71 results on '"Mehrdad Ghoreishi"'
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2. A Dedicated Veno-Venous Extracorporeal Membrane Oxygenation Unit during a Respiratory Pandemic: Lessons Learned from COVID-19 Part I: System Planning and Care Teams
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Sagar Dave, Aakash Shah, Samuel Galvagno, Kristen George, Ashley R. Menne, Daniel J. Haase, Brian McCormick, Raymond Rector, Siamak Dahi, Ronson J. Madathil, Kristopher B. Deatrick, Mehrdad Ghoreishi, James S. Gammie, David J. Kaczorowski, Thomas M. Scalea, Jay Menaker, Daniel Herr, Eric Krause, and Ali Tabatabai
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extracorporeal membrane oxygenation ,COVID-19 ,acute respiratory distress syndrome ,biocontainment unit ,Chemical technology ,TP1-1185 ,Chemical engineering ,TP155-156 - Abstract
Background: The most critically ill patients with coronavirus disease 2019 (COVID-19) may require advanced support modalities, such as veno-venous extracorporeal membrane oxygenation (VV-ECMO). A systematic, methodical approach to a respiratory pandemic on a state and institutional level is critical. Methods: We conducted retrospective review of our institutional response to the COVID-19 pandemic, focusing on the creation of a dedicated airlock biocontainment unit (BCU) to treat patients with refractory COVID-19 acute respiratory distress syndrome (CARDS). Data were collected through conversations with staff on varying levels in the BCU, those leading the effort to make the BCU and hospital incident command system, email communications regarding logistic changes being implemented, and a review of COVID-19 patient census at our institution from March through June 2020. Results: Over 2100 patients were successfully admitted to system hospitals; 29% of these patients required critical care. The response to this respiratory pandemic augmented intensive care physician staffing, created a 70-member nursing team, and increased the extracorporeal membrane oxygenation (ECMO) capability by nearly 200%. During this time period, 40 COVID-19 patients on VV-ECMO were managed in the BCU. Challenges in an airlock unit included communication, scarcity of resources, double-bunking, and maintaining routine care. Conclusions: Preparing for a surge of critically ill patients during a pandemic can be a daunting task. The implementation of a coordinated, system-level approach can help with the allocation of resources as needed. Focusing on established strengths of hospitals within the system can guide triage based on individual patient needs. The management of ECMO patients is still a specialty care, and a systematic and hospital based approach requiring an ECMO team composed of multiple experienced individuals is paramount during a respiratory viral pandemic.
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- 2021
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3. A Dedicated Veno-Venous Extracorporeal Membrane Oxygenation Unit during a Respiratory Pandemic: Lessons Learned from COVID-19 Part II: Clinical Management
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Aakash Shah, Sagar Dave, Samuel Galvagno, Kristen George, Ashley R. Menne, Daniel J. Haase, Brian McCormick, Raymond Rector, Siamak Dahi, Ronson J. Madathil, Kristopher B. Deatrick, Mehrdad Ghoreishi, James S. Gammie, David J. Kaczorowski, Thomas M. Scalea, Jay Menaker, Daniel Herr, Ali Tabatabai, and Eric Krause
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extracorporeal membrane oxygenation ,COVID-19 ,acute respiratory distress syndrome ,tracheostomy ,mechanical ventilation ,pneumothorax ,Chemical technology ,TP1-1185 ,Chemical engineering ,TP155-156 - Abstract
(1) Background: COVID-19 acute respiratory distress syndrome (CARDS) has several distinctions from traditional acute respiratory distress syndrome (ARDS); however, patients with refractory respiratory failure may still benefit from veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We report our challenges caring for CARDS patients on VV-ECMO and alterations to traditional management strategies. (2) Methods: We conducted a retrospective review of our institutional strategies for managing patients with COVID-19 who required VV-ECMO in a dedicated airlock biocontainment unit (BCU), from March to June 2020. The data collected included the time course of admission, VV-ECMO run, ventilator length, hospital length of stay, and major events related to bleeding, such as pneumothorax and tracheostomy. The dispensation of sedation agents and trial therapies were obtained from institutional pharmacy tracking. A descriptive statistical analysis was performed. (3) Results: Forty COVID-19 patients on VV-ECMO were managed in the BCU during this period, from which 21 survived to discharge and 19 died. The criteria for ECMO initiation was altered for age, body mass index, and neurologic status/cardiac arrest. All cannulations were performed with a bedside ultrasound-guided percutaneous technique. Ventilator and ECMO management were routed in an ultra-lung protective approach, though varied based on clinical setting and provider experience. There was a high incidence of pneumothorax (n = 19). Thirty patients had bedside percutaneous tracheostomy, with more procedural-related bleeding complications than expected. A higher use of sedation was noted. The timing of decannulation was also altered, given the system constraints. A variety of trial therapies were utilized, and their effectiveness is yet to be determined. (4) Conclusions: Even in a high-volume ECMO center, there are challenges in caring for an expanded capacity of patients during a viral respiratory pandemic. Though institutional resources and expertise may vary, it is paramount to proceed with insightful planning, the recognition of challenges, and the dynamic application of lessons learned when facing a surge of critically ill patients.
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- 2021
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4. Spinal Cord Infarction With Prolonged Femoral Venoarterial Extracorporeal Membrane Oxygenation
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Chetan Pasrija, Zachary N. Kon, Michael A. Mazzeffi, Jiafeng Zhang, Zhongjun J. Wu, Douglas Tran, Gregory J. Bittle, Mehrdad Ghoreishi, Timothy R. Miller, Hani Alkhatib, Nicole Tobin, Bradley S. Taylor, Kristopher B. Deatrick, Raymond Rector, Daniel L. Herr, and Bartley P. Griffith
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Anesthesiology and Pain Medicine ,Cardiology and Cardiovascular Medicine - Published
- 2023
5. Evaluating the Safety of Transcarotid Artery Revascularization under Local Anesthesia Prior to Coronary Artery Bypass Grafting Surgery
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Yamini Vyas, Eyerusalem Workneh, Joshua L. Leibowitz, Rajabrata Sarkar, Mehrdad Ghoreishi, and Shahab Toursavadkohi
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Surgery ,General Medicine ,Cardiology and Cardiovascular Medicine - Abstract
Controversy exists regarding the timing of intervention for patients with critical coronary artery disease (CAD) awaiting coronary artery bypass and severe carotid artery stenosis (CAS). Transcarotid artery revascularization (TCAR) is a minimally invasive revascularization alternative through direct transcervical carotid access that minimizes the chance of arch manipulation and consequent antegrade embolic stroke rate. While the TCAR procedure can be performed under local anesthesia (monitored anesthesia care [MAC]) versus general anesthesia, the hemodynamic benefits of local anesthesia in patients with severe CAD are significant. Patients receiving staged TCAR-coronary artery bypass grafting (CABG) have high-risk cardiovascular disease and require accurate perioperative neurological and hemodynamic evaluation that can be safely provided with local anesthesia.In this retrospective single-center study, 14 patients were systematically identified to have undergone staged TCAR prior to CABG surgery from December 2018 to October 2021. All patients underwent TCAR with local anesthesia and minimal sedation. Relevant patient demographics, medical and surgical history, preoperative covariates, and type of anesthesia administered were obtained from patients' charts. CAD was confirmed by either carotid duplex imaging or computed tomography angiography (CTA) of the head/neck.Staged TCAR-CABG interventions were performed on 14 patients (64% male; mean age 65.0 years). No major adverse cardiac events were reported including transient ischemic attack (TIA), stroke, myocardial infarction (MI), or TCAR-related death in the interval between their TCAR and CABG as well as in a 12-month follow-up period. One patient required to return to the operating room (OR) for evacuation of a neck hematoma.This study demonstrated high success rate of TCAR under local anesthesia prior to CABG (100%) with no incidence of perioperative stroke, MI, or death at 1-month, 6-month, and 12-month follow-up intervals. The authors support the use of staged TCAR-CABG with local anesthesia as a safe and promising treatment option for patients with high-grade cardiac disease, high risk of stroke, or multiple comorbidities that preclude a carotid endarterectomy (CEA).
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- 2023
6. Impact of Preoperative Hematocrit, Body Mass Index, and Red Cell Mass on Allogeneic Blood Product Usage in Adult Cardiac Surgical Patients: Report From a Statewide Quality Initiative
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Kenichi A. Tanaka, Diane Alejo, Mehrdad Ghoreishi, Rawn Salenger, Clifford Fonner, Niv Ad, Glenn Whitman, Bradley S. Taylor, and Michael A. Mazzeffi
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Anesthesiology and Pain Medicine ,Cardiology and Cardiovascular Medicine - Abstract
The study aims were to evaluate current blood transfusion practice in cardiac surgical patients and to explore associations between preoperative anemia, body mass index (BMI), red blood cell (RBC) mass, and allogeneic transfusion.Multicenter retrospective study.Academic and non-academic centers.After Institutional Review Board approval, 26,499 patients who underwent coronary artery bypass grafting ± valve replacement/repair between 2011 and 2019 were included from the Maryland Cardiac Surgery Quality Initiative database. Patients were stratified into BMI categories (25, 25 to30, and ≥30 kg/mPreoperative anemia was found in 55.4%, and any transfusion was administered to 49.3% of the entire cohort. Females and older patients had lower BMI and RBC mass. Increased RBC and cryoprecipitate transfusions occurred more frequently after surgery in the lower BMI group. After adjustments, increased transfusion was associated with a BMI25 relative to a BMI ≥30 at an odds ratio (OR) of 1.26 (95% confidence interval [CI]: 1.08-1.39). For each 1% increase in preoperative hematocrit, transfusion was decreased by 9% (OR: 0.91; 95% CI: 0.90-0.92). For every 500 mL increase in RBC mass, there was a 43% reduction of transfusion (OR: 0.57; 95% CI: 0.55-0.58).Transfusion probability modeling based on calculated RBC mass eliminated sex differences in transfusion risk based on preoperative hematocrit, and may better delineate which patients may benefit from more rigorous perioperative blood conservation strategy.
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- 2023
7. The Caged Knickerbocker: A Novel Modification to Targeted False Lumen Management in Complex Aortic Dissection
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David N. Blitzer, Gabriel A. Pereira, Charles Drucker, Nicholas Rolle, Khanjan Nagarsheth, John Karwowski, Michael Hall, Bradley Taylor, Mehrdad Ghoreishi, and Shahab Toursavadkohi
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Surgery ,General Medicine ,Cardiology and Cardiovascular Medicine - Abstract
Introduction Targeted false lumen management has been described for complex presentations of aortic dissection. The “Knickerbocker” technique is often referenced and includes dilating a focal portion of an oversized endograft in the true lumen to purposefully rupture the false lumen septum, but at the expense of increased risk for visceral propagation and malperfusion. This case series describes a novel modification of the Knickerbocker technique by caging the distal end of the endograft prior to focal dilation. Methods A retrospective chart review was conducted at a tertiary academic center from 2018-2020. Patients were included if they had a history or current presentation of aortic dissection and underwent a Caged Knickerbocker (CKB) repair. Data were collected to include demographics, indications for repair, technical success, perioperative outcomes, hospital course, mortality, and further aortic interventions. Results Five patients were included in our evaluation. Four patients (80%) presented with chronic Type B aortic dissection (cTBAD) and concomitant aneurysmal degeneration of the thoracic aorta; 1 patient (20%) presented with an acute rupture secondary to cTBAD. Three patients (60%) had previous aortic repairs, 2 of which were for Type A Aortic Dissection that additionally required redo sternotomy and total arch replacement prior to CKB. CKB was technically successful in all cases with no peri-operative complications. Two (40%) patients required further aortic intervention due to aneurysmal degeneration. Conclusion Achieving complete false lumen thrombosis is a considerable challenge when managing complex aortic dissections. Our data demonstrate the technical feasibly and early successful outcomes with the CKB approach. Importantly, CKB facilitates future distal extension into the para-visceral aorta in cases of complex thoracoabdominal aortic aneurysms. Further research should focus on discerning individual patients who will benefit from targeted false lumen management and compare outcomes between different approaches.
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- 2022
8. Anesthetic Considerations in Endovascular Repair of the Ascending Aorta
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Mehrdad Ghoreishi, Patrick Odonkor, Ashanpreet Grewal, and Seema P. Deshpande
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medicine.medical_specialty ,030204 cardiovascular system & hematology ,Aortic disease ,Endovascular therapy ,law.invention ,Blood Vessel Prosthesis Implantation ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,030202 anesthesiology ,law ,medicine.artery ,Ascending aorta ,Cardiopulmonary bypass ,medicine ,Humans ,cardiovascular diseases ,Aorta ,Hemodynamic forces ,Anesthetics ,Surgical repair ,Aortic dissection ,Aortic Aneurysm, Thoracic ,business.industry ,Endovascular Procedures ,medicine.disease ,Blood Vessel Prosthesis ,Surgery ,Treatment Outcome ,surgical procedures, operative ,Anesthesiology and Pain Medicine ,Anesthetic ,cardiovascular system ,Stents ,Cardiology and Cardiovascular Medicine ,business ,medicine.drug - Abstract
Since the first endovascular aortic repair in 1990, endovascular devices and the indications for their use have significantly grown. Considerable progress has been made in endovascular devices and techniques, such that endovascular repair is now considered first-line treatment for patients with descending aortic disease. However, for patients with ascending aortic disease, open surgical repair with cardiopulmonary bypass and hypothermic cardiac arrest was the only option until recently. Although the outcomes for open surgical repair of the ascending aorta have improved over the years, approximately 30% of patients with an emergent surgical indication, such as type A aortic dissection, are considered to be too high risk for open repair. For these patients, endovascular repair of the ascending aorta offers a life-saving procedure. The ascending aorta is regarded as the final frontier for endovascular therapy. Endovascular repair of it has posed a formidable challenge thus far, due to its unique anatomy, hemodynamic forces, and lack of an appropriate stent-graft designed specifically for the ascending aorta. Although currently there are no comprehensive data from randomized clinical trials, there are several case series and case reports that have shown favorable outcomes. Improvements in available devices soon will drive an exponential increase in the number of patients undergoing endovascular ascending aortic repair. In this review, the authors discuss multiple aspects of endovascular ascending aortic repair including the unique surgical and anesthetic considerations, the devices used, and the available outcomes data, and future directions are also explored.
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- 2021
9. Ascending Aortic Length and Type A Dissection: A Propensity Score-Matched Cohort Analysis
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Gregory Boyajian, Nikhil K. Prasad, Bryan Nixon, Zachary Bolten, Irina Kolesnik, Chetan Pasrija, Aakash Shah, Shahab Toursavadkohi, Sari D. Holmes, Jean Jeudy, Bradley Taylor, and Mehrdad Ghoreishi
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Background: Little information is available regarding the relationship between ascending aortic length and acute aortic events. We aim to evaluate whether patients with acute type A aortic dissection (ATAAD) exhibit differential aortic measurements compared to control patients. Methods: Data were collected on patients with ATAAD and control patients who received imaging for unrelated conditions. Propensity score matching was conducted using age, sex, race, body surface area, and hypertension in the logistic model. After matching, 67 patients remained in each group. Aortic morphometry was assessed via computed tomographic angiography. Ascending aortic length was defined as the centerline distance between the sinotubular junction (STJ) and the origin of the brachiocephalic trunk. Results: The mean ascending aortic length was 76.9 ± 15.7 mm (range 36.8 to 115.0 mm) for patients with ATAAD and was 62.0 ± 10.7 mm (range 34.0 to 87.8 mm) for control patients, which was a significant difference (t=-6.4, P5.5 cm (at either the PAB or STJ) was present in 12 of 67 cases (18%) and 0 of 67 controls (PConclusions: Ascending aortic length is significantly greater in patients who experienced ATAAD compared to matched controls. Elongation of the aorta may play a role in the pathogenesis of ATAAD, and assessment of ascending aortic length may be valuable as a predictive marker for aortic events.
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- 2022
10. Role of Cardiac Anesthesiologists in Intraoperative Enhanced Recovery After Cardiac Surgery (ERACS) Protocol: A Retrospective Single-Center Study Analyzing Preliminary Results of a Yearlong ERACS Protocol Implementation
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Samhati Mondal, Emily A.S. Bergbower, Enoch Cheung, Ashanpreet S. Grewal, Mehrdad Ghoreishi, Kimberly N. Hollander, Megan G. Anders, Bradley S. Taylor, and Kenichi A. Tanaka
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Anesthesiology and Pain Medicine ,Cardiology and Cardiovascular Medicine - Abstract
Enhanced recovery after cardiac surgery (ERACS) has been gaining rapid acceptance after multiple studies have demonstrated promising results in improved outcomes of enhanced recovery after surgery in other surgical fields (eg, colorectal, orthopedic, thoracic, etc). Cardiac surgery has several unique challenges, including sternotomy, cardiopulmonary bypass and associated coagulopathy, blood transfusion, and postoperative intensive care requirement. Nonetheless, selective cardiac surgical patients can still benefit from ERACS. Guidelines for perioperative care in cardiac surgery, previously published by the ERACS Society, are weighted heavily in preoperative and postoperative management without much focus on intraoperative care provided by anesthesiologists. To address this gap and to explore anesthesiology's contribution in achieving ERACS, the study authors' cardiac anesthesiology division, in collaboration with cardiac surgery, introduced the ERACS protocol in their institution in February 2020.The cardiac anesthesiology division, in collaboration with cardiac surgery, introduced the ERACS protocol consisting of multimodal opioid-sparing analgesia, including the introduction of regional blocks, hemostasis management protocol, reversal of neuromuscular blockade, and administration of antiemetics in the authors' institution in February 2020. They have conducted a retrospective chart review study comparing patients who have received ERACS measures with a similar historic cohort who underwent cardiac surgery prior to initiation of an ERACS protocol. The primary outcomes of the study were to determine patients' time to extubation, postoperative opioid consumption, intensive care unit (ICU) length of stay (LOS), and incidence of postoperative complications (eg, postoperative nausea vomiting [PONV], bleeding, ICU readmission, delirium.The ERACS patients showed reduced opioid consumption (intraoperative fentanyl; postoperative fentanyl, as well as oxycodone, in the first 6 hours postoperatively), lesser mechanical ventilation (2.5 hours less), shorter ICU stays (5 hours less), shorter hospital LOS (1 day), and lesser incidence of PONV. None of the ERACS patients required blood transfusion. The study authors performed an anonymous survey among the anesthesiologists and ICU providers to assess providers' satisfaction, which showed 92% of survey takers agreed that the ERACS protocol should be continued for future cardiac patients, and 61% of survey takers reported superior pain control in ERACS group of patients while managing those patients.The ERACS is achievable after the careful implementation of a series of measures. It does not signify only fast-track extubation and opioid-sparing analgesia, and must be implemented in the entire perioperative period beginning from preoperative clinic to postoperative rehabilitation. Cardiac anesthesiologists play a vital role in execution of intraoperative ERACS measures. Both providers and patients themselves are key stakeholders. A larger randomized prospective trial is warranted to solidify the inference.
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- 2022
11. The 10 Commandments of Aortic Arch Endovascular Repair
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Stephen D. Waterford, Mehrdad Ghoreishi, Shahab Toursavadkohi, and Bradley S. Taylor
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Pulmonary and Respiratory Medicine ,Aortic Aneurysm, Thoracic ,Endovascular Procedures ,Aorta, Thoracic ,General Medicine ,Prosthesis Design ,Blood Vessel Prosthesis ,Blood Vessel Prosthesis Implantation ,Treatment Outcome ,Humans ,Surgery ,Stents ,Cardiology and Cardiovascular Medicine ,Retrospective Studies - Published
- 2022
12. Red Blood Cell Transfusion and Postoperative Infection in Patients Having Coronary Artery Bypass Grafting Surgery: An Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database
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Michael A. Mazzeffi, Sari D. Holmes, Bradley Taylor, Mehrdad Ghoreishi, John S. McNeil, Miklos D. Kertai, Bruce A. Bollen, Kenichi Tanaka, Jacob Raphael, and Laurent Glance
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Adult ,Surgeons ,Anesthesiology and Pain Medicine ,Humans ,Thoracic Surgery ,Blood Transfusion ,Coronary Artery Bypass ,Erythrocyte Transfusion ,Retrospective Studies - Abstract
Coronary artery bypass grafting (CABG) is the most common cardiac surgical procedure in the world and up to one-third of patients are transfused red blood cells (RBCs). RBC transfusion may increase the risk for health care-associated infection (HAI) after CABG, but previous studies have shown conflicting results and many did not establish exposure temporality. Our objective was to explore whether intraoperative RBC transfusion is associated with increased odds of postoperative HAI. We hypothesized that intraoperative RBC transfusion would be associated with increased odds of postoperative HAI.We performed an observational cohort study of isolated CABG patients in the Society of Thoracic Surgeons adult cardiac surgery database from July 1, 2017, to June 30, 2019. The exposure was intraoperative RBC transfusion modeled as 0, 1, 2, 3, or 4+ units. The authors focused on intraoperative RBC transfusion as a risk factor, because it has a definite temporal relationship before postoperative HAI. The study's primary outcome was a composite HAI variable that included sepsis, pneumonia, and surgical site infection (both deep and superficial). Mixed-effects modeling, which controlled for hospital as a clustering variable, was used to explore the relationship between intraoperative RBC transfusion and postoperative HAI.Among 362,954 CABG patients from 1076 hospitals included in our analysis, 59,578 patients (16.4%) received intraoperative RBCs and 116,186 (32.0%) received either intraoperative or postoperative RBCs. Risk-adjusted odds ratios for HAI in patients who received 1, 2, 3, and 4+ intraoperative RBCs were 1.11 (95% confidence interval [CI], 1.03-1.20; P = .005), 1.13 (95% CI, 1.05-1.21; P = .001), 1.15 (95% CI, 1.04-1.27; P = .008), and 1.14 (95% CI, 1.02-1.27; P = .02) compared to patients who received no RBCs.Intraoperative RBC transfusion is associated with a small increase in odds of HAI in CABG patients. Future studies should explore whether reductions in RBC transfusion can also reduce HAIs.
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- 2022
13. Veno-arterial extracorporeal membrane oxygenation without allogeneic blood transfusion: An observational cohort study
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Alison Grazioli, Michael Plazak, Siamak Dahi, Joseph Rabin, Ashley Menne, Mehrdad Ghoreishi, Bradley Taylor, Seth Perelman, and Michael Mazzeffi
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Advanced and Specialized Nursing ,Radiology, Nuclear Medicine and imaging ,General Medicine ,Cardiology and Cardiovascular Medicine ,Safety Research - Abstract
Introduction It remains unclear whether patients who will not accept allogeneic blood transfusion can be managed successfully with veno-arterial (V-A) extracorporeal membrane oxygenation (ECMO). The objective of our study was to determine what percentage of V-A ECMO patients were managed without allogeneic blood transfusion. Methods This was a retrospective, observational cohort study of patients with cardiogenic shock requiring V-A ECMO between January 2016 and January 2019. The primary outcome was avoidance of any allogeneic blood transfusion. Results Of the 206 patients included, 23 (11.2%) were managed without any allogeneic blood transfusion. Fourteen (60.9%) avoided allogeneic blood transfusion during their entire hospitalization. “No-transfusion” patients were younger, more commonly men, were less likely to have a prior diagnosis of hypertension or coronary artery disease, had higher baseline hemoglobin, had higher SAVE scores, and were less likely to have received aspirin before ECMO. No patients in the “no-transfusion” group had major bleeding compared to 35% of patients in the blood transfusion group ( p < 0.001). In-hospital mortality was 17.4% for those who avoided blood transfusion and 41.5% for those who received blood transfusion ( p = 0.04). ECMO duration was significantly shorter in patients who avoided blood transfusion compared to those who received blood transfusion (median 3.5 vs 7 days, p < 0.001). Conclusions Select patients can be successfully managed on V-A ECMO without allogeneic blood transfusion. Jehovah’s Witnesses and other patients with objections to allogeneic transfusion might be offered V-A ECMO if its anticipated duration is short (e.g.
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- 2022
14. Peripheral cannulation for extracorporeal membrane oxygenation yields superior neurologic outcomes in adult patients who experienced cardiac arrest following cardiac surgery
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Lauren Levy, Bradley S. Taylor, Daniel Herr, Ronson J. Madathil, Mehrdad Ghoreishi, James S. Gammie, Bartley P. Griffith, Chetan Pasrija, Eric Krause, Gregory P. Boyajian, Michael A. Mazzeffi, Aakash Shah, Kristopher B. Deatrick, and David J. Kaczorowski
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Adult ,medicine.medical_specialty ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Catheterization ,03 medical and health sciences ,Extracorporeal Membrane Oxygenation ,0302 clinical medicine ,Neurologic function ,Refractory ,medicine ,Extracorporeal membrane oxygenation ,Humans ,Radiology, Nuclear Medicine and imaging ,Extracorporeal cardiopulmonary resuscitation ,Cardiac Surgical Procedures ,Retrospective Studies ,Advanced and Specialized Nursing ,Adult patients ,business.industry ,Cardiogenic shock ,030208 emergency & critical care medicine ,General Medicine ,medicine.disease ,Cardiopulmonary Resuscitation ,Heart Arrest ,Peripheral ,Cardiac surgery ,Treatment Outcome ,Anesthesia ,Cardiology and Cardiovascular Medicine ,business ,Safety Research - Abstract
Background: Extracorporeal cardiopulmonary resuscitation (ECPR) for refractory cardiac arrest has improved mortality in post-cardiac surgery patients; however, loss of neurologic function remains one of the main and devastating complications. We reviewed our experience with ECPR and investigated the effect of cannulation strategy on neurologic outcome in adult patients who experienced cardiac arrest following cardiac surgery that was managed with ECPR. Methods: Patients were categorized by central versus percutaneous peripheral VA-extracorporeal membrane oxygenation (ECMO) cannulation strategy. We reviewed patient records and evaluated in-hospital mortality, cause of death, and neurologic status 72 hours after cannulation. Results: From January 2010 to September 2019, 44 patients underwent post-cardiac surgery ECPR for cardiac arrest. Twenty-six patients received central cannulation; 18 patients received peripheral cannulation. Mean post-operative day of the cardiac arrest was 3 and 9 days (p = 0.006), and mean time between initiation of CPR and ECMO was 40 ± 24 and 28 ± 22 minutes for central and peripheral cannulation, respectively. After 72 hours of VA-ECMO support, 30% of centrally cannulated patients versus 72% of peripherally cannulated patients attained cerebral performance status 1–2 (p = 0.01). Anoxic brain injury was the cause of death in 26.9% of centrally cannulated and 11.1% of peripherally cannulated patients. Survival to discharge was 31% and 39% for central and peripheral cannulation, respectively. Conclusions: Peripheral VA-ECMO allows for continuous CPR and systemic perfusion while obtaining vascular access. Compared to central cannulation, a peripheral cannulation strategy is associated with improved neurologic outcomes and decreased likelihood of anoxic brain death.
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- 2021
15. Less-Invasive Aortic Valve Replacement: Trends and Outcomes From The Society of Thoracic Surgeons Database
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Bartley P. Griffith, Chetan Pasrija, Jeffrey C. Milliken, James S. Gammie, Malek G. Massad, Zachary Kon, Khaled Abdelhady, Mehrdad Ghoreishi, Matthew Brennan, Maria V. Grau-Sepulveda, Morgan L. Cox, Vinod H. Thourani, Jeffery P. Jacobs, Lars G. Svensson, Bradley S. Taylor, and Vinay Badhwar
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Pulmonary and Respiratory Medicine ,Aortic valve ,Database ,business.industry ,medicine.medical_treatment ,Operative mortality ,Less invasive ,030204 cardiovascular system & hematology ,medicine.disease ,computer.software_genre ,03 medical and health sciences ,Partial sternotomy ,0302 clinical medicine ,Postoperative stroke ,medicine.anatomical_structure ,030228 respiratory system ,Valve replacement ,Aortic valve replacement ,medicine ,Surgery ,Thoracotomy ,Cardiology and Cardiovascular Medicine ,business ,computer - Abstract
Background This study compares outcomes of conventional and less-invasive (LI) approaches for aortic valve replacement (AVR) using The Society of Thoracic Surgeons database. Methods Between 2011 and 2017, we identified 122,474 patients undergoing isolated primary AVR. Patients were categorized into 3 groups: (1) full sternotomy (FS) (n = 98,549; 78%), (2) partial sternotomy (PS) (n = 17,306; 15%), and (3) right thoracotomy (RT) (n = 6619; 7%). Results The rate of LI-AVR increased from 17% in 2011 to 23% in 2016 (P Conclusions Less-invasive AVR is associated with an operative mortality and postoperative stroke rate similar to that of FS. Less-invasive AVRs should serve as a benchmark for comparison between transcatheter aortic valve replacement and surgical AVR in low-risk patients.
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- 2021
16. Bedside angiography of distal perfusion catheter for veno-arterial extracorporeal membrane oxygenation
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Mehrdad Ghoreishi, Zachary N. Kon, Danielle Arons, Aakash Shah, and Chetan Pasrija
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Advanced and Specialized Nursing ,medicine.medical_specialty ,medicine.diagnostic_test ,business.industry ,medicine.medical_treatment ,General Medicine ,030204 cardiovascular system & hematology ,Limb ischemia ,03 medical and health sciences ,Catheter ,0302 clinical medicine ,030228 respiratory system ,Internal medicine ,Angiography ,medicine ,Cardiology ,Extracorporeal membrane oxygenation ,Radiology, Nuclear Medicine and imaging ,Cardiology and Cardiovascular Medicine ,business ,Safety Research ,Perfusion - Abstract
Background: The aim of this study was to evaluate the ipsilateral lower extremity (ILE) outcomes of patients who underwent bedside angiography via the distal perfusion catheter while on femoral veno-arterial extracorporeal membrane oxygenation (VA ECMO). Methods: This is a retrospective analysis of all patients placed on VA ECMO at a single center from January 2017 to December 2019 who underwent bedside angiography via the distal perfusion catheter. Results: Twenty-four patients underwent bedside angiography via the distal perfusion catheter after being placed on VA ECMO. A vasodilator was directly administered in three patients for suspected spasm. One patient had distal thrombus and underwent thrombectomy and fasciotomy. One patient had a dislodged catheter and underwent thrombectomy, fasciotomy, and replacement of the catheter. One patient had severe ILE ischemia, however was not intervened upon due to critical acuity. Finally, one patient had inadvertent placement in the saphenous vein and had a new catheter placed in the SFA. No patients underwent amputation. Ultimately, 21 patients (87.5%) had no ILE compromise at the end their ECMO course. Survival to decannulation was 66.7% ( n = 16). Conclusions: Bedside angiography of the distal perfusion catheter is feasible and can be a useful adjunct in informing the need for further intervention to the ILE. Classifications: extracorporeal membrane oxygenation, ischemia
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- 2021
17. Emergent Total Endovascular Arch Repair for Contained Aortic Arch Rupture: Another Tool in the Box
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Nicole Kus, Justin A. Robinson, Michael R. Hall, Mehrdad Ghoreishi, Bradley Taylor, and Shahab Toursavadkohi
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Surgery ,General Medicine ,Cardiology and Cardiovascular Medicine - Abstract
To date, emergent total endovascular aortic arch repair has not been described in the literature. We present a 67-year-old female with a poorly differentiated posterior mediastinal sarcoma. Imaging obtained was concerning for intravascular extension of the tumor into the thoracic aorta. While awaiting radiation therapy, the patient complained of worsening chest and arm pain, vital signs demonstrating tachypnea and hypoxia. Subsequent imaging revealed an increase in vascular erosion, concerning for a contained rupture, with complete obliteration of the left mainstem bronchus. The patient was emergently taken for percutaneous endovascular repair of her aortic arch. A three-vessel physician modified fenestrated graft was created and deployed with concurrent stenting of the innominate, left carotid, and left subclavian arteries. Interval computed tomography angiography revealed patency in all stented vessels, with no endoleak and no evidence of pseudoaneurysm. The patient was able to undergo chemotherapy with favorable decrease in tumor burden. Total endovascular aortic arch repair, when planned carefully, is an attractive option in high-risk patients who are otherwise not ideally suited for open total arch replacement.
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- 2023
18. Transcarotid Approach for Ascending Aortic Endovascular Repair
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Shahab Toursavadkouhi, Mehrdad Ghoreishi, Gregory P. Boyajian, Michael R. Hall, Anuj Gupta, Bradley S. Taylor, and Nikhil K. Prasad
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Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Right external iliac artery ,03 medical and health sciences ,0302 clinical medicine ,medicine.artery ,Ascending aorta ,medicine ,cardiovascular diseases ,Stroke ,Chronic occlusion ,business.industry ,Stent ,medicine.disease ,Left external iliac artery ,Surgery ,Stenosis ,surgical procedures, operative ,030228 respiratory system ,cardiovascular system ,Open repair ,Cardiology and Cardiovascular Medicine ,business - Abstract
This report describes a case of penetrating aortic ulcer in zone 0 of the ascending aorta with concern for free rupture that was treated with a transcarotid endovascular stent graft. The patient was noted to be a poor candidate for open repair given comorbidities, frailty, and age. She had chronic occlusion of the right external iliac artery and stenosis of the left external iliac artery. Endovascular ascending aortic stenting was deployed successfully through right common carotid access. The patient had an uncomplicated postoperative course without evidence of stroke. The transcarotid approach is an optimal alternative access for patients undergoing endovascular ascending aortic repair.
- Published
- 2021
19. Racial Disparity in Cardiac Surgery Risk and Outcome: Report From a Statewide Quality Initiative
- Author
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Mehrdad Ghoreishi, Michael A. Mazzeffi, Glenn J. Whitman, Niv Ad, Rawn Salenger, Bradley S. Taylor, Robert S.D. Higgins, Chetan Pasrija, Diane Alejo, Clifford E. Fonner, Thomas S. Metkus, Stefano Schena, and Sari D. Holmes
- Subjects
Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Heart Diseases ,Racial disparity ,Psychological intervention ,MEDLINE ,030204 cardiovascular system & hematology ,Risk Assessment ,Odds ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Risk Factors ,Internal medicine ,Health care ,medicine ,Humans ,Cardiac Surgical Procedures ,Aged ,Retrospective Studies ,Maryland ,business.industry ,Incidence (epidemiology) ,Racial Groups ,Retrospective cohort study ,Middle Aged ,Quality Improvement ,Cardiac surgery ,Survival Rate ,030228 respiratory system ,Female ,Surgery ,Morbidity ,Cardiology and Cardiovascular Medicine ,business ,Follow-Up Studies - Abstract
Racial disparities persist in health care. Our study objective was to evaluate racial disparity in cardiac surgery in Maryland.A statewide database was used to identify patients. Demographics, comorbidities, and predicted risk of death were compared between races. Crude mortality and incidence of complications were compared between groups, as were risk-adjusted odds for mortality and major morbidity or mortality.The study included 23,094 patients. Most patients were white (75.8%), followed by African American (16.3%), Asian (3.8%), and other races (4.1%). African Americans had a higher preoperative risk for mortality based on The Society of Thoracic Surgeons predictive models compared with white patients (3.0% vs 2.3%, P.001). African Americans also had higher prevalence of diabetes mellitus, hypertension, peripheral vascular disease, and cerebral vascular disease than white patients. After adjustment for preoperative risk, there was no difference in 30-day mortality between African Americans (odds ratio [OR], 1.26; 95% confidence interval [CI], 0.99-1.59), Asians (OR, 1.22; 95% CI, 0.75-1.97), and other races (OR, 1.18; 95% CI, 0.74-1.89) compared with whites. African Americans had lower risk-adjusted odds of major morbidity or mortality compared with whites (OR, 0.83; 95% CI, 0.75-0.93).African American cardiac surgical patients have the highest preoperative risk in Maryland. Patients appeared to receive excellent cardiac surgical care, regardless of race, as risk-adjusted mortality did not differ between groups, and African American patients had lower risk-adjusted odds of major morbidity or mortality than white patients. Future interventions in Maryland should be aimed at reducing preoperative risk disparity in cardiac surgical patients.
- Published
- 2020
20. Degenerative Mitral Valve Repair Simplified: An Evolution to Universal Artificial Cordal Repair
- Author
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Chetan Pasrija, David Na, Rachael W. Quinn, Ethan Kotloff, David N. Yim, Bartley P. Griffith, Douglas Tran, Murtaza Y. Dawood, Sari D. Holmes, Filomena Koenigsberg, James S. Gammie, Mehrdad Ghoreishi, Joshua Finkel, and Stephen Devlin
- Subjects
Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Time Factors ,Cardiopulmonary bypass time ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Repair rate ,03 medical and health sciences ,0302 clinical medicine ,Primary outcome ,Mitral valve ,medicine ,Humans ,Endocarditis ,Cardiac Surgical Procedures ,Polytetrafluoroethylene ,Stroke ,Aged ,Retrospective Studies ,Mitral regurgitation ,Mitral valve repair ,Sutures ,business.industry ,Mitral Valve Insufficiency ,Middle Aged ,medicine.disease ,Surgery ,Treatment Outcome ,medicine.anatomical_structure ,030228 respiratory system ,Chordae Tendineae ,Mitral Valve ,Female ,Cardiology and Cardiovascular Medicine ,business - Abstract
Resectional and artificial cordal repair techniques are effective strategies for degenerative mitral valve (MV) repair. However, resectional repair requires a tailored approach using various techniques, whereas cordal repair offers a simpler, easily reproducible repair. The approach described in this study approach has evolved from resectional to cordal over time, and outcomes are compared between the eras.Clinical and echocardiographic outcomes of all patients undergoing MV repair for degenerative mitral regurgitation (MR) from January 2004 to September 2017 were reviewed. Patients were stratified by era: from January 2004 to June 2011 (era 1; n = 405), resectional techniques were used in 62% and artificial cordal techniques were used in 38%. From July 2011 to September 2017 (era 2; n = 438), artificial cordal repair was used in 98% of patients. The primary outcome was repair failure, defined as greater than moderate MR or MV reoperation.Of 847 patients with degenerative MR, successful repair was achieved in 843 patients (99.5% repair rate). Leaflet prolapse was posterior in 66%, anterior in 8%, and bileaflet in 26%. Cardiopulmonary bypass time and cross-clamp times were shorter in era 2 (CPB: 109 [IQR, 92-128] minutes vs 97 [IQR, 76-121] minutes; P.001; cross-clamp: 88 [IQR, 73-106] minutes vs. 79 [IQR, 61-99] minutes; P.001). Predismissal echocardiography demonstrated no MR or trace MR in 95%, mild MR in 4.7%, and moderate MR in 0.3% of patients. Operative mortality was similar in the eras (0.5% vs 0.5%; P.999). The rates of 5-year freedom from repair failure (95.1% vs 95.5%; P = .707), stroke (96.8% vs 95.3%; P = .538), and endocarditis (99.3% vs 99.7%; P = .604) were similar between the eras.Artificial cordal repair for all patients with degenerative MR simplifies MV repair and yields equivalent, excellent outcomes compared with a tailored resectional approach.
- Published
- 2020
21. Extracorporeal Membrane Oxygenation for COVID-19
- Author
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Jay Menaker, Mehrdad Ghoreishi, Raymond Rector, Samuel M. Galvagno, Kristopher B. Deatrick, Ali Tabatabai, Joseph Rabin, David J. Kaczorowski, Daniel Herr, Michael A. Mazzeffi, Ronson J. Madathil, and Zachary Sanford
- Subjects
Pulmonary and Respiratory Medicine ,2019-20 coronavirus outbreak ,Coronavirus disease 2019 (COVID-19) ,medicine.medical_treatment ,Pneumonia, Viral ,Betacoronavirus ,Extracorporeal Membrane Oxygenation ,Pandemic ,Disease Transmission, Infectious ,medicine ,Extracorporeal membrane oxygenation ,Humans ,Pandemics ,Personal Protective Equipment ,biology ,SARS-CoV-2 ,Viral Epidemiology ,business.industry ,COVID-19 ,General Medicine ,biology.organism_classification ,medicine.disease ,Virology ,Pneumonia ,Surgery ,Coronavirus Infections ,Cardiology and Cardiovascular Medicine ,business ,Disease transmission - Published
- 2020
22. Predictors of Recovery in Patients Supported With Venoarterial Extracorporeal Membrane Oxygenation for Acute Massive Pulmonary Embolism
- Author
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Chetan Pasrija, Zachary N. Kon, Kristopher B. Deatrick, Anahita Ghazi, Laura DiChiacchio, Bartley P. Griffith, Jean Jeudy, and Mehrdad Ghoreishi
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,Embolectomy ,Retrospective cohort study ,030204 cardiovascular system & hematology ,Brain natriuretic peptide ,medicine.disease ,03 medical and health sciences ,0302 clinical medicine ,Text mining ,030228 respiratory system ,Internal medicine ,Cohort ,medicine ,Cardiology ,Extracorporeal membrane oxygenation ,Surgery ,In patient ,Thrombus ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has emerged as a promising initial support strategy for acute massive pulmonary embolism. However, it remains unclear which patients will ultimately require surgical pulmonary embolectomy (SPE) vs anticoagulation alone. Methods All consecutive patients (2015-2018) with confirmed massive PE, placed on VA-ECMO utilizing a protocolized approach, were reviewed. Per protocol, patients were supported for 3 to 5 days before reevaluation of right ventricular (RV) function via echocardiography. If RV function recovered, VA-ECMO was discontinued with no further intervention (no-SPE group). In patients with persistent RV dysfunction, SPE was performed. Results Forty-five patients were identified, and 41 patients were treated per protocol. Seventy-three percent responded to anticoagulation alone, and 27% required SPE. Factors associated with SPE rather than decannulation with anticoagulation alone included prolonged shortness of breath, elevated N-terminal prohormone of brain natriuretic peptide, enlarged pulmonary artery diameter, and history of venous thromboembolism. A predictive algorithm was developed with a negative predictive value of 97% and a specificity of 97% for a low-risk score, and a positive predictive value of 100% and sensitivity of 67% for a high-risk score. Overall, 90-day survival was 97% in the no-SPE group and 100% in the SPE group. Conclusions In this cohort, greater than 70% of patients who presented with massive PE and supported with VA-ECMO ultimately recovered with anticoagulation alone. Specific risk factors, likely related to thrombus chronicity, may be associated with lack of RV recovery, and can be utilized for consideration of early surgical intervention to minimize VA-ECMO duration.
- Published
- 2020
23. Endovascular Repair of Ascending Aortic Disease in High-Risk Patients Yields Favorable Outcome
- Author
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Aakash Shah, Mehrdad Ghoreishi, Joshua Lebowitz, Chetan Pasrija, Bradley S. Taylor, Anuj Gupta, Jean Jeudy, Shahab Toursavadkohi, and David J. Kaczorowski
- Subjects
Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,medicine.medical_treatment ,Aortic Diseases ,030204 cardiovascular system & hematology ,Transcatheter Aortic Valve Replacement ,03 medical and health sciences ,Pseudoaneurysm ,Aortic aneurysm ,Postoperative Complications ,0302 clinical medicine ,Aneurysm ,Valve replacement ,Risk Factors ,medicine.artery ,medicine ,Humans ,cardiovascular diseases ,Aorta ,Aged ,business.industry ,Endovascular Procedures ,Stent ,Middle Aged ,medicine.disease ,Aortic Aneurysm ,Surgery ,Aortic Dissection ,030228 respiratory system ,Descending aorta ,Cuff ,cardiovascular system ,Female ,Stents ,Cardiology and Cardiovascular Medicine ,business ,Aneurysm, False ,Follow-Up Studies - Abstract
Background Up to 30% of patients presenting with ascending aortic disease are deemed inoperable. Ascending aortic endovascular repair provides an alternative option for these patients. Methods From 2018 to 2019, 13 patients who were considered to have prohibitive risk for open ascending aortic repair underwent endovascular repair. Aortic disease included type A dissection (n = 8), pseudoaneurysm (n = 3), penetrating ulcer (n = 3), and chronic aortic aneurysm (n = 1). Ascending aortic stent placement with thoracic endovascular aortic repair was performed in 9 patients, endovascular cuff extension was inserted in 3, and in 1 patient endovascular coil embolization was undertaken. Preoperative and follow-up electrocardiogram-gated computed tomographic analysis was performed to compare the remodeling effect of the stent on the aorta. The median follow-up time was 13 months. Results The stent graft was successfully implanted in all patients (100%). Operative mortality and stroke rate were 15% (2 of 13) and 8% (1 of 13), respectively. One patient required transcatheter aortic valve replacement for severe aortic insufficiency 5 months after ascending thoracic endovascular aortic repair. The location of the aortic pathologic process was in zone 0A in 2 patients, zone 0B in 7 patients, and zone 0C in 3 patients. No endoleak was observed after the ascending endovascular repair in 9 patients (70%). Follow-up computed tomographic scan analysis revealed a tendency of favorable aortic remodeling in the mid-ascending and descending aorta. Conclusions Ascending aortic stent placement for ascending aortic disease is feasible and is associated with favorable aortic remodeling. Despite persistent perfusion to the false lumen in a subset of patients, there is minimal aortic dilation at short-term follow-up with excellent survival.
- Published
- 2020
24. Long-term Performance of Fresh Autologous Pericardium for Mitral Valve Leaflet Repair
- Author
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Mehrdad Ghoreishi, James S. Gammie, Nathaniel Foster, Chetan Pasrija, Libin Wang, Rachael W. Quinn, and Murtaza Y. Dawood
- Subjects
Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Time Factors ,medicine.medical_treatment ,Heart Valve Diseases ,030204 cardiovascular system & hematology ,Dehiscence ,03 medical and health sciences ,0302 clinical medicine ,Aneurysm ,medicine ,Humans ,Endocarditis ,cardiovascular diseases ,Cardiac Surgical Procedures ,Survival rate ,Retrospective Studies ,Mitral valve repair ,Mitral regurgitation ,business.industry ,Calcinosis ,Mitral Valve Insufficiency ,Middle Aged ,medicine.disease ,Surgery ,Treatment Outcome ,030228 respiratory system ,Infective endocarditis ,cardiovascular system ,Mitral Valve ,Female ,Cardiology and Cardiovascular Medicine ,business ,Pericardium ,Calcification - Abstract
Background Glutaraldehyde-fixed autologous or bovine pericardial patches used for mitral valve leaflet reconstruction have been associated with late calcification. Fresh autologous pericardium (FAP) may be a durable alternative. Methods Transthoracic echocardiography was used to assess valve function (regurgitation, mean pressure gradient, patch pliability, and calcification) in patients undergoing FAP mitral leaflet repairs. Pliability was scored between 1 (similar to native leaflets) and 4 (rigid). Calcification was scored between 1 (echobrightness similar to native leaflets) and 4 (very bright). Results Between 2002 and 2018, 62 consecutive patients (50% male, 51 ± 2 years, 69% infective endocarditis) underwent mitral valve repair with FAP, and Patch placement was on the anterior (31 of 62), posterior (27 of 62), or both (1 of 62) leaflets. Late echocardiographic follow-up was available for 43 of 62 patients (median follow-up, 3.6 years; range, 0.5-6 years). Average pliability scores were unchanged between discharge (1.2 ± 0.1) and follow-up (1.2 ± 0.2, P = .79). Average brightness scores increased modestly (predischarge, 1.6 ± 0.1; follow-up, 1.8 ± 0.1; P = .01). Three patients had recurrent severe mitral regurgitation, and 2 underwent reoperation, 1 at 1 year postoperatively for recurrent endocarditis and 1 at 6 years postoperatively for degenerative disease progression. At reoperation, patches were pliable, free from calcification, and comparable in thickness to adjacent native leaflet. One patient developed suture line leak, which was repaired. No other evidence of patch dehiscence, retraction, or aneurysm was observed. The 10-year freedom from reoperation of 82% and survival rate of 84% are comparable to repair with glutaraldehyde-fixed or bovine pericardial patches. Conclusions FAP is an excellent substrate for complex mitral valve leaflet patch repairs and can be used with the expectation of durable, long-term valve function, without evidence of late patch calcification, stiffness, or aneurysmal degeneration.
- Published
- 2020
25. Neomedia Aortic Root Repair for Type A Aortic Dissection Despite Anomalous Right Coronary Artery
- Author
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Douglas Tran, Mehrdad Ghoreishi, Bradley S. Taylor, and David J. Kaczorowski
- Subjects
Male ,Pulmonary and Respiratory Medicine ,Aortic valve ,medicine.medical_specialty ,Coronary Vessel Anomalies ,Aortic root ,Dissection (medical) ,030204 cardiovascular system & hematology ,Anatomic variant ,03 medical and health sciences ,0302 clinical medicine ,Aneurysm ,medicine.artery ,Internal medicine ,medicine ,Humans ,Coronary sinus ,Aortic dissection ,business.industry ,Middle Aged ,medicine.disease ,Aortic Dissection ,medicine.anatomical_structure ,030228 respiratory system ,Aortic Valve ,Right coronary artery ,Cardiology ,Surgery ,Cardiology and Cardiovascular Medicine ,business - Abstract
An anomalous right coronary artery arising from the left coronary sinus is a rare anatomic variant. Here we report a patient who presented with an acute type A dissection and underwent successful aortic root reconstruction with resuspension of the aortic valve and neomedia creation in the presence of an anomalous right coronary artery with a good clinical outcome.
- Published
- 2020
26. The Learning Curve of Robotic Coronary Arterial Bypass Surgery: A Report From The STS Database
- Author
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Amit Iyengar, John D. Kelly, Xingmei Wang, William L. Patrick, Nimesh D. Desai, Jarvis C. Mays, Mark R. Helmers, Pavan Atluri, Matthew Williams, Mehrdad Ghoreishi, Bradley S. Taylor, and Jason J. Han
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Databases, Factual ,Bypass grafting ,Coronary Artery Disease ,Logistic regression ,Independent predictor ,Article ,Coronary artery disease ,Continuous variable ,Postoperative Complications ,Robotic Surgical Procedures ,medicine ,Humans ,Coronary Artery Bypass ,Retrospective Studies ,business.industry ,Odds ratio ,medicine.disease ,Confidence interval ,Surgery ,Treatment Outcome ,Bypass surgery ,Learning curve ,Expert opinion ,Restricted cubic splines ,Cardiology and Cardiovascular Medicine ,business ,Learning Curve - Abstract
BACKGROUND: There is limited data to inform minimum case requirements for training in robotically assisted coronary artery bypass grafting (RA-CABG). Current recommendations rely on nonclinical endpoints and expert opinion. OBJECTIVES: To determine the minimum number of RA-CABG procedures required to achieve stable clinical outcomes. METHODS: We included isolated RA-CABG in the Society of Thoracic Surgeons (STS) registry performed between 2014 and 2019 by surgeons without prior RA-CABG experience. Outcomes were approach conversion, reoperation, major morbidity or mortality, and procedural success. Case sequence number was used as a continuous variable in logistic regression with restricted cubic splines with fixed effects. Outcomes were compared between operations performed earlier versus later in case sequences using unadjusted and adjusted metrics. RESULTS: There were 1195 cases performed by 114 surgeons. A visual inflection point occurs by a surgeon’s 10th procedure for approach conversion, major morbidity or mortality, and overall procedural success after which outcomes stabilize. There was a significant decrease in the rate of approach conversion (7.7% and 2.5%), reoperation (18.9% and 10.8%), and major morbidity or mortality (21.7% and 12.9%), as well as an increase in the rate of procedural success (72.9% and 85.3%) with increasing experience between groups. In a multivariable logistic regression model, case sequences of >10 were an independent predictor of decreased approach conversion (odds ratio [OR]: 0.27; 95% confidence interval [CI]: 0.09-0.84) and increased rate procedural success (OR: 1.96; 95% CI: 1.00-3.84). CONCLUSIONS: The learning curve for RA-CABG is initially steep, but stable clinical outcomes are achieved after the 10th procedure.
- Published
- 2021
27. Venoarterial Extracorporeal Membrane Oxygenation for Massive Pulmonary Embolism: When Is the Time to Wean?
- Author
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Zachary Kon, Mehrdad Ghoreishi, and Chetan Pasrija
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,business.industry ,MEDLINE ,medicine.disease ,Pulmonary embolism ,Extracorporeal Membrane Oxygenation ,Emergency medicine ,medicine ,Humans ,Surgery ,Pulmonary Embolism ,Cardiology and Cardiovascular Medicine ,business ,Lung ,Retrospective Studies - Published
- 2022
28. A Novel Risk Score Predicts Operative Mortality After Acute Type A Aortic Dissection Repair
- Author
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Bartley P. Griffith, Charles B. Drucker, Eric S. Wise, Douglas Tran, James S. Gammie, Bradley S. Taylor, Luqman Croal-Abrahams, Robert S. Crawford, Chetan Pasrija, and Mehrdad Ghoreishi
- Subjects
Adult ,Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Multivariate analysis ,Aortic Diseases ,030204 cardiovascular system & hematology ,Risk Assessment ,03 medical and health sciences ,chemistry.chemical_compound ,Postoperative Complications ,0302 clinical medicine ,Internal medicine ,Linear regression ,Humans ,Medicine ,Aged ,Aged, 80 and over ,Aortic dissection ,Creatinine ,Framingham Risk Score ,medicine.diagnostic_test ,business.industry ,Middle Aged ,Prognosis ,medicine.disease ,Aortic Dissection ,030228 respiratory system ,chemistry ,Concomitant ,Acute Disease ,Cardiology ,Female ,Surgery ,Cardiology and Cardiovascular Medicine ,business ,Liver function tests ,Risk assessment - Abstract
Current stratification systems for patients presenting with acute type A aortic dissection rely on signs of malperfusion to predict mortality. The authors sought to develop an algorithm to readily risk stratify these patients using admission characteristics.Two hundred sixty-nine consecutive patients who underwent type A repair between 2002 and 2015 were reviewed for easily obtainable preoperative demographics and laboratory values deemed a priori as potential predictors of operative mortality. Multiple logistic regression analysis was performed to determine independent significance, and linear regression was performed to generate the concomitant regression expression of the variables significant on bivariate analysis.Operative mortality was 16% (43/269) and was 29% (34/119) among patients who presented with malperfusion. Upon multivariate analysis, creatinine (p = 0.008), liver malperfusion (p = 0.006), and lactic acid level (p = 0.0007) remained independent significant predictors. Regression coefficients allowed the generation of a risk score as 5.5 × (lactic acid [mmol/L]) + 8 × (creatinine [mg/dL]) ± 8 (+ if liver malperfusion presents, - if no liver malperfusion). Upon receiver-operating characteristic curve analysis this model generated a c-statistic of 0.75. Operative mortality among patients within the lowest tertile (risk score7) was 4%, whereas patients in the middle (7 to 20) and highest (≥20) tertiles had mortality rates of 14% 37%, respectively.Although still requiring external validation, the innovative risk score presented necessitates knowledge of lactic acid, serum creatinine, and liver function tests. The algorithm predicts operative mortality with high accuracy and offers clinicians a novel tool to improve preoperative guidance and prognosis.
- Published
- 2018
29. Preoperative Venoarterial Extracorporeal Membrane Oxygenation Slashes Risk Score in Advanced Structural Heart Disease
- Author
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Mehrdad Ghoreishi, A. Claire Watkins, Murtaza Y. Dawood, Bradley S. Taylor, James S. Gammie, Zachary N. Kon, Si M. Pham, Bartley P. Griffith, and Nathan L. Maassel
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Framingham Risk Score ,Heart disease ,business.industry ,medicine.medical_treatment ,Cardiogenic shock ,EuroSCORE ,030204 cardiovascular system & hematology ,medicine.disease ,Cardiac surgery ,03 medical and health sciences ,0302 clinical medicine ,medicine.anatomical_structure ,030228 respiratory system ,Heart failure ,Internal medicine ,medicine ,Extracorporeal membrane oxygenation ,Cardiology ,Surgery ,Heart valve ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background Cardiac surgery for structural heart disease has poor outcomes in the presence of cardiogenic shock or advanced heart failure. We applied venoarterial extracorporeal membrane oxygenation (ECMO) to restore end-organ function and resuscitate patients before high-risk cardiac operation. Methods Twelve patients with cardiogenic shock and end-organ failure were evaluated for cardiac surgery. The average Society of Thoracic Surgeons mortality risk was 24% ± 13%. Patients were peripherally cannulated on ECMO for 7 ± 4 days, before undergoing operation for prosthetic mitral stenosis (n = 4), ruptured papillary muscle (n = 4), ischemic ventricular septal defect (n = 3), or severe aortic stenosis (n = 1). Results Mean age was 61 ± 8 years. Comorbidities included acute renal failure (n = 11), inotrope requirement (n = 10), intraaortic balloon pump (n = 8), severe acidosis (n = 6), high-dose vasopressor requirement (n = 8), and cardiac arrest (n = 1). With ECMO support, vasopressor requirement, central venous pressure, creatinine, lactate, pH, pulmonary hypertension, and The Society of Thoracic Surgeons mortality risk and EuroSCORE (European System for Cardiac Operative Risk Evaluation) II all improved significantly. Care was withdrawn in 1 patient on ECMO with initially unknown anoxic brain injury. No patients required dialysis at discharge. Complications included 1 permanent stroke. All operative patients survived to hospital discharge. Average length of follow-up was 420 days, with 2 patient deaths at 76 and 230 days and 6 patients surviving over 1 year. Conclusions ECMO can be used as a bridge to heart valve or septal defect surgery in severely decompensated patients. Through recovery of end-organ function, ECMO may allow surgical correction of structural heart disease in patients considered inoperable or convert a salvage situation to an elective operation.
- Published
- 2018
30. A Dedicated Veno-Venous Extracorporeal Membrane Oxygenation Unit during a Respiratory Pandemic: Lessons Learned from COVID-19 Part II: Clinical Management
- Author
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Raymond Rector, Eric Krause, Kristen George, Samuel M. Galvagno, Ronson J. Madathil, Aakash Shah, Brian McCormick, Jay Menaker, David J. Kaczorowski, Kristopher B. Deatrick, Mehrdad Ghoreishi, Daniel Haase, Daniel Herr, Sagar Dave, Ashley Menne, Thomas M. Scalea, James S. Gammie, Ali Tabatabai, and Siamak Dahi
- Subjects
medicine.medical_specialty ,ARDS ,Percutaneous ,pneumothorax ,medicine.medical_treatment ,Sedation ,Filtration and Separation ,Pharmacy ,tracheostomy ,TP1-1185 ,macromolecular substances ,030204 cardiovascular system & hematology ,mechanical ventilation ,Article ,03 medical and health sciences ,Chemical engineering ,0302 clinical medicine ,Extracorporeal membrane oxygenation ,Chemical Engineering (miscellaneous) ,Medicine ,030212 general & internal medicine ,anticoagulation ,Mechanical ventilation ,business.industry ,Chemical technology ,Process Chemistry and Technology ,COVID-19 ,extracorporeal membrane oxygenation ,acute respiratory distress syndrome ,medicine.disease ,surgical procedures, operative ,Respiratory failure ,Pneumothorax ,sedation ,Emergency medicine ,TP155-156 ,medicine.symptom ,business - Abstract
(1) Background: COVID-19 acute respiratory distress syndrome (CARDS) has several distinctions from traditional acute respiratory distress syndrome (ARDS), however, patients with refractory respiratory failure may still benefit from veno-venous extracorporeal membrane oxygenation (VV-ECMO) support. We report our challenges caring for CARDS patients on VV-ECMO and alterations to traditional management strategies. (2) Methods: We conducted a retrospective review of our institutional strategies for managing patients with COVID-19 who required VV-ECMO in a dedicated airlock biocontainment unit (BCU), from March to June 2020. The data collected included the time course of admission, VV-ECMO run, ventilator length, hospital length of stay, and major events related to bleeding, such as pneumothorax and tracheostomy. The dispensation of sedation agents and trial therapies were obtained from institutional pharmacy tracking. A descriptive statistical analysis was performed. (3) Results: Forty COVID-19 patients on VV-ECMO were managed in the BCU during this period, from which 21 survived to discharge and 19 died. The criteria for ECMO initiation was altered for age, body mass index, and neurologic status/cardiac arrest. All cannulations were performed with a bedside ultrasound-guided percutaneous technique. Ventilator and ECMO management were routed in an ultra-lung protective approach, though varied based on clinical setting and provider experience. There was a high incidence of pneumothorax (n = 19). Thirty patients had bedside percutaneous tracheostomy, with more procedural-related bleeding complications than expected. A higher use of sedation was noted. The timing of decannulation was also altered, given the system constraints. A variety of trial therapies were utilized, and their effectiveness is yet to be determined. (4) Conclusions: Even in a high-volume ECMO center, there are challenges in caring for an expanded capacity of patients during a viral respiratory pandemic. Though institutional resources and expertise may vary, it is paramount to proceed with insightful planning, the recognition of challenges, and the dynamic application of lessons learned when facing a surge of critically ill patients.
- Published
- 2021
31. A Dedicated Veno-Venous Extracorporeal Membrane Oxygenation Unit during a Respiratory Pandemic: Lessons Learned from COVID-19 Part I: System Planning and Care Teams
- Author
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Brian McCormick, Kristen George, Daniel Herr, Eric Krause, Ronson J. Madathil, David J. Kaczorowski, Samuel M. Galvagno, Siamak Dahi, Aakash Shah, Jay Menaker, Mehrdad Ghoreishi, Daniel Haase, Kristopher B. Deatrick, James S. Gammie, Ashley Menne, Raymond Rector, Thomas M. Scalea, Sagar Dave, and Ali Tabatabai
- Subjects
medicine.medical_treatment ,Specialty ,Staffing ,Filtration and Separation ,lcsh:Chemical technology ,Article ,03 medical and health sciences ,0302 clinical medicine ,Incident Command System ,Pandemic ,medicine ,Extracorporeal membrane oxygenation ,Chemical Engineering (miscellaneous) ,lcsh:TP1-1185 ,030212 general & internal medicine ,lcsh:Chemical engineering ,biocontainment unit ,Modalities ,business.industry ,Process Chemistry and Technology ,lcsh:TP155-156 ,COVID-19 ,030208 emergency & critical care medicine ,extracorporeal membrane oxygenation ,acute respiratory distress syndrome ,medicine.disease ,Biocontainment ,Triage ,Medical emergency ,business - Abstract
Background: The most critically ill patients with coronavirus disease 2019 (COVID-19) may require advanced support modalities, such as veno-venous extracorporeal membrane oxygenation (VV-ECMO). A systematic, methodical approach to a respiratory pandemic on a state and institutional level is critical. Methods: We conducted retrospective review of our institutional response to the COVID-19 pandemic, focusing on the creation of a dedicated airlock biocontainment unit (BCU) to treat patients with refractory COVID-19 acute respiratory distress syndrome (CARDS). Data were collected through conversations with staff on varying levels in the BCU, those leading the effort to make the BCU and hospital incident command system, email communications regarding logistic changes being implemented, and a review of COVID-19 patient census at our institution from March through June 2020. Results: Over 2100 patients were successfully admitted to system hospitals, 29% of these patients required critical care. The response to this respiratory pandemic augmented intensive care physician staffing, created a 70-member nursing team, and increased the extracorporeal membrane oxygenation (ECMO) capability by nearly 200%. During this time period, 40 COVID-19 patients on VV-ECMO were managed in the BCU. Challenges in an airlock unit included communication, scarcity of resources, double-bunking, and maintaining routine care. Conclusions: Preparing for a surge of critically ill patients during a pandemic can be a daunting task. The implementation of a coordinated, system-level approach can help with the allocation of resources as needed. Focusing on established strengths of hospitals within the system can guide triage based on individual patient needs. The management of ECMO patients is still a specialty care, and a systematic and hospital based approach requiring an ECMO team composed of multiple experienced individuals is paramount during a respiratory viral pandemic.
- Published
- 2021
32. Mitral Valve Translocation: A Novel Operation for the Treatment of Secondary Mitral Regurgitation
- Author
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Rachael W. Quinn, Erik Strauss, Aakash Shah, Douglas Tran, James S. Gammie, Chetan Pasrija, Mehrdad Ghoreishi, Michael N. D'Ambra, Hani Alkhatib, MaryJoe Rice, David L.S. Morales, Reney Henderson, and Daniel S. Bernstein
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Percutaneous ,Mitral Valve Annuloplasty ,Swine ,medicine.medical_treatment ,Infarction ,Interquartile range ,Internal medicine ,Mitral valve ,medicine ,Animals ,cardiovascular diseases ,Circumflex ,Embolization ,Mitral regurgitation ,business.industry ,Mitral Valve Insufficiency ,medicine.disease ,Disease Models, Animal ,medicine.anatomical_structure ,Treatment Outcome ,Echocardiography ,cardiovascular system ,Cardiology ,Mitral Valve ,Surgery ,Cardiology and Cardiovascular Medicine ,business ,Artery - Abstract
Background Conventional annuloplasty repair of secondary (functional) ischemic mitral regurgitation (IMR) is associated with a 60% recurrence of moderate or greater mitral regurgitation at 2 years. We developed a novel repair technique for IMR that addresses the underlying geometric alterations of the mitral valve apparatus and compared outcomes with those of conventional repair in a swine model. Methods Chronic IMR was induced by percutaneous embolization of the circumflex artery. Swine with severe IMR (median 9 weeks after infarction) underwent undersized rigid annuloplasty (n = 5) or translocation repair (n = 6). Translocation repair consisted of detaching the mitral valve en bloc at the annulus, creating a 1 cm wide frustum-shaped pericardial patch, and suturing the outer circumference of the patch to the annulus and inner circumference to the mitral valve. Results Operative survival was 92% (11 of 12). All animals had none/trace residual central mitral regurgitation, and mean inflow gradients were similar (1 mm Hg [interquartile range, 1 to 2] vs 2 mm Hg [interquartile range, 1 to 2]; P = .75) in the annuloplasty and translocation groups, respectively. Median coaptation length marginally improved in conventional swine (3 to 4 mm, P = .05), but dramatically improved in translocation swine (3 to 8 mm, P = .003). Posterior leaflet angle increased from 39 to 80 degrees (P = .05) in annuloplasty swine but decreased from 50 to 31 degrees (P = .03) in translocation swine. The posterior leaflet was immobile after annuloplasty but had preserved motion after translocation (excursion, 1 degree vs 24 degrees; P = .045). Conclusions Mitral valve translocation effectively treats mitral regurgitation by relieving leaflet tethering. Compared with annuloplasty, mitral valve translocation creates a larger surface of coaptation and preserves leaflet mobility without compromising diastolic function.
- Published
- 2021
33. Which One Would You Rather Have If You Are 50: TAVR vs Small-Incision AVR vs Full Sternotomy AVR
- Author
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Mehrdad Ghoreishi, Chetan Pasrija, and Zachary Kon
- Subjects
Pulmonary and Respiratory Medicine ,Heart Valve Prosthesis Implantation ,medicine.medical_specialty ,business.industry ,Aortic Valve Stenosis ,Sternotomy ,Surgery ,Transcatheter Aortic Valve Replacement ,Text mining ,Treatment Outcome ,Small incision ,Aortic Valve ,Medicine ,Humans ,Minimally Invasive Surgical Procedures ,Cardiology and Cardiovascular Medicine ,business ,Retrospective Studies - Published
- 2020
34. OPTIMAL REPERFUSION STRATEGY IN ACUTE HIGH-RISK PULMONARY EMBOLISM REQUIRING EXTRACORPOREAL MEMBRANE OXYGENATION SUPPORT: A SYSTEMATIC REVIEW AND META-ANALYSIS
- Author
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Romain Chopard, Peter Nielsen, Fabio Ius, Serghei Cebotari, Fiona Ecarnot, Hugo Pilichowski, Matthieu Schmidt, Benedict Kjaergaard, Iago Sousa-Casasnovas, Mehrdad Ghoreishi, Rajeev L. Narayan, Su Nam Lee, Gregory Piazza, and Nicolas Meneveau
- Subjects
Pulmonary and Respiratory Medicine ,Extracorporeal Membrane Oxygenation/methods ,pulmonary embolism ,Embolectomy/methods ,Embolectomy ,Critical Care and Intensive Care Medicine ,pulmonary revascularization ,meta-analysis ,Extracorporeal Membrane Oxygenation ,Treatment Outcome ,Thrombolytic Therapy/methods ,Pulmonary Embolism/therapy ,Acute Disease ,Reperfusion ,Humans ,Thrombolytic Therapy ,Pulmonary Embolism ,Cardiology and Cardiovascular Medicine ,extra-corporeal membrane oxygenation - Abstract
BackgroundThe optimal pulmonary revascularisation strategy in high-risk pulmonary embolism (PE) requiring implantation of extracorporeal membrane oxygenation (ECMO) remains controversial.MethodsWe conducted a systematic review and meta-analysis of evidence comparing mechanical embolectomy and other strategies, including systemic thrombolysis, catheter-directed thrombolysis or ECMO as stand-alone therapy, with regard to mortality and bleeding outcomes.ResultsWe identified 835 studies, 17 of which were included, comprising 327 PE patients. Overall, 32.4% were treated with mechanical pulmonary reperfusion (of whom 85.9% had surgical embolectomy), while 67.6% received other strategies. The mortality rate was 22.6% in the mechanical reperfusion group and 42.8% in the “other strategies” group. The pooled odds ratio for mortality with mechanical reperfusion was 0.439 (95% CI 0.237–0.816) (p=0.009; I2=35.2%)versusother reperfusion strategies and 0.368 (95% CI 0.185–0.733) (p=0.004; I2=32.9%) for surgical embolectomyversusthrombolysis. The rate of bleeding in patients under ECMO was 22.2% in the mechanical reperfusion group and 19.1% in the “other strategies” group (OR 1.27, 95% CI 0.54–2.96; I2=7.7%). The meta-regression model did not identify any relationship between the covariates “more than one pulmonary reperfusion therapy”, “ECMO implantation before pulmonary reperfusion therapy”, “clinical presentation of PE” or “cancer-associated PE” and the associated outcomes.ConclusionsThe results of the present meta-analysis and meta-regression suggest that mechanical reperfusion, notably by surgical embolectomy, may yield favourable results regardless of the timing of ECMO implantation in the reperfusion timeline, independent of thrombolysis administration or cardiac arrest presentation.
- Published
- 2022
35. Complete percutaneous decannulation from femoral venoarterial extracorporeal membrane oxygenation
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Michael Mazzeffi, Bartley P. Griffith, Mohamed Abdullah, Mehrdad Ghoreishi, Ronson J. Madathil, Douglas Tran, David J. Kaczorowski, Kristopher B. Deatrick, Bradley S. Taylor, Jay Menaker, Aakash Shah, Shahab Toursavadkohi, Chetan Pasrija, Ashley Menne, and James S. Gammie
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Percutaneous ,medicine.medical_treatment ,Embolectomy ,percutaneous vascular closure ,Pseudoaneurysm ,Hematoma ,SFA, superficial femoral artery ,medicine ,Extracorporeal membrane oxygenation ,Vascular closure device ,mechanical circulatory support ,business.industry ,Perioperative ,extracorporeal membrane oxygenation ,medicine.disease ,Cannula ,VA, venoarterial ,Surgery ,CT, computed tomography ,surgical procedures, operative ,Adult: Mechanical Circulatory Support ,business ,ECMO, extracorporeal membrane oxygenation - Abstract
Objectives To evaluate the clinical outcomes and perioperative complications associated with complete percutaneous decannulation of femoral venoarterial extracorporeal membrane oxygenation (VA-ECMO) with the MANTA closure device. Methods This is a retrospective analysis of a single surgeon consecutive series of 14 patients at a single center who underwent decannulation from VA-ECMO, 10 of whom underwent a percutaneous method of femoral cannula removal. Results After a mean duration of VA-ECMO support of 7.4 ± 3.8 days, all 10 patients, with arterial cannulas ranging in size from 17 to 21 Fr, underwent percutaneous decannulation with the MANTA closure device, with immediate hemostasis. One patient had acute lower limb ischemia that was recognized intraoperatively and successfully treated with suction embolectomy. Two patients had a pseudoaneurysm at the distal perfusion catheter site recognized on perioperative imaging studies, one resolving with observation and the other necessitating thrombin injection. One patient had a hematoma that resolved with observation. Conclusions Percutaneous decannulation from VA-ECMO using the MANTA large-bore vascular closure device is feasible and results in immediate hemostasis with excellent angiographic results.
- Published
- 2020
36. A Novel Quantitative Ex Vivo Model of Functional Mitral Regurgitation
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Chetan Pasrija, Rachael Quinn, Mehrdad Ghoreishi, Thomas Eperjesi, Eric Lai, Robert C. Gorman, Joseph H. Gorman, Alison Pouch, Felino V. Cortez, Michael N D'Ambra, and James S. Gammie
- Subjects
Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Swine ,0206 medical engineering ,02 engineering and technology ,030204 cardiovascular system & hematology ,03 medical and health sciences ,0302 clinical medicine ,Imaging, Three-Dimensional ,Mitral valve ,Internal medicine ,medicine ,Animals ,Functional mitral regurgitation ,Ischemic mitral regurgitation ,business.industry ,Models, Cardiovascular ,Mitral Valve Insufficiency ,General Medicine ,020601 biomedical engineering ,Disease Models, Animal ,medicine.anatomical_structure ,Cardiology ,Mitral Valve ,Surgery ,Cardiology and Cardiovascular Medicine ,business ,Ex vivo ,Echocardiography, Transesophageal - Abstract
Objective Durability of mitral valve (MV) repair for functional mitral regurgitation (FMR) remains suboptimal. We sought to create a highly reproducible, quantitative ex vivo model of FMR that functions as a platform to test novel repair techniques. Methods Fresh swine hearts ( n = 10) were pressurized with air to a left ventricular pressure of 120 mmHg. The left atrium was excised and the altered geometry of FMR was created by radially dilating the annulus and displacing the papillary muscle tips apically and radially in a calibrated fashion. This was continued in a graduated fashion until coaptation was exhausted. Imaging of the MV was performed with a 3-dimensional (3D) structured-light scanner, which records 3D structure, texture, and color. The model was validated using transesophageal echocardiography in patients with normal MVs and severe FMR. Results Compared to controls, the anteroposterior diameter in the FMR state increased 32% and the annular area increased 35% ( P < 0.001). While the anterior annular circumference remained fixed, the posterior circumference increased by 20% ( P = 0.026). The annulus became more planar and the tenting height increased 56% (9 to 14 mm, P < 0.001). The median coaptation depth significantly decreased (anterior leaflet: 5 vs 2 mm; posterior leaflet: 7 vs 3 mm, P < 0.001). The ex vivo normal and FMR models had similar characteristics as clinical controls and patients with severe FMR. Conclusions This novel quantitative ex vivo model provides a simple, reproducible, and inexpensive benchtop representation of FMR that mimics the systolic valvular changes of patients with FMR.
- Published
- 2020
37. Programmatic and Surgeon Specialization Improves Mortality in Isolated Coronary Bypass Grafting
- Author
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Bartley P. Griffith, A. Claire Watkins, Filiz Demirci, Nathan L. Maassel, James S. Gammie, Mehrdad Ghoreishi, Bradley S. Taylor, and Brody Wehman
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Male ,Pulmonary and Respiratory Medicine ,Program evaluation ,medicine.medical_specialty ,Time Factors ,Blood transfusion ,Databases, Factual ,medicine.medical_treatment ,Prom ,030204 cardiovascular system & hematology ,Risk Assessment ,law.invention ,03 medical and health sciences ,0302 clinical medicine ,law ,Outcome Assessment, Health Care ,Cardiopulmonary bypass ,Humans ,Medicine ,Hospital Mortality ,030212 general & internal medicine ,Coronary Artery Bypass ,Program Development ,Stroke ,Aged ,Retrospective Studies ,Academic Medical Centers ,business.industry ,General surgery ,Thoracic Surgery ,Retrospective cohort study ,Middle Aged ,medicine.disease ,Quality Improvement ,Survival Analysis ,United States ,medicine.anatomical_structure ,Female ,Surgery ,Cardiology and Cardiovascular Medicine ,business ,Complication ,Program Evaluation ,Specialization ,Artery - Abstract
Background Throughout surgery, specialization in a procedure has been shown to improve outcomes. Currently, there is no evidence for or against subspecialization in coronary surgery. Tasked with the goal of improving outcomes after isolated coronary artery bypass grafting (CABG), our institution sought to determine whether the development of a subspecialized coronary surgery program would improve morbidity and mortality. Methods All isolated CABG operations at a single institution were retrospectively examined in two distinct periods, 2002 to 2013 and 2013 to 2016, before and after the implementation of a subspecialized coronary surgery program. Improved policies included leadership and subspecialization of a program director, standardization of surgical technique and postoperative care, and monthly multidisciplinary quality review. Outcomes were collected and compared. Results Between 2002 and 2013, 3,256 CABG operations were done by 16 surgeons, the most frequent surgeon doing 33%. Between 2013 and 2016, 1,283 operations were done by 10 surgeons, 70% by the coronary program director. CABGs done in the specialized era had shorter bypass and clamps times and increased use of bilateral internal mammary arteries. Blood transfusion and complication rates, including permanent stroke and prolonged ventilation, were significantly decreased after implementation of the coronary program. Likewise, overall operative mortality (2.67% vs 1.48%, p = 0.02) was significantly reduced. Conclusions Subspecialization in CABG and dedicated coronary surgery programs may lead to faster operations, increased use of bilateral internal mammary arteries, fewer complications, and improved survival after isolated CABG.
- Published
- 2018
38. Isolated Mitral Valve Surgery: The Society of Thoracic Surgeons Adult Cardiac Surgery Database Analysis
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Rachael W. Quinn, Mehrdad Ghoreishi, Rakesh M. Suri, Vinod H. Thourani, Steven F. Bolling, Marc Gillinov, Jeffrey P. Jacobs, J. Scott Rankin, Gorav Ailawadi, Dylan Thibault, Joanna Chikwe, Nathaniel Foster, Vinay Badhwar, Alice Wang, David H. Adams, James S. Gammie, and Sreekanth Vemulapalli
- Subjects
Male ,Pulmonary and Respiratory Medicine ,Aortic valve ,medicine.medical_specialty ,Databases, Factual ,medicine.medical_treatment ,030204 cardiovascular system & hematology ,Risk Assessment ,Severity of Illness Index ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Cause of Death ,Mitral valve ,Humans ,Medicine ,Hospital Mortality ,cardiovascular diseases ,Cardiac Surgical Procedures ,Societies, Medical ,Aged ,Surgeons ,Mitral valve repair ,Mitral regurgitation ,Ejection fraction ,business.industry ,Mitral Valve Insufficiency ,Thoracic Surgery ,Atrial fibrillation ,Middle Aged ,Prognosis ,medicine.disease ,Survival Analysis ,Tricuspid Valve Insufficiency ,Cardiac surgery ,Surgery ,medicine.anatomical_structure ,030228 respiratory system ,Echocardiography ,Cardiothoracic surgery ,cardiovascular system ,Female ,Cardiology and Cardiovascular Medicine ,business - Abstract
Data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database were analyzed to identify trends in patient characteristics and outcomes of mitral valve operations in North America.All patients with isolated primary mitral valve operations with or without tricuspid valve repair, surgical atrial fibrillation ablation, or atrial septal defect closure performed July 2011 to September 2016 were identified. A subgroup analysis assessed patients with degenerative leaflet prolapse (DLP).Isolated primary mitral valve operations were performed on 87,214 patients at 1,125 centers, increasing by 24% between 2011 (n = 14,442) and 2016 (n = 17,907). The most common etiology was DLP (60.7%); 4.3% had functional mitral regurgitation. Preoperatively, 47.3% of patients had an ejection fraction less than 60% and 34.2% had atrial fibrillation. Overall mitral valve repair rate was 65.6%, declining from 67.1% (2011) to 63.2% (2016; p 0.0001). Repair rates were related to etiology (DLP, 82.5%; rheumatic, 17.5%). Of the 29,970 mitral valve replacements, 16.2% were preceded by an attempted repair. Repair techniques included prosthetic annuloplasty (94.3%), leaflet resection (46.5%), and artificial cord implantation (22.7%). Bioprosthetic valves were implanted with increasing frequency (2011, 65.4%; 2016, 75.8%; p 0.0001). Less-invasive operations were performed in 23.0% and concomitant tricuspid valve repair in 15.7%. Unadjusted operative mortality was 3.7% (replacements) and 1.1% (repairs).Patients undergoing primary isolated mitral valve operations commonly have ventricular dysfunction, atrial fibrillation, and heart failure. Although contemporary outcomes are excellent, earlier guideline-directed referral and increased frequency and quality of repair may further improve results of mitral valve operations.
- Published
- 2018
39. Cost and Outcome of Minimally Invasive Techniques for Coronary Surgery Using Robotic Technology
- Author
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Chetan Pasrija, Eric J. Lehr, Bartley P. Griffith, Zachary N. Kon, Johannes Bonatti, Mehrdad Ghoreishi, James S. Gammie, and Bradley S. Taylor
- Subjects
Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Treatment outcome ,MEDLINE ,Coronary surgery ,030204 cardiovascular system & hematology ,Outcome (game theory) ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Text mining ,Robotic Surgical Procedures ,Humans ,Minimally Invasive Surgical Procedures ,Medicine ,030212 general & internal medicine ,Coronary Artery Bypass ,Hospital Costs ,Aged ,Retrospective Studies ,Distal anastomosis ,business.industry ,Retrospective cohort study ,General Medicine ,Length of Stay ,Middle Aged ,Surgery ,Treatment Outcome ,medicine.anatomical_structure ,Female ,Cardiology and Cardiovascular Medicine ,business ,Artery - Abstract
Objective Totally endoscopic coronary artery bypass (TECAB) with robotic distal anastomosis and robotic-assisted minimally invasive coronary artery bypass (RA-MIDCAB) with robotic internal mammary artery harvest and direct hand-sewn distal anastomosis via an anterior thoracotomy have both been reported as safe and efficacious. We compared hospital cost and short-term outcomes between these techniques. Methods Patients who underwent robotic-assisted minimally invasive single-vessel Coronary artery bypass grafting (2011–2014) were retrospectively reviewed. One hundred consecutive patients underwent either TECAB (n = 50) or RA-MIDCAB (n = 50). The two groups were sequential with TECAB performed by one surgeon in the first portion of the study interval and RA-MIDCAB by another surgeon in the latter. Demographics, short-term outcomes, and hospital cost data were compared between the two groups. Results Patient demographics and preoperative risk factors were similar between the TECAB and RA-MIDCAB groups, as total operating room time. Cardiopulmonary bypass was used for 56% of TECAB and 0% of RA-MIDCAB cases ( P < 0.001). Intensive care unit and hospital lengths of stay, along with postoperative morbidities, were similar between the two groups. Operative mortality was 2% in the TECAB and 0% in the RA-MIDCAB group ( P = NS). Total hospital cost was significantly higher with TECAB compared with RA-MIDCAB (US $33,769 vs. $22,679, P < 0.001), which was primarily driven by operative costs (US $17,616 vs. $26,803, P < 0.001). Conclusions Totally endoscopic coronary artery bypass and RA-MIDCAB both demonstrated excellent short-term clinical outcomes. However, TECAB was associated with significantly higher hospital costs. Further comparisons, including long-term outcomes, patient satisfaction, and functional status, are needed to evaluate whether this additional cost is justified.
- Published
- 2018
40. Early Operation in Patients With Mitral Valve Infective Endocarditis and Acute Stroke Is Safe
- Author
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Bartley P. Griffith, Rachael W. Quinn, Murtaza Y. Dawood, Chetan Pasrija, Nate Foster, Aakash Shah, Sam Maghami, A. Claire Watkins, Mehrdad Ghoreishi, Charlie F. Evans, Brody Wehman, Bradley S. Taylor, and James S. Gammie
- Subjects
Adult ,Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Adolescent ,Heart Valve Diseases ,030204 cardiovascular system & hematology ,Asymptomatic ,Young Adult ,03 medical and health sciences ,0302 clinical medicine ,Early Medical Intervention ,Mitral valve ,Humans ,Medicine ,Endocarditis ,cardiovascular diseases ,Young adult ,Stroke ,Aged ,Retrospective Studies ,Aged, 80 and over ,medicine.diagnostic_test ,business.industry ,Retrospective cohort study ,Magnetic resonance imaging ,Endocarditis, Bacterial ,Middle Aged ,medicine.disease ,Surgery ,Treatment Outcome ,medicine.anatomical_structure ,Infective endocarditis ,Mitral Valve ,Female ,medicine.symptom ,Cardiology and Cardiovascular Medicine ,business ,030217 neurology & neurosurgery - Abstract
Background To determine if preoperative embolic stroke is associated with an increased risk of postoperative stroke among patients undergoing early operation for mitral valve (MV) infective endocarditis (IE), we compared outcomes among patients presenting with and without acute stroke. Methods From 2003 to 2015, 243 consecutive patients underwent surgery for active MV IE. Patients were categorized into 2 groups: 72% (174 of 243 patients) with no preoperative acute stroke (clinical, radiographic or both) and 28% (69 of 243 patients) with stroke. Both preoperative and postoperative strokes were confirmed in all patients with brain computed tomography or magnetic resonance imaging and comprehensive examination by a neurologist. Results Among patients presenting with stroke, 33% (23 of 69 patients) were asymptomatic and had only positive imaging findings. The median time from admission to operation was 5 days. The overall rate of new postoperative stroke was 4% (10 of 243 patients). The rate of postoperative stroke was not different between the 2 groups: 4% (7 of 174 patients) among patients with no preoperative stroke and 4% (3 of 69 patients) with stroke ( p = 0.9). One patient developed a hemorrhagic conversion of an acute infarct. Operative mortality was 7% (13 of 174 patients) among patients with no preoperative stroke and 7% (5 of 69 patients) among patients with stroke ( p = 0.9). Conclusions MV surgery for IE and acute stroke can be performed early with a low risk of postoperative neurologic complications. When indicated, surgical intervention for MV IE complicated by acute stroke should not be delayed.
- Published
- 2018
41. Minimally Invasive Surgical Pulmonary Embolectomy
- Author
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Michael Rouse, Bartley P. Griffith, Elliot A. Sultanik, Gregory J. Bittle, Aakash Shah, Mehrdad Ghoreishi, Chetan Pasrija, Zachary N. Kon, and Francesca Boulos
- Subjects
Adult ,Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,Time Factors ,Ventricular Dysfunction, Right ,Operative Time ,MEDLINE ,Hospital mortality ,Embolectomy ,030204 cardiovascular system & hematology ,law.invention ,03 medical and health sciences ,Postoperative Complications ,0302 clinical medicine ,Pulmonary embolectomy ,law ,Sepsis ,medicine ,Cardiopulmonary bypass ,Humans ,Minimally Invasive Surgical Procedures ,Surgical Wound Infection ,Hospital Mortality ,Cardiopulmonary Bypass ,business.industry ,General Medicine ,Length of Stay ,Middle Aged ,medicine.disease ,Respiration, Artificial ,Sternotomy ,Surgery ,Pulmonary embolism ,Stroke ,Intensive Care Units ,030228 respiratory system ,Operative time ,Female ,Pulmonary Embolism ,Cardiology and Cardiovascular Medicine ,business - Abstract
Objective Surgical pulmonary embolectomy has gained increasing popularity over the past decade with multiple series reporting excellent outcomes in the treatment of submassive pulmonary embolism. However, a significant barrier to the broader adoption of surgical pulmonary embolectomy remains the large incision and long recovery after a full sternotomy. We report the safety and efficacy of using a minimally invasive approach to surgical pulmonary embolectomy. Methods All consecutive patients undergoing surgical pulmonary embolectomy for a submassive pulmonary embolism (2015–2017) were reviewed. Patients were stratified as conventional or minimally invasive. The minimally invasive approach included a 5- to 7-cm skin incision with upper hemisternotomy to the third intercostal space. The primary outcomes were in-hospital and 90-day survival. Results Thirty patients (conventional = 20, minimally invasive = 10) were identified. Operative time was similar between the two groups, but cardiopulmonary bypass time was significantly longer in the minimally invasive group (58 vs 94 minutes, P = 0.04). While ventilator time and intensive care unit length of stay were similar between groups, hospital length of stay was 4.5 days shorter in the minimally invasive group, and there was a trend toward less blood product use. In-hospital and 90-day survival was 100%. Within the minimally invasive cohort, median right ventricular dysfunction at discharge was none-mild and no patient experienced postoperative renal failure, deep sternal wound infection, sepsis, or stroke. Conclusions Minimally invasive surgical pulmonary embolectomy appears to be a feasible approach in the treatment of patients with a submassive pulmonary embolism. A larger, prospective analysis comparing this modality with conventional surgical pulmonary embolectomy may be warranted.
- Published
- 2017
42. Bedside VA-ECMO Cannulation for a Patient with CTEPH and RV Failure
- Author
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Chetan Pasrija, Mehrdad Ghoreishi, Bartley P. Griffith, Daniel Haase, E.K. Powell, and Ashley Menne
- Subjects
Pulmonary and Respiratory Medicine ,Transplantation ,medicine.medical_specialty ,Pulmonary thromboendarterectomy ,business.industry ,medicine.medical_treatment ,Embolectomy ,medicine.disease ,Cannula ,surgical procedures, operative ,Internal medicine ,medicine ,Cardiology ,Extracorporeal membrane oxygenation ,Intubation ,Milrinone ,Surgery ,Thrombus ,Transthoracic echocardiogram ,Cardiology and Cardiovascular Medicine ,business ,medicine.drug - Abstract
Introduction Acute pulmonary embolus (PE) in the setting of chronic thromboembolic pulmonary hypertension (CTEPH) with elevated PA pressures and right ventricular (RV) failure is a complex condition associated with increased mortality if left untreated. We demonstrate an alternative bedside veno-arterial extracorporeal membrane oxygenation (VA-ECMO) strategy used to facilitate stabilization and pre-operative optimization. Case Report A 29-year-old female with a history of previous PE (on Lovenox), RV dysfunction with elevated PA pressures, and IVC thrombus requiring VV-ECMO assisted suction embolectomy presented to an outside hospital with shortness of breath, hypoxia and CT demonstrating acute on chronic, bilateral PEs. A transthoracic echocardiogram (TTE) showed worsening RV function. She was normotensive, had a heart rate of 140, and was hypoxic so was placed on BiPAP. She was transferred to our facility for further management. On arrival, the patient was tachypneic and hypoxic. She was started on Epinephrine, Milrinone, and inhaled Epoprostenol but was persistently hypoxic with a rising lactic acid and worsening metabolic acidosis. With evidence of worsening RV failure, the patient was cannulated for VA-ECMO to facilitate optimization for advanced management. Prior to cannulation, bedside ultrasound revealed occlusive thrombus in both femoral and iliac veins. The venous drainage cannula was placed in the right internal jugular vein and the arterial return cannula was placed in the right common femoral artery, with antegrade reperfusion cannula. Bedside TTE was used to aide in cannula placement and cannula position was confirmed with x-ray.The patient was on VA-ECMO for 72 hours. During this time, her acidosis improved, Milrinone was weaned off, and she was diuresed. On ECMO day 3, she was taken to the OR for a pulmonary thromboendarterectomy and decannulated from VA-ECMO. The following day she was extubated and a TTE revealed improved right ventricular function. Summary Stabilization with VA-ECMO in patients with PE can be beneficial. This case illustrates the use of an alternative VA-ECMO cannulation strategy to optimize a patient with CTEPH. Of note, the cannulation occurred at the bedside with the use of ultrasound and without the need for intubation. Though this cannulation strategy is theoretically described in the literature, this case illustrates a concrete example of its use.
- Published
- 2021
43. Thoracic endovascular aortic repair for type A aortic dissection: a promising option for inoperable patients
- Author
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Mehrdad Ghoreishi, Gregory P. Boyajian, Bradley S. Taylor, Irina Kolesnik, Shahab Toursavadkohi, and Anahita Ghazi
- Subjects
Aortic dissection ,medicine.medical_specialty ,business.industry ,medicine ,medicine.disease ,Aortic repair ,business ,Surgery - Published
- 2021
44. Two cases of ascending TEVAR for primary repair of acute type A dissection. Pre-operative and post-operative CT scans are included to demonstrate the location of the intimal tear and final position of the stent grafts
- Author
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Gregory P. Boyajian, Mehrdad Ghoreishi, Bradley S. Taylor, Irina Kolesnik, Anahita Ghazi, and Shahab Toursavadkohi
- Subjects
medicine.medical_specialty ,business.industry ,medicine.medical_treatment ,Stent ,Dissection (medical) ,medicine.disease ,Pre operative ,Surgery ,Position (obstetrics) ,Primary repair ,Acute type ,Materials Chemistry ,Medicine ,Post operative ,business - Published
- 2021
45. Commentary: Keep the head cool. Keep the spine cooler
- Author
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Joseph S. Coselli and Mehrdad Ghoreishi
- Subjects
Pulmonary and Respiratory Medicine ,Aorta ,business.industry ,Anatomy ,Spinal cord ,Cerebrovascular Circulation ,Spine (zoology) ,medicine.anatomical_structure ,medicine.artery ,medicine ,Head (vessel) ,Surgery ,Cardiology and Cardiovascular Medicine ,business - Published
- 2020
46. Mitigating the Risk: Transfusion or Reoperation for Bleeding After Cardiac Surgery
- Author
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Mehrdad Ghoreishi, Sari D. Holmes, Michael A. Mazzeffi, Bradley S. Taylor, Diane Alejo, Niv Ad, Chetan Pasrija, Stefano Schena, Clifford E. Fonner, Glenn J.R. Whitman, and Rawn Salenger
- Subjects
Pulmonary and Respiratory Medicine ,Male ,Reoperation ,medicine.medical_specialty ,MEDLINE ,030204 cardiovascular system & hematology ,Risk Assessment ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Postoperative Complications ,Risk of mortality ,Medicine ,Humans ,Blood Transfusion ,Cardiac Surgical Procedures ,Aged ,Retrospective Studies ,business.industry ,Retrospective cohort study ,Middle Aged ,Surgery ,Cardiac surgery ,030228 respiratory system ,Female ,Cardiology and Cardiovascular Medicine ,business ,Risk assessment ,Operative morbidity ,Cohort study - Abstract
Several studies have established morbidity associated with bleeding after cardiac surgery. Although reoperation has been implicated as the marker for this morbidity, there remains limited understanding regarding relative morbidities of reoperation and substantial transfusion.The Society of Thoracic Surgeons (STS) Maryland Adult Cardiac Surgery Database (July 2011-September 2018) was reviewed (N = 23,240). Substantial transfusion was defined as requiring greater than the reoperation group median red blood cells (5 units) and non-red blood cells (4 units). Patients were stratified into 4 subgroups: group 1, no reoperation without substantial transfusion (n = 22,365); group 2, reoperation without substantial transfusion (n = 351); group 3, no reoperation with substantial transfusion (n = 350); and group 4, reoperation with substantial transfusion (n = 167). Operative morbidity and mortality were compared.Reoperation patients were older with a higher STS predicted risk of mortality (1.8% vs 1.2%, P.001). Multivariable analysis demonstrated that group 4 increased the odds of renal failure (odds ratio [OR] 7.36, P.001), stroke (OR 3.24, P = .002), and operative mortality (OR 8.68, P.001) compared with group 1. Both group 2 and group 3 increased the odds of mortality and renal failure compared with group 1. However, group 3 had greater risk for renal failure (OR 3.48, P.001) and mortality (OR 2.91, P.001) than group 2.Although reoperation for bleeding is associated with morbidity after cardiac surgery, substantial transfusion without reoperation appears to increase morbidity compared with a limited-transfusion reoperative approach. Better timing for reoperation and guided transfusion approaches may mitigate morbidity compared with substantial transfusion alone.
- Published
- 2019
47. Type B Aortic Dissection Complicated by Intimo-Intimal Intussusception and Extensive Intimal Denuding: Case Report with Long-term Follow-up
- Author
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Charles B. Drucker, Hemi Thaker, Aakash Shah, Siamak Dahi, Mehrdad Ghoreishi, Mary Lin, Alison O. Flentje, Shahab Toursavadkohi, and Bradley S. Taylor
- Subjects
Aortic dissection ,medicine.medical_specialty ,Aorta ,Aortic Segment ,business.industry ,medicine.medical_treatment ,General Medicine ,030204 cardiovascular system & hematology ,medicine.disease ,030218 nuclear medicine & medical imaging ,Surgery ,03 medical and health sciences ,0302 clinical medicine ,Aneurysm ,Blood vessel prosthesis ,medicine.artery ,Angioplasty ,cardiovascular system ,medicine ,Balloon dilation ,cardiovascular diseases ,Embolization ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background Acute aortic dissection rarely results in circumferential dissections of the aortic intima that may lead to intimo-intimal intussusception (IIS) with complete separation from the aortic wall. Circumferential dissection may then result in distal embolization of the involved intima and media, adding considerable complexity to the management of such cases. Despite the severity of this complication, the natural history of aortic disease following extensive intimal denuding and IIS is not well documented in the literature. Here we present a case with long-term follow-up of type B aortic dissection (TBAD) complicated by IIS and embolization of the intima into the distal aorta following thoracic endovascular aortic repair. Methods Medical records and imaging studies were retrospectively reviewed with the approval of the Institutional Review Board. A single patient underwent repair of a TBAD that was complicated by IIS, with follow-up for 6 years. Aortic recovery was monitored with serial computerized tomography scans. Results During endovascular stent deployment, the patient’s dissection progressed circumferentially, leading to distal embolization of the intima and aortic occlusion. An open transabdominal aortic exploration was performed to extract the embolized intima. Despite this severe aortic structural disruption, the patient recovered well postoperatively and exhibited favorable aortic remodeling over long-term follow-up. The denuded aorta did not rupture or develop progressive worsening aneurysmal dilation and the diameter of the involved aortic segment remained stable during follow-up. Conclusions Acute TBADs can progress to circumferential intimal separation and IIS when managed with endovascular stenting and balloon dilation. Continued endovascular management once IIS has occurred may lead to further intimal damage, resulting in distal embolization of the intima and aortic occlusion. Thus, IIS may require conversion to open repair. However, in the event that loss of the aortic intima does occur following IIS, it is possible for the denuded aorta to recover well and remain stable with favorable remodeling over long-term follow-up.
- Published
- 2020
48. Undersized Rigid Nonplanar Annuloplasty: The Key to Effective and Durable Repair of Functional Tricuspid Regurgitation
- Author
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Dhruv Adawal, Sam Maghami, Murtaza Y. Dawood, Mary Walterhoefer, Isa Mohammed, Bartley P. Griffith, Xavier Y. Diao, Bradley S. Taylor, Eddy D Zandee van Rilland, Nathaniel Foster, Mehrdad Ghoreishi, Patrick Stafford, James S. Gammie, and Gerald R. Hobbs
- Subjects
Male ,Pulmonary and Respiratory Medicine ,Aortic valve ,medicine.medical_specialty ,Tricuspid stenosis ,Regurgitation (circulation) ,030204 cardiovascular system & hematology ,Dehiscence ,Cardiac Valve Annuloplasty ,03 medical and health sciences ,0302 clinical medicine ,Tricuspid Valve Insufficiency ,Mitral valve ,Humans ,Medicine ,Aged ,Aged, 80 and over ,business.industry ,Perioperative ,Middle Aged ,Surgery ,medicine.anatomical_structure ,030228 respiratory system ,Female ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background Previous clinical experiences have demonstrated high early and late recurrence rates after repair of functional tricuspid regurgitation (TR). We investigated the results of functional TR repair with undersized rigid nonplanar annuloplasty rings. Methods From January 2007 to December 2013, 216 consecutive patients with moderate or greater functional TR were treated with undersized (size 26 mm or 28 mm) rigid nonplanar annuloplasty rings. Results The mean age was 69 ± 13 years. There was a previous history of cardiac operation in 25% (54 of 216 patients). Tricuspid regurgitation was graded as severe in 47% (102 of 216) and moderate in 53% (114 of 216). Concomitant operations included mitral valve procedures in 92% (198 of 216), coronary artery bypass grafting in 21% (45 of 216), aortic valve procedures in 9% (20 of 216), and cryomaze procedures in 35% (76 of 216). Size 26 mm rings were used in 38% of patients (81 of 216), and size 28 mm in 62% (135 of 216). The perioperative mortality rate was 6% (14 of 216). On predischarge echocardiography, TR grade was none or mild in 94% (176 of 187 patients), moderate in 4% (7 of 187), and severe in 2% (4 of 187). At a mean follow-up of 33.0 ± 24.0 months, TR grade was none or mild in 81% of patients (130 of 160), moderate in 16% (26 of 160), and severe in 2% (4 of 160). There were no reoperations for recurrent TR, and no patients have had tricuspid stenosis or annuloplasty ring dehiscence. Conclusions Treatment of functional TR with undersized (26 mm or 28 mm) nonplanar rigid annuloplasty rings is safe and highly effective, with a near absence of recurrent severe TR at midterm follow-up.
- Published
- 2016
49. Contemporary Outcomes of Operations for Tricuspid Valve Infective Endocarditis
- Author
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Faisal H. Cheema, Bartley P. Griffith, Murtaza Y. Dawood, Robert Villanueva, Nathaniel Foster, Mehrdad Ghoreishi, James S. Gammie, and Rawn Salenger
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Adult ,Male ,Pulmonary and Respiratory Medicine ,medicine.medical_specialty ,medicine.medical_treatment ,Heart Valve Diseases ,Young Adult ,medicine ,Humans ,Endocarditis ,Aged ,Retrospective Studies ,Tricuspid valve ,business.industry ,Retrospective cohort study ,Endocarditis, Bacterial ,Middle Aged ,medicine.disease ,Surgery ,Treatment Outcome ,medicine.anatomical_structure ,Concomitant ,Bacteremia ,Infective endocarditis ,Patent foramen ovale ,Female ,Tricuspid Valve ,Hemodialysis ,Cardiology and Cardiovascular Medicine ,business - Abstract
Background Tricuspid valve infective endocarditis (TVIE) is uncommon. Patients are traditionally treated with antibiotics alone, and indications for operation are not clearly established. We report our operative single-center experience. Methods We retrospectively reviewed 56 patients who underwent operations for TVIE between January 2002 and December 2012. Results Methicillin-resistant Staphylococcus aureus was present in 41% of patients, septic pulmonary emboli in 63%, moderate/severe tricuspid regurgitation in 66%, and 86% were intravenous drug abusers. Patients underwent early operation if there was concomitant left-sided endocarditis with indications for operation (n = 18), atrial septal defect (n = 6), infected pacemaker lead (n = 4), or prosthetic TVIE (n = 1). The remaining 27 patients were treated with intravenous antibiotics. Five patients completed a 6-week course of intravenous antibiotics before requiring an operation for symptomatic severe tricuspid regurgitation or persistent bacteremia. Twenty-two patients did not complete the antibiotic therapy and underwent operation for symptomatic severe tricuspid regurgitation (n = 15), persistent fevers/bacteremia (n = 3), or patient-specific factors (n = 4). Valve repair was successful in 57% of patients. Overall operative mortality was 7.1%. No operative deaths occurred in patients with isolated native TVIE. Recurrent TVIE was diagnosed in 21% (5 of 24) of the replacement group and in 0% (0 of 32) in the repair group. Use of repair was strongly protective against recurrent TVIE ( p Conclusions In contrast to previously published reports of high operative mortality with TVIE, this experience demonstrates improved outcomes with low morbidity and mortality, particularly for native isolated TVIE. Future prospective comparisons between surgically and medically treated patients may help to further define indications and timing for operation for patients with TVIE.
- Published
- 2015
50. Peripheral Distribution of Thrombus Does Not Affect Outcomes After Surgical Pulmonary Embolectomy
- Author
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Francis Brigante, Chetan Pasrija, Mehrdad Ghoreishi, James S. Gammie, Aakash Shah, Bartley P. Griffith, Jean Jeudy, Isa Mohammed, Bradley S. Taylor, Praveen George, and Zachary N. Kon
- Subjects
Pulmonary and Respiratory Medicine ,Adult ,Male ,medicine.medical_specialty ,Computed Tomography Angiography ,Operative Time ,030204 cardiovascular system & hematology ,Embolectomy ,Pulmonary Artery ,Single Center ,Risk Assessment ,Severity of Illness Index ,Cohort Studies ,03 medical and health sciences ,0302 clinical medicine ,Internal medicine ,medicine ,Humans ,Hospital Mortality ,Thrombus ,Survival rate ,Contraindication ,Computed tomography angiography ,Aged ,Retrospective Studies ,Academic Medical Centers ,medicine.diagnostic_test ,business.industry ,Retrospective cohort study ,Length of Stay ,Middle Aged ,medicine.disease ,Prognosis ,Pulmonary embolism ,Peripheral ,Survival Rate ,Treatment Outcome ,030228 respiratory system ,Cardiology ,Surgery ,Female ,Cardiology and Cardiovascular Medicine ,business ,Pulmonary Embolism - Abstract
Thrombus located distal to the main or primary pulmonary arteries has been previously viewed as a relative contraindication to surgical pulmonary embolectomy. We compared outcomes for surgical pulmonary embolectomy for submassive and massive pulmonary embolism (PE) in patients with central vs peripheral thrombus burden.All consecutive patients (2011 to 2016) undergoing surgical pulmonary embolectomy at a single center were retrospectively reviewed. Computed tomography angiography of each patient was used to define central PE as any thrombus originating within the lateral pericardial borders (main or right/left pulmonary arteries). Peripheral PE was defined as thrombus exclusively beyond the lateral pericardial borders, involving the lobar pulmonary arteries or distal. The primary outcome was in-hospital and 90-day survival.We identified 70 patients: 52 (74%) with central PE and 18 (26%) with peripheral PE. Preoperative vital signs and right ventricular dysfunction were similar between the two groups. Compared with the central PE cohort, operative time was significantly longer in the peripheral PE group (191 vs 210 minutes, p0.005). Median right ventricular dysfunction decreased from moderate dysfunction preoperatively to no dysfunction at discharge in both groups. Overall 90-day survival was 94%, with 100% survival in patients with submassive PE in both cohorts.This single-center experience demonstrates excellent overall outcomes for surgical pulmonary embolectomy, with resolution of right ventricular dysfunction and comparable morbidity and mortality for central and peripheral PE. In an experienced center and when physiologically warranted, surgical pulmonary embolectomy for peripheral distribution of thrombus is technically feasible and effective.
- Published
- 2017
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