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1.
J Surg Res ; 292: 91-96, 2023 12.
Artigo em Inglês | MEDLINE | ID: mdl-37597454

RESUMO

INTRODUCTION: Few known risk factors for certain surgical complications are prospectively analyzed to ascertain their influence on outcomes. Health systems can use integrated machine-learning-derived algorithms to provide information regarding patients' risk status in real time and pair this data with interventions to improve outcomes. The purpose of this work was to evaluate whether real-time knowledge of patients' calculated risk status paired with a stratified intervention was associated with a reduction in acute kidney injury and 30-d readmission following colorectal surgery. METHODS: Unblinded, retrospective study, evaluating the impact of an electronic health record-integrated and autonomous algorithm-based clinical decision support tool (KelaHealth, San Francisco, California) on acute kidney injury and 30-d readmission following colorectal surgery at a single academic medical center between January 1, 2020, and December 31, 2020, relative to a propensity-matched historical cohort (2014-2018) prior to algorithm integration (January 11, 2019). RESULTS: 3617 patients underwent colorectal surgery during the control period and 665 underwent surgery during the treatment period; 1437 historical control patients were matched to 479 risk-based patients for the study. Utilization of the risk-based management platform was associated with a 2.5% decrease in the rate of acute kidney injury (11.3% to 8.8%) and 3.1% decrease in rate of readmissions (12% to 8.9%). CONCLUSIONS: In this study, we found significant reductions in postoperative acute kidney injury (AKI) and unplanned readmissions after the implementation of an algorithm based clinical decision support tool that risk-stratified populations and offered stratified interventions. This opens up an opportunity for further investigation in translating similar risk platform approaches across surgical specialties.


Assuntos
Injúria Renal Aguda , Cirurgia Colorretal , Procedimentos Cirúrgicos do Sistema Digestório , Humanos , Readmissão do Paciente , Estudos Retrospectivos , Cirurgia Colorretal/efeitos adversos , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/epidemiologia , Injúria Renal Aguda/etiologia , Procedimentos Cirúrgicos do Sistema Digestório/efeitos adversos , Fatores de Risco , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle
2.
J Pediatr ; 190: 163-168.e4, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-29144241

RESUMO

OBJECTIVES: To update previously described trends for neonates with congenital diaphragmatic hernia (CDH) receiving ECMO with changes in recommendations for care, and to determine how recent advancements in respiratory care have affected this patient population. STUDY DESIGN: This study is a retrospective review of more than 2500 neonates with CDH who received ECMO listed in the Extracorporeal Life Support Organization (ELSO) registry. Cochran-Armitage and multivariate regression analyses were used to analyze changes in the patient population over time and in mortality-related risk factors. RESULTS: Almost one-half (48.1%) of the term neonates survived to discharge, representing a 13.8% decline in survival over the past 25 years (P < .0001). Over the past 10 years, the prevalence of respiratory acidosis more than doubled (P < .0001) and the prevalence of major complications increased (P < .001). During the same period, the number of ECMO courses longer than 1 week increased (P < .001), whereas the prevalence of multiple complications (>4) decreased (P < .0001). Surgeries performed on ECMO were associated with worse outcomes than those performed off ECMO. ECMO duration no longer represents a mortality-related risk factor. CONCLUSIONS: Survival rates for neonates with CDH receiving ECMO have continued to drop in the modern era. Although the safety of ECMO has improved over the last decade, the number of patients experiencing significant respiratory acidosis has more than doubled-increasing the risk of intracranial hemorrhage and overall mortality. The evidence for permissive hypercapnia remains mixed; nonetheless, we believe that the risks outweigh the rewards in this patient population.


Assuntos
Oxigenação por Membrana Extracorpórea , Hérnias Diafragmáticas Congênitas/terapia , Oxigenação por Membrana Extracorpórea/efeitos adversos , Feminino , Hérnias Diafragmáticas Congênitas/mortalidade , Humanos , Recém-Nascido , Modelos Logísticos , Masculino , Análise Multivariada , Sistema de Registros , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Resultado do Tratamento
3.
Am J Respir Cell Mol Biol ; 52(6): 683-94, 2015 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-25317669

RESUMO

Mucociliary clearance (MCC) and submucosal glands are major components of airway innate immunity that have impaired function in cystic fibrosis (CF). Although both of these defense systems develop postnatally in the ferret, the lungs of newborn ferrets remain sterile in the presence of a functioning cystic fibrosis transmembrane conductance regulator gene. We evaluated several components of airway innate immunity and inflammation in the early CF ferret lung. At birth, the rates of MCC did not differ between CF and non-CF animals, but the height of the airway surface liquid was significantly reduced in CF newborn ferrets. CF ferrets had impaired MCC after 7 days of age, despite normal rates of ciliogenesis. Only non-CF ferrets eradicated Pseudomonas directly introduced into the lung after birth, whereas both genotypes could eradicate Staphylococcus. CF bronchoalveolar lavage fluid (BALF) had significantly lower antimicrobial activity selectively against Pseudomonas than non-CF BALF, which was insensitive to changes in pH and bicarbonate. Liquid chromatography-tandem mass spectrometry and cytokine analysis of BALF from sterile Caesarean-sectioned and nonsterile naturally born animals demonstrated CF-associated disturbances in IL-8, TNF-α, and IL-ß, and pathways that control immunity and inflammation, including the complement system, macrophage functions, mammalian target of rapamycin signaling, and eukaryotic initiation factor 2 signaling. Interestingly, during the birth transition, IL-8 was selectively induced in CF BALF, despite no genotypic difference in bacterial load shortly after birth. These results suggest that newborn CF ferrets have defects in both innate immunity and inflammatory signaling that may be important in the early onset and progression of lung disease in these animals.


Assuntos
Regulador de Condutância Transmembrana em Fibrose Cística/genética , Fibrose Cística/imunologia , Animais , Animais Recém-Nascidos , Fibrose Cística/genética , Fibrose Cística/metabolismo , Regulador de Condutância Transmembrana em Fibrose Cística/metabolismo , Citocinas/metabolismo , Furões , Técnicas de Inativação de Genes , Imunidade Inata , Mediadores da Inflamação/metabolismo , Depuração Mucociliar , Proteoma/metabolismo , Infecções por Pseudomonas/imunologia , Infecções por Pseudomonas/microbiologia , Pseudomonas aeruginosa/imunologia , Traqueia/patologia
4.
Ann Thorac Surg ; 115(6): 1520-1525, 2023 06.
Artigo em Inglês | MEDLINE | ID: mdl-35643332

RESUMO

BACKGROUND: Value-based bundles require surgeons to understand their costs. Current approaches to cost reporting are confusing and difficult to reproduce. Using the Epic surgical receipt function, we describe an intuitive and systematic approach for evaluating financial data within the operating room. METHODS: We conducted a retrospective review of all congenital cardiac procedures performed at a single academic medical center between January 1, 2020, and January 1, 2021. Direct operating room supply costs were obtained using the Epic surgical receipt function. Costs were analyzed on the basis of contribution to total annual cost and variability in case cost. Implications for strategies identified within congenital cardiac surgery were then evaluated in adult cardiac surgery. RESULTS: Five procedures representing 71 patients accounted for more than 50% of the total direct operating room supply costs (left ventricular assist device, Norwood procedure, pulmonary valve replacement, right ventricle-to-pulmonary artery shunt, and aortic arch augmentation). Disposable vascular clips, suture brand preference, and surgical patch materials accounted for 3.7%, 6.6%, and 26.5% of annual direct operating room supply costs, respectively. Improvements to these categories would represent 12% to 14% ($250 000) in annual savings without an anticipated effect on outcomes. Across adult and congenital cardiac surgery, 95% of all name-brand suture use was tied to preference cards. An opt-in vs default approach to name-brand polypropylene suture could save more than $250 000 annually. CONCLUSIONS: The surgical receipt represents a reliable and intuitive way for reporting surgical costs. Systematically analyzing costs and their impact on outcomes will help surgeons improve the value of care they provide.


Assuntos
Procedimentos Cirúrgicos Cardíacos , Cirurgiões , Adulto , Humanos , Salas Cirúrgicas , Procedimentos Neurocirúrgicos , Redução de Custos
5.
JTCVS Open ; 15: 394-405, 2023 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-37808016

RESUMO

Objectives: To develop a more holistic measure of center performance than operative mortality, we created a composite "textbook outcome" for the Norwood operation using several postoperative end points. We hypothesized that achieving the textbook outcome would have a positive prognostic and financial impact. Methods: This was a single-center retrospective study of primary Norwood operations from 2005 to 2021. Through interdisciplinary clinician consensus, textbook outcome was defined as freedom from operative mortality, open or catheter-based reintervention, 30-day readmission, extracorporeal membrane oxygenation, cardiac arrest, reintubation, length of stay >75%ile from Society of Thoracic Surgeons data report (66 days), and mechanical ventilation duration >75%ile (10 days). Multivariable logistic regression and Cox proportional hazards modeling were used to determine predictive factors for textbook outcome achievement and association of the outcome with long-term survival, respectively. Results: Overall, 30% (58/196) of patients met the textbook outcome. Common reasons for failure to attain textbook outcome were prolonged ventilation (68/138, 49%) and reintubation (63/138, 46%). In multivariable analysis, greater weight (odds ratio [OR], 2.11; 95% confidence interval [CI], 1.17-3.95; P = .02) was associated with achieving the textbook outcome whereas preoperative shock (OR, 0.36; 95% CI, 0.13-0.87; P = .03) and longer bypass time (OR, 0.99; 95% CI, 0.98-1.00; P = .002) were negatively associated. Patients who met the outcome incurred fewer hospital costs ($152,430 [141,798-177,983] vs $269,070 [212,451-372,693], P < .001), and after adjusting for patient factors, achieving textbook outcome was independently associated with decreased risk of all-cause mortality (hazard ratio, 0.45; 95% CI, 0.22-0.89; P = .02). Conclusions: Outcomes continue to improve within congenital heart surgery, making operative mortality a less-sensitive metric. The Norwood textbook outcome may represent a balanced measure of a successful episode of care.

6.
Semin Thorac Cardiovasc Surg ; 35(1): 140-147, 2023.
Artigo em Inglês | MEDLINE | ID: mdl-35176496

RESUMO

We developed a technique for the Norwood operation utilizing continuous perfusion of the head, heart, and lower body at mild hypothermia named Sustained Total All-Region (STAR) perfusion. We hypothesized that STAR perfusion would be associated with shorter operative times, decreased coagulopathy, and expedited post-operative recovery compared to standard perfusion techniques. Between 2012 and 2020, 80 infants underwent primary Norwood reconstruction at our institution. Outcomes for patients who received successful STAR perfusion (STAR, n = 37) were compared to those who received standard Norwood reconstruction utilizing regional cerebral perfusion only (SNR, n = 33), as well as to Norwood patients reported in the PC4 national database during the same timeframe (n = 1238). STAR perfusion was performed with cannulation of the innominate artery, descending aorta, and aortic root at 32-34°C. STAR patients had shorter median CPB time compared to SNR (171 vs 245 minutes, P < 0.0001), shorter operative time (331 vs 502 minutes, P < 0.0001), and decreased intraoperative pRBC transfusion (100 vs 270 mL, P < 0.0001). STAR patients had decreased vasoactive-inotropic score on ICU admission (6 vs 10.8, P = 0.0007) and decreased time to chest closure (2 vs 4.5 days, P = 0.0004). STAR patients had lower peak lactate (8.1 vs 9.9 mmol/L, P = 0.03) and more rapid lactate normalization (18.3 vs 27.0 hours, P = 0.003). In-hospital mortality in STAR patients was 2.7% vs 15.1% with SNR (P = 0.06) and 10.3% in the PC4 aggregate (P = 0.14). STAR perfusion is a novel approach to Norwood reconstruction associated with excellent survival, decreased transfusions, shorter operative time, and improved convalescence in the early post-operative period.


Assuntos
Aorta , Procedimentos de Norwood , Lactente , Humanos , Resultado do Tratamento , Perfusão/métodos , Procedimentos de Norwood/métodos , Ácido Láctico
7.
Cardiol Clin ; 40(1): 89-101, 2022 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-34809920

RESUMO

Chronic thromboembolic pulmonary hypertension is a progressive disease, which may lead to severe right ventricular dysfunction and debilitating symptoms. Pulmonary thromboendarterectomy (PTE) provides the best opportunity for complete resolution of obstructing thromboembolic disease and functional improvement in appropriately selected patients. In this article, the authors review preoperative workup, patient selection, operative technique, postoperative care, and outcomes after PTE.


Assuntos
Hipertensão Pulmonar , Embolia Pulmonar , Disfunção Ventricular Direita , Doença Crônica , Endarterectomia , Humanos , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/cirurgia , Embolia Pulmonar/complicações , Embolia Pulmonar/cirurgia
8.
Innovations (Phila) ; 17(4): 358-360, 2022.
Artigo em Inglês | MEDLINE | ID: mdl-35770608

RESUMO

Cardiac hemangiomas are a rare tumor traditionally resected by median sternotomy. We performed a minimally invasive right ventricular cardiac hemangioma resection via a left anterior mini-incision (LAMI). The procedure was without complication, and the patient was discharged on postoperative day 2. The LAMI has been used broadly by our team for operations involving the right ventricular outflow tract, as an alternative to median sternotomy. Here we show that it can also be used for the resection of a cardiac tumor.


Assuntos
Neoplasias Cardíacas , Hemangioma , Adolescente , Neoplasias Cardíacas/diagnóstico por imagem , Neoplasias Cardíacas/cirurgia , Hemangioma/diagnóstico por imagem , Hemangioma/cirurgia , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Esternotomia/métodos , Toracotomia/métodos , Resultado do Tratamento
9.
J Thorac Cardiovasc Surg ; 164(6): e411-e424, 2022 12.
Artigo em Inglês | MEDLINE | ID: mdl-33933257

RESUMO

BACKGROUND: Galactose-α-1,3-galactose (alpha-gal) is a carbohydrate that is ubiquitously expressed in all mammals except for primates and humans. Patients can become sensitized to this antigen and develop alpha-gal syndrome (AGS), or a red meat allergy. Symptoms range from generalized gastroenteritis and malaise to anaphylaxis, and in endemic areas, the prevalence can be as high as 20%. Although AGS patients commonly avoid alpha-gal by avoiding meat, patients have also developed symptoms due to animal-derived medical products and devices. With the rise in transcatheter aortic valve replacement, we investigate the immunogenicity of common cardiac materials and valves. OBJECTIVE: To assess the in vitro immunoglobulin E response toward common medical products, including cardiac patch materials and bioprosthetic valves in patients with AGS. METHODS: Immunoblot and immunohistochemistry techniques were applied to assess immunoglobulin E reactivity to various mammalian derived tissues and medical products for patients with AGS. RESULTS: AGS serum showed strong reactivity to all of the commercially available, nonhuman products tested, including various decellularized cardiac patch materials and bioprosthetic aortic valves. AGS serum did not react to tissues prepared using alpha-gal knockout pigs. CONCLUSIONS: Despite commercial decellularization processes, alpha-gal continues to be present in animal-derived medical products, including bioprosthetic valves. Serum from patients with AGS demonstrates a strong affinity for these products in vitro. This may have serious potential implications for sensitized patients undergoing cardiac surgery, including early valve failure and accelerated coronary artery disease.


Assuntos
Anafilaxia , Hipersensibilidade Alimentar , Humanos , Suínos , Animais , Galactose , Imunoglobulina E , Anafilaxia/diagnóstico , Síndrome , Mamíferos
10.
J Thorac Dis ; 13(11): 6587-6593, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34992837

RESUMO

Chronic lung allograft dysfunction remains the leading cause of long-term morbidity and mortality for lung transplant recipients. Lung retransplantation currently represents the only therapeutic option for patients for refractory allograft dysfunction. However, debate remains regarding both the efficacy and ethicality of lung retransplantation in light of the shortage of lung allografts. The aim of this review is to discuss the available literature on lung retransplantation in the current era. Through this we hope to provide insight into ideal patient selection, donor organ selection, surgical approaches, and future considerations within the field in order to improve outcomes and best address organ utilization while a waitlist continues to exist. Lung retransplantation in select patients can offer comparable survival outcomes to primary lung transplantation. However, several risk factors including retransplantation with the first year of primary transplantation, older age, poor functional status, and ICU level requirements prior to transplantation are associated with worsened outcomes. Donor organ selection considerations are comparable to those in primary lung transplantation. However, surgical approach is often impacted by dense pleural and mediastinal adhesions in the recipient which increase the complexity of the hilar dissection. The postoperative course is often more complex for patients undergoing retransplantation compared to those undergoing primary lung transplant as well. However, pending more data on long term outcomes in lung retransplantation and the potential impact of retransplant recipients on waitlist mortality, lung retransplantation should remain in use primarily for the treatment of chronic graft dysfunction in carefully selected patients.

11.
J Thorac Dis ; 13(10): 5818-5825, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-34795930

RESUMO

BACKGROUND: Cardiac surgery is a technically demanding field with an appreciable learning curve that extends beyond formal training. Minimally invasive congenital cardiac surgery has one of the steepest learning curves. Early complications often discourage surgeons, particularly those at lower volume centers, from pursuing innovative approaches. Over the past three years, we have utilized a number of minimally invasive approaches including pulmonary valve replacement, anomalous aortic origin coronary artery repair, atrial septal defect repair, epicardial lead placement, and partial anomalous pulmonary venous return. Herein we report on our experience performing minimally invasive congenital cardiac surgery, lessons learned, and how our approach has evolved. METHODS: We performed a single institution, retrospective review, wherein continuous variables were reported as median (interquartile range). RESULTS: Between September 2017 and May 2020, minimally invasive approaches were attempted on 49 patients with a median age of 19 years (14-47 years) for nine distinct congenital cardiac diagnoses. Seven patients (14%) required conversion to larger incisions, including four patients or 36% of those undergoing anomalous aortic origin of a coronary artery repair. Patients who were converted had a higher body mass index 33.1 (31.7-37.8) than those who were not (24.2, 20.8-29.3) (P=0.009). CONCLUSIONS: Minimally invasive approaches for congenital cardiac conditions require a team approach. Patients with a body mass index greater than 30 should be counseled on the higher rate of conversion. We no longer perform minimally invasive anomalous aortic origin of a coronary artery repair given the high rate of conversions and complications. Surgeons attempting this procedure should do so cautiously.

12.
World J Pediatr Congenit Heart Surg ; 12(6): 790-793, 2021 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-34353178

RESUMO

We report a case of an 18-year-old female who presented with severe aortic stenosis and insufficiency, eight years following resection of a subaortic membrane. On echocardiography, she was found to have a completely fused or nullicuspid valve, with three equal sinuses and three commissural fusions. Aortic valve repair included leaflet tricuspidization, three commissurotomies, trileaflet ring annuloplasty, and pericardial leaflet reconstruction. At one year follow-up, the patient is asymptomatic, with stable gradients.


Assuntos
Insuficiência da Valva Aórtica , Anuloplastia da Valva Cardíaca , Adolescente , Valva Aórtica/diagnóstico por imagem , Valva Aórtica/cirurgia , Feminino , Humanos , Valva Mitral
13.
Innovations (Phila) ; 16(5): 480-484, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34338072

RESUMO

OBJECTIVE: The benefits of minimally invasive adult cardiac surgery are well established. Nevertheless, minimally invasive congenital cardiac procedures, even for adult patients, are uncommon. In 2018, we started repairing anomalous aortic origin of a coronary artery (AAOCA) through a 5 cm anterior minithoracotomy when possible to improve cosmesis and avoid sternal precautions. We hypothesized this approach was safe and reliable. METHODS: A 5 cm incision was made in the right second intercostal space. The incision was carried down to the pericardium while preserving the internal mammary artery. With the pericardium in view, the second and third ribs were disarticulated. Central cardiopulmonary bypass was established, and the repair was carried out based on the patient's anatomy. The technique was modified to a left anterior minithoracotomy for 1 patient who required pulmonary artery translocation. At any point, if the dissection or repair was not progressing appropriately, the minimally invasive exposure was converted to a partial or traditional median sternotomy. RESULTS: Between June 2018 and June 2019, 11 patients underwent minimally invasive anomalous coronary repair. Four patients (3 with body mass index >30) were converted to traditional sternotomy due to poor visualization. Postoperatively, 1 patient required coronary artery bypass after 335 days, due to extensive collaterals and stable angina. Otherwise, at a median follow-up of 437 days (IQR 340 to 480), patients had resumed baseline activity without recurrent symptoms. CONCLUSIONS: Minimally invasive AAOCA repair may be appealing, although surgeons should be cautious given the high conversion rate.


Assuntos
Vasos Coronários , Artéria Torácica Interna , Adulto , Aorta , Ponte de Artéria Coronária , Vasos Coronários/cirurgia , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos , Toracotomia
14.
Innovations (Phila) ; 15(2): 111-113, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32352907

RESUMO

A 12-year-old, 32 kg male with history of Tetralogy of Fallot status post repair at 8 days of life presented with progressive pulmonary insufficiency and left pulmonary artery stenosis. Surgical options were discussed, and the patient and his family elected to pursue minimally invasive pulmonary valve replacement with left pulmonary artery augmentation through a 5-cm left anterior mini-incision. The procedure was performed without complication, and he was discharged on postoperative day 3. At the time of his last follow-up, the patient was recovering well without evidence of pulmonary stenosis or insufficiency.


Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Insuficiência da Valva Pulmonar/cirurgia , Estenose de Artéria Pulmonar/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Criança , Ecocardiografia Doppler/métodos , Implante de Prótese de Valva Cardíaca/métodos , Humanos , Masculino , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/etiologia , Estenose de Artéria Pulmonar/diagnóstico por imagem , Ferida Cirúrgica/classificação , Tetralogia de Fallot/complicações , Tetralogia de Fallot/cirurgia , Resultado do Tratamento
15.
Innovations (Phila) ; 15(2): 101-105, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32352905

RESUMO

The majority of congenital and adult cardiac surgery is performed through a median sternotomy. For surgeons, this incision provides excellent exposure; however, for patients, a median sternotomy confers a poorer cosmetic outcome and the possibility of postoperative respiratory dysfunction, chronic pain, and deep sternal wound infections. Despite the advances in adult cardiac surgery, the use of minimally invasive techniques in pediatric patients is largely limited to small case series and less complex repairs. In this article, we review the risks, benefits, and limitations of the minimally invasive congenital cardiac approaches being performed today. The interest in these approaches continues to grow as more data supporting reduced morbidity, decreased length of stay, and faster recovery are published. In the future, as the technology and surgical familiarity improve, these alternative approaches will become more common, and may someday become the standard of care.


Assuntos
Procedimentos Cirúrgicos Cardíacos/métodos , Cardiopatias Congênitas/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/efeitos adversos , Cirurgiões/estatística & dados numéricos , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Procedimentos Cirúrgicos Minimamente Invasivos/estatística & dados numéricos , Morbidade , Complicações Pós-Operatórias/epidemiologia , Recuperação de Função Fisiológica , Segurança , Cirurgia Torácica Vídeoassistida/efeitos adversos , Toracotomia/efeitos adversos , Resultado do Tratamento
16.
Innovations (Phila) ; 15(2): 106-110, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32352906

RESUMO

Pulmonary insufficiency is a known complication following Tetralogy of Fallot repair. With over 90% of patients now surviving to adulthood, surgeons are once again faced with the question of when, and more importantly, how to reintervene. We developed a novel approach to pulmonary valve replacement in this population through a 5-cm left anterior mini-incision. The incision is optimized for exposing and operating on the right ventricular outflow tract and the main pulmonary artery in patients with a history of median sternotomy. Early outcomes are reassuring, and we believe our approach is a safe and reliable alternative to median sternotomy within this patient population, with the ability to quickly convert intraoperatively when needed.


Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Insuficiência da Valva Pulmonar/cirurgia , Valva Pulmonar/cirurgia , Tetralogia de Fallot/cirurgia , Adolescente , Adulto , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Criança , Implante de Prótese de Valva Cardíaca , Humanos , Pessoa de Meia-Idade , Complicações Pós-Operatórias/epidemiologia , Valva Pulmonar/fisiopatologia , Insuficiência da Valva Pulmonar/etiologia , Reoperação/estatística & dados numéricos , Esternotomia/métodos , Ferida Cirúrgica/classificação , Tetralogia de Fallot/complicações , Resultado do Tratamento , Adulto Jovem
17.
Innovations (Phila) ; 14(6): 577-580, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31739722

RESUMO

Pulmonary fibroelastomas are a rare primary cardiac tumor with less than 50 cases reported in the literature to date. We performed a minimally invasive valve-sparing tumor resection through a left anterior mini-incision (LAMI). The procedure was performed without cardiac arrest or aortic cross clamp, expediting postoperative recovery and allowing for an uncomplicated discharge on postoperative day 5. LAMI is a safe and reliable alternative to median sternotomy for patients requiring interventions on the right ventricular outflow tract and main pulmonary artery, including pulmonary fibroelastoma resection and pulmonary valve replacement when needed.


Assuntos
Fibroma/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Artéria Pulmonar/cirurgia , Insuficiência da Valva Pulmonar/cirurgia , Procedimentos Cirúrgicos Cardíacos/tendências , Ponte Cardiopulmonar/normas , Cateterismo/métodos , Ecocardiografia/métodos , Feminino , Artéria Femoral/cirurgia , Fibroma/patologia , Doenças das Valvas Cardíacas/patologia , Doenças das Valvas Cardíacas/cirurgia , Humanos , Imageamento por Ressonância Magnética/métodos , Pessoa de Meia-Idade , Insuficiência da Valva Pulmonar/diagnóstico por imagem , Insuficiência da Valva Pulmonar/patologia , Toracotomia/métodos , Resultado do Tratamento
19.
Innovations (Phila) ; 13(6): 455-457, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30540590

RESUMO

Traditionally, pacing leads are placed transvenously, although smaller pediatric patients who require permanent pacemakers may benefit from delaying tranvenous lead placement until they are larger. Alternative, minimally invasive atrioventricular pacing options have not previously existed for this patient population, leaving many of these children with large sternotomies or thoracotomies. Using three port sites and an adjustable shaft dual-needle suturing device, we placed a steroid-eluting, sew-on epicardial lead on the right atrium of a 9-year-old patient. This is one of the earliest reported cases of a minimally invasive technique for sew-on epicardial lead placement on the atrium of a child. Although based on a single case, we believe that this approach is safe, reliable, and reproducible and that it can be used to place leads on any aspect of the heart. Adoption of this technique will allow for earlier atrioventricular pacing, which may decrease the incidence of pacemaker syndrome, and thus improve overall outcomes in this patient population.


Assuntos
Cardiopatias Congênitas/cirurgia , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Marca-Passo Artificial , Implantação de Prótese/métodos , Criança , Eletrodos Implantados , Feminino , Humanos
20.
Innovations (Phila) ; 12(2): 109-115, 2017.
Artigo em Inglês | MEDLINE | ID: mdl-28346262

RESUMO

OBJECTIVE: Numerous surgical approaches regarding aortic arch advancement for neonatal arch hypoplasia have been described. These repairs can be classified into two categories: those that incorporate a patch and those that do not. The decision between repairs remains largely experiential, rather than empirical, because of the limited number of reported outcomes. We report early outcomes from neonates undergoing modified aortic arch advancement with an anterior patch and our experience using computational fluid dynamic modeling to better understand the hemodynamic consequences associated with this repair. METHODS: A retrospective review of neonates undergoing aortic arch advancement with anterior patch in 2014 at a single institution was performed. Anatomical, perioperative, and follow-up data were collected. Three-dimensional cardiac magnetic resonance images were used to generate computational fluid dynamic models of the modified anterior patch and direct end-to-side repairs. Cardiac waveform inputs were simulated and hemodynamic analyzed. RESULTS: Ten neonates underwent modified aortic arch advancement. No hemodynamically significant gradients were observed at a median follow-up of 0.77 (0.30-1.2) years. Asymmetrical flow was observed in the end-to-side repair, whereas more concentric laminar flow was observed throughout the modified model. Spatial variations in velocities immediately distal to the anastomosis were greater in the end-to-side model (0.35 vs 0.17 m/s, P < 0.001). Time-averaged variations in wall shear stress during systole were greater in the end-to-side model at the same location (3.44 vs 1.98 dynes/cm, P < 0.001). CONCLUSIONS: Early outcomes after the use of an anterior patch for neonatal hypoplastic aortic arch repair show favorable hemodynamic outcomes.


Assuntos
Aorta Torácica/diagnóstico por imagem , Doenças da Aorta/congênito , Doenças da Aorta/cirurgia , Procedimentos Cirúrgicos Cardíacos/métodos , Procedimentos Cirúrgicos Vasculares , Aorta Torácica/anormalidades , Aorta Torácica/cirurgia , Doenças da Aorta/diagnóstico por imagem , Feminino , Hemodinâmica , Humanos , Imageamento Tridimensional , Recém-Nascido , Imagem Cinética por Ressonância Magnética/métodos , Masculino , Modelos Anatômicos , Estudos Retrospectivos , Resultado do Tratamento , Procedimentos Cirúrgicos Vasculares/métodos , Recursos Humanos
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