Robert J. Moraca

Preoperative statin is associated with decreased operative mortality in high risk coronary artery bypass patients

BackgroundStatins are widely prescribed to patients with atherosclerosis. A retrospective database analysis was used to examine the role of preoperative statin use in hospital mortality, for patients undergoing isolated coronary artery bypass grafting (CABG.)MethodsThe study population comprised 2377 patients who had isolated CABG at Allegheny General Hospital between 2000 and 2004. Mean age of the patients was 65 ± 11 years (range 27 to 92 years). 1594 (67%) were male, 5% had previous open heart procedures, and 4% had emergency surgery. 1004 patients (42%) were being treated with a statin at the time of admission. Univariate, bivariate (Chi2, Fishers Exact and Students t-tests) and multivariate (stepwise linear regression) analyses were used to evaluate the association of statin use with mortality following CABG.ResultsAnnual prevalence of preoperative statin use was similar over the study period and averaged 40%. Preoperative clinical risk assessment demonstrated a 2% risk of mortality in both the statin and non-statin groups. Operative mortality was 2.4% for all patients, 1.7% for statin users and 2.8% for non-statin users (p < 0.07). Using multivariate analysis, lack of statin use was found to be an independent predictor of mortality in high-risk patients (n = 245, 12.9% vs. 5.6%, p < 0.05).ConclusionsBetween 2000 and 2004 less than 50% of patients at this institution were receiving statins before admission for isolated CABG. A retrospective analysis of this cohort provides evidence that preoperative statin use is associated with lower operative mortality in high-risk patients.

Contemporary incidence and risk factors for carotid artery disease in patients referred for coronary artery bypass surgery.

BackgroundIn the past decade, there has been an increase in the amount of patients with medical co-morbidities referred for coronary artery bypass surgery (CABG). Significant carotid artery disease in patients undergoing CABG procedures increases the risk of neurological complications. We review the results of routine carotid screening in patients undergoing CABG to determine the contemporary incidence and risk factors for carotid artery disease.MethodsBetween 2008 through 2010, 673 patients were referred for isolated coronary artery bypass surgery at a single institution. Patients were identified through a systematic review of The Department of Cardiothoracic Surgery Society of Thoracic Surgery Outcomes Database. A retrospective analysis of prospectively collected demographic, clinical data and outcomes were performed. All patients with screening preoperative carotid duplex were reviewed. We defined the degree of carotid disease as: none to mild stenosis (<50%), moderate stenosis (50-69%), severe stenosis (70-99%). Multivariate analysis was performed to identify risk factors.Results559 (83%) patients underwent screening preoperative carotid ultrasonography prior to CABG. The incidence of carotid artery disease (>50% stenosis) was 36% with 18% unilateral moderate disease, 10% bilateral moderate and 8% severe disease. Risk factors associated with carotid artery disease included: advanced age, renal failure, previous stroke, peripheral vascular disease, left main coronary artery disease, and previous myocardial infarction.ConclusionsThere is a significant incidence of carotid artery stenosis in patients referred for CABG. Routine screening will identify patients with carotid artery disease and may reduce the risk of postoperative stroke.

Salvage Peripheral Extracorporeal Membrane Oxygenation Using Cobe Revolution® Centrifugal Pump as a Bridge to Decision for Acute Refractory Cardiogenic Shock

Abstract  Objectives: Acute refractory cardiogenic shock with early multisystem organ failure has a poor outcome without mechanical circulatory support. We review our experience with emergent peripheral cardiopulmonary support as a bridge to decision in these patients. Methods: A retrospective review from January 2009 through December 2010 was conducted of 26 consecutive adult patients at a single institution with acute refractory cardiogenic shock who underwent salvage peripheral cardiopulmonary support. Results: There were 18 men and 8 women with a mean age of 54 years (range 18 to 76). Indications for support: acute myocardial infarction (n = 16), decompensated chronic heart failure (n = 2), refractory arrhythmic arrest (n = 3), acute valvular pathology (n = 4), and unknown (n = 1). Patients with primary postcardiotomy shock were excluded. Median duration of support was 3 days (range 1 to 14). Decisions included: withdraw of support (n = 4), recovery (n = 5), and bridge to a procedure (n = 17). The procedures were percutaneous coronary intervention (n = 4), left ventricular assist device (n = 9), heart transplantation (n = 1), and miscellaneous cardiac surgery (n = 3). Overall survival to discharge was 65%. In the recovery and bridge to a procedure group, 78% were discharged from the hospital and survival at three months was 72%. Conclusions: Salvage peripheral cardiopulmonary support is a useful tool to rapidly stabilize acute refractory cardiogenic shock permitting an assessment of neurologic and end‐organ viability. (J Card Surg 2012;27:521‐527)

Strategies and Outcomes of Cardiac Surgery in Jehovah's Witnesses

Abstract  Background: Jehovahs Witnesses (JW) are a Christian faith, with an estimated 1.1 million members in the United States, well recognized for their refusal of blood and blood products. JW may not be considered for cardiac surgery due to perceived higher risks of morbidity and mortality. This study reviews our contemporary strategies and experience with JW undergoing routine and complex cardiac surgery. Methods: From November 2001 to April 2010, 40 JW were referred for cardiac surgery at a single quaternary referral institution. A retrospective analysis of demographic data, perioperative management, and clinical outcomes was examined. Published validated clinical risk calculator and model for prediction of transfusion were used to identify high‐risk patients (risk of mortality >6% or probability of transfusion >0.80). Results: The mean age was 70 (± 9.5) years with 21 men and 19 women. Patients were classified as high risk (45%, n = 18) and low risk (55%, n = 22) with demographics and comorbidities listed in Table 2. Operative procedures included: isolated coronary artery bypass grafting (CABG) (n = 19), isolated valve replacement/repair (n = 7), valve/CABG (n = 7), reoperative valve replacement (n = 4), reoperative CABG (n = 2), valve/ascending aorta replacement (n = 1), and CABG/ascending aorta replacement (n = 1). All JW were evaluated by The Department of Bloodless Medicine to individually define acceptable blood management strategies. The mean preoperative hemoglobin was 14.1 g/dL (±1.6). Overall mortality was 5% (n = 2) all of which were in the high‐risk group. Discussion: Using a multidisciplinary approach to blood management, JW can safely undergo routine and complex cardiac surgery with minimal morbidity and mortality. (J Card Surg 2011;26:135‐143)

Thoracic endovascular aortic repair of an aberrant right subclavian artery: technique and long-term outcome.

Abstract  Background: Aberrant right subclavian artery (ARSA) is the most common congenital arch anomaly, which can be complicated by aneursymal dilation at its ostium. We describe a successful repair of an ARSA with a three‐stage operative procedure using a left carotid to subclavian bypass, coiling of the ARSA, and thoracic endovascular aortic repair with long‐term clinical and radiographic follow‐up. (J Card Surg 2010;25:390‐393)

Temporary Mechanical Circulatory Support for Takotsubo Cardiomyopathy Secondary to Primary Mediastinal B‐Cell Lymphoma

Abstract  Background: Left heart mechanical circulatory support (MCS) through the left chest via the pulmonary vein and descending thoracic aorta is a good option for patients with an inaccessible anterior mediastinum and/or poor peripheral access. Materials and Methods: We report the case of a 19‐year‐old small female with a newly discovered bulky primary mediastinal diffuse large B‐cell lymphoma (PMBL) who developed refractory inverted Takotsubo cardiomyopathy (TC) with cardiogenic shock. Results: Temporary MCS was implemented in order to stabilize the patient and proceed with a chemotherapy treatment. Given the patients oncologic “frozen” mediastinum and the presence of poor peripheral arterial access, the left heart temporary MCS was successfully implanted through a left mini‐thoracotomy via the left inferior pulmonary vein and descending thoracic aorta. Conclusions: This is the first report of temporary MCS to treat inverted TC and diffuse PMBL. (J Card Surg 2012;27:119–121)

Chronic Thromboembolic Pulmonary Hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) is a potentially life-threatening condition characterized by obstruction of pulmonary arterial vasculature by acute or recurrent thromboemboli with subsequent organization, leading to progressive pulmonary hypertension and right heart failure. Until relatively recently, CTEPH was a diagnosis made primarily at autopsy, but advances made in diagnostic modalities and surgical pulmonary endarterectomy techniques have made this disease treatable and even potentially curable. Although published guidelines are available, in the absence of randomized controlled trials regarding CTEPH there is a lack of standardization, and treatment options have to be individualized.

A parallel wire robot for epicardial interventions.

This paper describes the design and preliminary testing of a planar parallel wire robot that adheres to the surface of the beating heart and provides a stable platform for minimally invasive epicardial therapies. The device is deployed through a small subxiphoid skin incision and attaches to the heart using suction. This methodology obviates mechanical stabilization and lung deflation, which are typically required during minimally invasive beating-heart surgery. The prototype design involves three vacuum chambers connected by two flexible arms. The chambers adhere to the epicardium, forming the vertices of a triangular base structure. Three cables connect a movable end-effector head to the three bases; the cables then pass out of the body to external actuators. The surgical tool moves within the triangular workspace to perform injections, ablation, or other tasks on the beating heart. Tests in vitro and in vivo were conducted to demonstrate the capabilities of the system. Tests in vivo successfully demonstrated the ability to deploy through a subxiphoid incision, adhere to the surface of the beating heart, move the surgical tool head within the robots workspace, and perform injections into the myocardium.

Aortic Valve Replacement in Patients with Systemic Mastocytosis

Abstract  Systemic mastocytosis is a hematologic disorder with important perioperative implications. A variety of stimuli and medications can cause severe anaphylaxis in these patients. We report successful preoperative, intraoperative, and postoperative management of a patient with systemic mastocytosis who underwent an aortic valve replacement and review the literature pertaining to cardiac surgery in these patients.

Parallel Force/Position Control of an Epicardial Parallel Wire Robot

Gene therapies for heart failure have emerged in recent years, yet they lack an effective method for minimally invasive, uniform delivery. To address this need we developed a minimally invasive parallel wire robot for epicardial interventions. Accurate and safe interventions using this device require control of force in addition to injector position. Accounting for the nonidealities of the device design, however, yields nonlinear and underconstrained statics. This work solves these equations and demonstrates the efficacy of using this information in a parallel control scheme, which is shown to provide superior positioning compared to a position-only controller.