Emergency resternotomy in the intensive care unit (ICU) is a rarely performed, yet potentially li... more Emergency resternotomy in the intensive care unit (ICU) is a rarely performed, yet potentially life-saving intervention. Success relies on recognition of a deteriorating clinical condition, timely deployment of equipment/personnel and rapid execution. Given how infrequently it is performed, we sought to develop a large animal model of resternotomy to prepare ICU nurses and technicians at our low-volume cardiac surgery military centre. A porcine model of resternotomy was developed at the end of an already-scheduled trauma lab. Participants worked their way through a pre-planned simulation scenario, culminating in the need for resternotomy. Pre-simulation surveys assessing knowledge and comfort level with aspects of resternotomy were compared to post-simulation surveys. Participants improved their knowledge of resternotomy by 20.4% (P < 0.0001; 14.7% for nurses and 26.9% for technicians). Improvements were seen in all aspects assessed relating to subjective comfort/preparedness of ...
Seminars in Thoracic and Cardiovascular Surgery, 2020
Iatrogenic coronary injury after mitral repair is related to blind annuloplasty suture ligation o... more Iatrogenic coronary injury after mitral repair is related to blind annuloplasty suture ligation or kinking of the circumflex artery (CxA) and can present with early ST segment changes, malignant ventricular arrhythmias and segmental wall motion abnormalities. Corrective treatment is imperative to avoid myocardial infarction and can include removal of the annuloplasty ring or CxA bypass. We present a novel hybrid approach for the rapid diagnosis and management of iatrogenic CxA injury after mitral repair.
Atrial septal defect (ASD) repair has been conventionally performed via midline sternotomy with v... more Atrial septal defect (ASD) repair has been conventionally performed via midline sternotomy with very low operative risk and excellent early and late outcomes. Recently, many of these patients with suitable anatomy are being treated with percutaneous catheter-based closure of their ASD, but issues of prosthetic device implantation, long-term antiplatelet therapy and late device complications persist. Minimally invasive repair of ASD via a 3-cm right minithoracotomy provides patients with a much less invasive surgical repair with all the durable benefits of autologous pericardial patch closure. However, widespread adoption of the minithoracotomy approach to ASD closure remains slow. This study describes the simple steps to ASD repair via a right minithoracotomy.
Arteriosclerosis, Thrombosis, and Vascular Biology, May 1, 2016
Introduction: Ascertaining the biological age of patients with advanced vascular disease could ad... more Introduction: Ascertaining the biological age of patients with advanced vascular disease could advance risk assessment and management. The extent to which telomeres shorten in leukocytes could be a marker of biological age because it reflects the accumulation of replication stresses imposed on leukocyte progenitors. However, because of wide, genetic variability in leukocyte telomere length (TL), a single leukocyte TL measurement does not reliably indicate telomere shortening. Hypothesis: We hypothesized that the difference in length of telomeres in “non-replicating” muscle-rich tissue and that of circulating leukocytes provides a patient-specific index of telomere shortening in patients with advanced vascular disease. Methods: TL in leukocytes, skeletal muscle, and right atrial cardiac muscle were measured from 134 patients undergoing coronary or thoracic aortic surgery, using quantitative polymerase chain reaction. Relationships between leukocyte TL or the muscle-leukocyte TL difference (ΔTL) and early post-operative outcomes were tested using Cox proportional hazard and binary logistic regression analyses. Results: Telomeres in cardiac muscle and skeletal muscle were significantly longer than those in leukocytes (p&amp;amp;lt;0.001) but with synchrony among these measures in an individual (p&amp;amp;lt;0.001). Leukocyte TL and skeletal muscle TL inversely correlated with chronological age (p&amp;amp;lt;0.001) however cardiac muscle TL did not (p=0.283). There was no relationship between leukocyte TL and either the post-operative length of stay in the intensive care unit (ICU) or major complications. However, cardiac-leukocyte ΔTL was associated with length of ICU stay (hazard ratio 1.26, p=0.043) and post-operative complications (odds ratio 3.03, p=0.029). Conclusions: Right atrium-leukocyte ΔTL provides an index of telomere shortening and may inform outcomes in patients with advanced vascular disease. This two-component telomere measurement may reflect the biological age of individuals with chronic vascular disease.
Patients with atrial fibrillation are at significant risk for sustaining a thromboembolic stroke.... more Patients with atrial fibrillation are at significant risk for sustaining a thromboembolic stroke. More than 90% of thromboemboli form in the left atrial appendage. Ligation of the left atrial appendage to reduce the risk of stroke is often performed in connection with other cardiac surgical procedures. As a stand-alone procedure, however, left atrial ligation has generally been deemed too invasive and has gained little support as an alternative therapeutic option. We report a case of port-access robotic-assisted left atrial ligation as a stand-alone procedure in a patient with chronic atrial fibrillation in whom anticoagulation was a contraindication. To our knowledge, this is the first reported case of stand-alone robotic-assisted left atrial ligation in the literature.
Emergency resternotomy in the intensive care unit (ICU) is a rarely performed, yet potentially li... more Emergency resternotomy in the intensive care unit (ICU) is a rarely performed, yet potentially life-saving intervention. Success relies on recognition of a deteriorating clinical condition, timely deployment of equipment/personnel and rapid execution. Given how infrequently it is performed, we sought to develop a large animal model of resternotomy to prepare ICU nurses and technicians at our low-volume cardiac surgery military centre. A porcine model of resternotomy was developed at the end of an already-scheduled trauma lab. Participants worked their way through a pre-planned simulation scenario, culminating in the need for resternotomy. Pre-simulation surveys assessing knowledge and comfort level with aspects of resternotomy were compared to post-simulation surveys. Participants improved their knowledge of resternotomy by 20.4% (P < 0.0001; 14.7% for nurses and 26.9% for technicians). Improvements were seen in all aspects assessed relating to subjective comfort/preparedness of ...
Seminars in Thoracic and Cardiovascular Surgery, 2020
Iatrogenic coronary injury after mitral repair is related to blind annuloplasty suture ligation o... more Iatrogenic coronary injury after mitral repair is related to blind annuloplasty suture ligation or kinking of the circumflex artery (CxA) and can present with early ST segment changes, malignant ventricular arrhythmias and segmental wall motion abnormalities. Corrective treatment is imperative to avoid myocardial infarction and can include removal of the annuloplasty ring or CxA bypass. We present a novel hybrid approach for the rapid diagnosis and management of iatrogenic CxA injury after mitral repair.
Atrial septal defect (ASD) repair has been conventionally performed via midline sternotomy with v... more Atrial septal defect (ASD) repair has been conventionally performed via midline sternotomy with very low operative risk and excellent early and late outcomes. Recently, many of these patients with suitable anatomy are being treated with percutaneous catheter-based closure of their ASD, but issues of prosthetic device implantation, long-term antiplatelet therapy and late device complications persist. Minimally invasive repair of ASD via a 3-cm right minithoracotomy provides patients with a much less invasive surgical repair with all the durable benefits of autologous pericardial patch closure. However, widespread adoption of the minithoracotomy approach to ASD closure remains slow. This study describes the simple steps to ASD repair via a right minithoracotomy.
Arteriosclerosis, Thrombosis, and Vascular Biology, May 1, 2016
Introduction: Ascertaining the biological age of patients with advanced vascular disease could ad... more Introduction: Ascertaining the biological age of patients with advanced vascular disease could advance risk assessment and management. The extent to which telomeres shorten in leukocytes could be a marker of biological age because it reflects the accumulation of replication stresses imposed on leukocyte progenitors. However, because of wide, genetic variability in leukocyte telomere length (TL), a single leukocyte TL measurement does not reliably indicate telomere shortening. Hypothesis: We hypothesized that the difference in length of telomeres in “non-replicating” muscle-rich tissue and that of circulating leukocytes provides a patient-specific index of telomere shortening in patients with advanced vascular disease. Methods: TL in leukocytes, skeletal muscle, and right atrial cardiac muscle were measured from 134 patients undergoing coronary or thoracic aortic surgery, using quantitative polymerase chain reaction. Relationships between leukocyte TL or the muscle-leukocyte TL difference (ΔTL) and early post-operative outcomes were tested using Cox proportional hazard and binary logistic regression analyses. Results: Telomeres in cardiac muscle and skeletal muscle were significantly longer than those in leukocytes (p&amp;amp;lt;0.001) but with synchrony among these measures in an individual (p&amp;amp;lt;0.001). Leukocyte TL and skeletal muscle TL inversely correlated with chronological age (p&amp;amp;lt;0.001) however cardiac muscle TL did not (p=0.283). There was no relationship between leukocyte TL and either the post-operative length of stay in the intensive care unit (ICU) or major complications. However, cardiac-leukocyte ΔTL was associated with length of ICU stay (hazard ratio 1.26, p=0.043) and post-operative complications (odds ratio 3.03, p=0.029). Conclusions: Right atrium-leukocyte ΔTL provides an index of telomere shortening and may inform outcomes in patients with advanced vascular disease. This two-component telomere measurement may reflect the biological age of individuals with chronic vascular disease.
Patients with atrial fibrillation are at significant risk for sustaining a thromboembolic stroke.... more Patients with atrial fibrillation are at significant risk for sustaining a thromboembolic stroke. More than 90% of thromboemboli form in the left atrial appendage. Ligation of the left atrial appendage to reduce the risk of stroke is often performed in connection with other cardiac surgical procedures. As a stand-alone procedure, however, left atrial ligation has generally been deemed too invasive and has gained little support as an alternative therapeutic option. We report a case of port-access robotic-assisted left atrial ligation as a stand-alone procedure in a patient with chronic atrial fibrillation in whom anticoagulation was a contraindication. To our knowledge, this is the first reported case of stand-alone robotic-assisted left atrial ligation in the literature.
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