was documented in 11 patients. In this observational study, discordance between hemodynamic monitoring and episodic TEE was qualitatively observed in 14 patients (66%). CONCLUSION The authors demonstrated the ability of episodic monoplane TEE to identify discordance between hemodynamic monitoring to better define clinical scenarios in unstable cardiac surgery patients. For these challenging patients, limited episodic TEE assessment has become a cornerstone of ICU care in this institution.

Stem cell therapy for chronic heart failure: an updated appraisal

Introduction: Significant advances have been made to understand the mechanisms involved in cardiac cell-based therapies. The early translational application of basic science knowledge has led to several animal and human clinical trials. The initial promising beneficial effect of stem cells on cardiac function restoration has been eclipsed by the inability of animal studies to translate into sustained clinical improvements in human clinical trials. Areas covered: In this review, the authors cover an updated overview of various stem cell populations used in chronic heart failure. A critical review of clinical trials conducted in advanced heart failure patients is proposed, and finally promising avenues for developments in the field of cardiac cell-based therapies are presented. Expert opinion: Several questions remain unanswered, and this limits our ability to understand basic mechanisms involved in stem cell therapeutics. Human studies have revealed critical unresolved issues. Further elucidation of the proper timing, mode delivery and prosurvival factors is imperative, if the field is to advance. The limited benefits seen to date are simply not enough if the potential for substantial recovery of nonfunctioning myocardium is to be realized.

2012 American college of cardiology foundation/society for cardiovascular angiography and interventions expert consensus document on cardiac catheterization laboratory standards update: American college of cardiology foundation task force on expert consensus documents society of thoracic surgeons society for vascular medicine

WRITING COMMITTEE MEMBERS* Thomas M. Bashore, MD, FACC, FSCAI, chair, Stephen Balter, PhD, FAAPM, FACR, FSIR, Ana Barac, MD, PhD, John G. Byrne, MD, FACC, Jeffrey J. Cavendish, MD, FACC, FSCAI, Charles E. Chambers, MD, FACC, FSCAI, James Bernard Hermiller, Jr, MD, FACC, FSCAI, Scott Kinlay, MBBS, PhD, FACC, FSCAI, Joel S. Landzberg, MD, FACCk, Warren K. Laskey, MD, MPH, FACC, FSCAI, Charles R. McKay, MD, FACC, Julie M. Miller, MD, FACC, David J. Moliterno, MD, FACC, FSCAI, John W.M. Moore, MD, MPH, FACC, FSCAI, Sandra M. Oliver-McNeil, DNP, ACNP-BC, AACC, Jeffrey J. Popma, MD, FACC, FSCAI, and Carl L. Tommaso, MD, FACC, FSCAI

Minimally-Invasive Fibrillating Mitral Valve Replacement for Patients with Advanced Cardiomyopathy: a Safe and Effective Approach to Treat a Complex Problem

OBJECTIVE The optimal management of mitral regurgitation (MR) in patients with cardiomyopathy has been controversial. Minimally invasive fibrillating mitral valve replacement (mini-MVR) might limit postoperative morbidity and mortality by minimizing recurrent MR. We hypothesized that mini-MVR with complete chordal sparing would offer low mortality and halt left ventricular (LV) remodeling in patients with severe cardiomyopathy and severe MR. METHODS From January 2006 to August 2009, 65 patients with an LV ejection fraction (LVEF) of ≤35% underwent mini-MVR. The demographic, echocardiographic, and clinical outcomes were analyzed. RESULTS The operative mortality compared with the Society of Thoracic Surgeons-predicted mortality was 6.2% versus 6.6%. It was 5.6% versus 7.4% for patients with an LVEF of ≤20% and 8.3% versus 17.9% among patients with a Society of Thoracic Surgeons-predicted mortality of ≥10%. At a median follow-up of 17 months, no recurrent MR or change in the LV dimensions or LVEF had developed, but the right ventricular systolic pressure had decreased (P=.02). At the first postoperative visit and latest follow-up visit, the New York Heart Association class had decreased from 3.0±0.6 to 1.7±0.7 and 2.0±1.0, respectively (P<.0001 for both). Patients with an LVEF of ≤20% and LV end-diastolic diameter of ≥6.5 cm were more likely to meet a composite of death, transplantation, or LV assist device insertion (P=.046). CONCLUSIONS Our results have shown that mini-MVR is safe in patients with advanced cardiomyopathy and resulted in no recurrent MR, stabilization of the LVEF and LV dimensions, and a decrease in right ventricular systolic pressure. This mini-MVR technique can be used to address severe MR in patients with advanced cardiomyopathy.

Minimally Invasive Surgery for Valvular Heart Disease

Opinion statementValvular heart disease imposes varying degrees of stress on the myocardium, which, untreated, leads to eventual ventricular dysfunction. The pathophysiologic mechanisms by which these lesions act depend not only on the affected valve, but also the degree to which they causes stenosis, regurgitation, or both. The goal of patient treatment is to identify and correct the defect before irreversible ventricular changes have occurred. Historically, the conventional surgical approach for valvular disease was via median sternotomy. Minimally invasive valve surgery (MIVS) refers to alternative surgical techniques, which avoid the trans-sternal approach. The objective is to (1) minimize surgical trauma, (2) reduce blood utilization, and (3) hasten postoperative convalesce. These goals are accomplished through the use of partial sternal, para-sternal, or thoracotomy incisions and can be adapted to robotic technologies. As with all evolving surgical techniques, the therapeutic aim of valve repair or replacement must be performed at or above the same standard of conventional surgery. Outcomes must not be sacrificed for the sake of better cosmesis. In addition, percutaneous catheter-based valvular interventions have seen rapid advances. These emerging technologies have dramatically broadened the therapeutic options, especially for an ever-increasing group of high-risk patients. As expected with all minimally invasive techniques, the major differences in the hard outcomes of mortality and major morbidity are seen in these highest risk groups. However, intermediate and low risk patients receive a tremendous benefit with regard to shortened hospital stay and quicker functional recovery. With the myriad of interventional options now available, the clinical challenge now is how best to individualize the treatment approach to a given patient providing the most durable result in order to alleviate symptoms and preserve myocardial function.

Altered ADAMTS5 Expression and Versican Proteolysis: A Possible Molecular Mechanism in Barlow's Disease

BACKGROUND We hypothesized that gene expression profiles of mitral valve (MV) leaflets from patients with Barlows disease (BD) are distinct from those with fibroelastic deficiency (FED). METHODS MVs were obtained from patients with BD (7 men, 3 women; 61.4 ± 12.7 years old) or FED (6 men, 5 women; 54.5 ± 6.0 years old) undergoing operations for severe mitral regurgitation (MR). Normal MVs were obtained from 6 donor hearts unmatched for transplant (3 men, 3 women; 58.3 ± 7.5 years old), and gene expression was assessed using cDNA microarrays. Select transcripts were validated by quantitative reverse-transcription polymerase chain reaction, followed by an assessment of protein levels by immunostaining. RESULTS The global gene expression profile for BD was clearly distinct from normal and FED groups. A total of 4,684 genes were significantly differential (fold-difference >1.5, p < 0.05) among the three groups, 1,363 of which were commonly altered in BD and FED compared with healthy individuals (eg TGFβ2 [transforming growth factor β2] and TGFβ3 were equally upregulated in BD and FED). Most interesting were 329 BD-specific genes, including ADAMTS5 (a disintegrin-like and metalloprotease domain with thrombospondin-type 5), which was uniquely downregulated in BD based on microarrays and quantitative reverse-transcription polymerase chain reaction. Consistent with this finding, the ADAMTS5 substrate versican was increased in BD and conversely lower in FED. CONCLUSIONS MV leaflets in BD and FED exhibit distinct gene expression patterns, suggesting different pathophysiologic mechanisms are involved in leaflet remodeling. Moreover, downregulation of ADAMTS5 in BD, along with the accumulation of its substrate versican in the valvular extracellular matrix, might contribute to leaflet thickening and enlargement.

Pulmonary Artery Catheter Deviation on Chest Roentgenogram After Cardiac Operation: A Sign of Tamponade

Tamponade after cardiac operations often does not manifest the classic clinical or even echocardiographic features of tamponade and may therefore be difficult to diagnose. We present 3 patients with cardiac tamponade in the early postoperative period in whom portable chest roentgenogram revealed marked leftward pulmonary artery catheter displacement at the level of the right atrium and superior vena cava due to adjacent hematoma. Awareness of this radiographic finding may allow immediate triage to a life-saving reoperation, obviating the need for further imaging or diagnostic delay.