Papers by Hratch Karamanoukian
Health Care on the Internet, Jun 1, 2000
It is common knowledge nowadays that diet, exercise, and lifestyle play important roles in heart ... more It is common knowledge nowadays that diet, exercise, and lifestyle play important roles in heart health. Clearly, consumers around the world are better informed about heart health and disease prevention. Due to the availability of information about diet and a raised awareness of sound lifestyles, people are living longer healthier lives. Consumers are learning how to apply better lifestyle habits into daily activities. Perhaps less understood by the consumer is how genes influence health in general, and not just inherited problems ...
The Heart Surgery …, 2003
Background: Many investigators have demonstrated the short-term and midterm efficacy of minimally... more Background: Many investigators have demonstrated the short-term and midterm efficacy of minimally invasive direct coronary artery bypass (MIDCAB). However, the influence of heparin dosing during MIDCAB on postoperative and immediate graft patency is less well defined. This report outlines our experience with MIDCAB employing a variety of heparinization protocols. Methods: The traditional MIDCAB approach was used in 152 patients who underwent single-vessel off-pump coronary artery bypass. Before the left internal mammary artery was divided, a 150-U/kg bolus of heparin sodium was given to 76 patients (group 1), and 300 U/kg was given to another 76 patients (group 2). Additional heparin was given during the procedures to maintain an activated clotting times of greater than 300 seconds for group 1 and greater than 400 seconds for group 2. Results: On average, patients in group 1 required more boluses of heparin during treatment than patients in group 2. A larger standard deviation from the mean was observed for the activated clotting time in group 1 at any time during treatment than for patients in group 2. The number of revised grafts was smaller in group 2 (1/76, 1.3%) than in group 1 (4/76, 5.2%). All of these revisions revealed thrombus at the site of anastomosis. In addition, noncoronary thrombotic complications were seen in 5 patients in group 1, and none were seen in group 2. Conclusion: Coronary artery surgery without cardiopulmonary bypass does not trigger the systemic inflammatory response, but surgical tissue trauma remains a constant. The preserved hemostasis theoretically may lead to a procoagulant state. This study demonstrates that insufficient anticoagulation therapy can lead to intracoronary thrombosis following MIDCAB as well as increased noncoronary thrombotic complications.
The heart surgery forum, 2003
The primary goal of this study was to (1) determine patients&... more The primary goal of this study was to (1) determine patients' access to and use of the Internet for healthrelated information before and after endoscopic atraumatic coronary artery bypass (Endo-ACAB) surgery, (2) investigate patients' methods of searching for such information, and (3) suggest future improvements for Internet-based patient education. The secondary goal of this study was to determine (1) patients' health-related quality of life and (2) degree of satisfaction following the Endo-ACAB procedure. A follow-up study was conducted of 50 consecutive patients who had undergone Endo-ACAB procedures at the Center for Less Invasive Cardiac Surgery and Robotic Heart Surgery in Buffalo, New York. Study surveys were designed cooperatively by a communication scientist specializing in Internet studies and cardiac surgeons. Patients completed surveys over a period of 18 months, from January 2001 to June 2002. All 50 patients (100%) in the targeted study group completed the survey. Forty-four (88%) of these respondents reported having Internet access. The Web was cited as the most popular source of initial information on Endo-ACAB, with 36% of patients (18) first learning about the procedure through an Internet search. All 44 patients with Internet access used the Web as an additional source of information before surgery, but only 20% (7/35) did so after surgery. Most patients (91%, 40/44) felt that their surgeon should develop a Web site to detail the Endo-ACAB procedure. An investigation of patient quality of life showed that 96% of patients were not experiencing any symptoms related to t heir surgery. All 50 patients reported high degrees of satisfaction with the Endo-ACAB procedure, and 98% (49) said that they would recommend the surgery to someone else. A vast majority of patients are realizing the benefits of the Internet as a tool to educate themselves, both before and after surgery. The request by an overwhelming majority of patients that surgeons develop Web sites, however, shows that patients may not be completely satisfied with the current form or content of health sites on the Internet. Surgeons will see the benefits of Web-based education only when they ensure that their patients have access to adequate and credible health-related information. The early results of robotic surgery suggest a promising future and the need to investigate the role of the Internet in its growth.
Journal of Burn Care & Research, 2006
Snap-caps are marketed as a relatively safe pyrotechnic (explosive) device for children 8 years a... more Snap-caps are marketed as a relatively safe pyrotechnic (explosive) device for children 8 years and older. Individually, the snap-caps pose very little threat because the amount of explosive compounds contained in each is limited to 1 mg. However, the accidental explosion of numerous snap-caps may cause significant burns. This study highlights a series of pediatric patients who presented with severe second- and third-degree burns as a result of accidental explosion of snap-caps. Seven patients with snap-caps-related injuries were treated at the University of California, San Diego Regional Burn Center from January 1996 to April 1999. Study foci included 1) mode and extent of injury, 2) management, 3) associated morbidity, and 4) functional outcome. Six patients (84%) required hospital admission. Four patients (57%) underwent split-thickness skin grafting to repair mean TBSA burns of 4.1% (range, 2-8%). Three patients (43%) received aggressive management of burns with topical medications and dressing changes. The nature and extent of snap-cap injuries support the contention that snap-caps have the potential to harm children to whom they are marketed.
Journal of Pediatric Surgery, Aug 31, 1996
In the pediatric population, there is strong evidence to suggest that a delay in treatment result... more In the pediatric population, there is strong evidence to suggest that a delay in treatment results in an increased risk of appendiceal perforation. However, it is not clear whether this delay arises from the parent seeking medical advice, the referring physician seeking surgical consultation, or the surgeon deciding to operate. To resolve this issue, the authors performed a retrospective chart review of all cases of confirmed acute appendicitis that presented to the pediatric surgical service of the Children's Hospital of Buffalo during a 4-year period (January 1990 through December 1993). All children (_<16 years of age} were categorized with respect to type of insurance coverage: Medicaid (or uninsured), health maintenance organization (HMO), or private fee-for-service. Their time until emergency room (ER) presentation, operating room (OR) presentation, and hospital discharge were recorded and compared. Their complications and perforation rates also were noted. Two hundred eighty-eight cases were reviewed. The rate of appendiceal perforation was significantly higher among the Medicaid patients (Medicaid, 44%; HMO, 27%; private, 23%; P < .05); their duration of symptoms before presentation was significantly longer (Medicaid, 47.3 _+ 4.1 hours; HMO, 29.3 -+ 1.9 hours; private, 23.1 -2.5 hours; P < .01), and their hospital stay was longer (Medicaid, 7.9 -+ 0.9 days; HMO, 4.8 -+ 0.27 days; private, 4.6 -+ 0.44 days; P < .01). However, there were no significant differences in the time from presentation to the ER until definitive surgery in the OR. Children covered by Medicaid (or unin-sured} presented later, had a higher risk of appendiceal perforation, and required a longer hospital stay. The parents of these children either failed to recognize the significance of their children's symptoms, or delayed seeking medical advice because of financial or logistical reasons. The gatekeeper consultation, required by the health maintenance organizations (HMO) did not result in a delay in presentation or have a negative impact on morbidity. Providing easier access to a primary care physician and improving parental health education/awareness may shorten the time until presentation for the uninsured/Medicaid patient.
The Heart Surgery Forum, 1999
J Cardiac Surg, 2010
The "single suture" technique, which consists of placing a suture in the oblique sinus of the pos... more The "single suture" technique, which consists of placing a suture in the oblique sinus of the posterior pericardium and connecting it to a vaginal tape, is commonly adopted in off-pump coronary artery revascularization to obtain elevation of the heart and coronary artery exposure. This report describes the use of this technique to expose the anterior wall of the heart in the setting of ventricular aneurysm repair. (J Card Surg 1999;74:460-467)
The Heart Surgery Forum, Feb 1, 2000
We started to use this approach for reoperative CABG in 1971 utilizing femoral cannulation for CP... more We started to use this approach for reoperative CABG in 1971 utilizing femoral cannulation for CPB ]. In the last several years, CPB has been avoided in the majority of cases. After induction with general anesthesia and double lumen endotracheal intubation, the patient was
Heart Surgery Forum, 2003
The application of robotically assisted coronary artery surgery continues to be investigated clin... more The application of robotically assisted coronary artery surgery continues to be investigated clinically. Consequently, there is a need for a simple method to train surgeons in performing these operations. The aim of the present study was to assess a model using an excised porcine heart for the training of surgeons in creating a robotically assisted arterial anastomosis.
The Annals of Thoracic Surgery, Apr 1, 2001
population. Recent studies states the case for these medications even more compelling, and in som... more population. Recent studies states the case for these medications even more compelling, and in some instances, with first-line evidence of therapeutic success for patients undergoing myocardial revascularization. The Atorvastatin versus Revascularization Treatment (AVERT) study showed that pronounced lowering of serum-cholesterol levels using high-dose medical treatment with the statin atorvastatin entailed a 36% reduction of ischemic events during a follow-up period of 18 months compared with percutaneous transluminal coronary angioplasty with or without concomitant stenting [2]. The authors speculate that the effect of atorvastatin is related to enhanced plaque stability and could be even more pronounced long-term. The MERIT-HF investigators studied the selective  1 -blocker metoprolol as an adjunct to standard medical heart failure therapy (ACEI in combination with a diuretic Ϯ digoxin). Effects on mortality and morbidity were appalling, and the study was terminated prematurely after 1 year, with a relative risk reduction of 66% for death of any cause and of 51% for death from worsened heart failure [3]. The APRES study was undertaken to give evidence to the assumption that ACEI is of value in the sizeable yet hitherto unstudied population of patients with asymptomatic moderate left ventricular dysfunction undergoing CABG or percutaneous transluminal coronary angioplasty. Onehundred and fifty-nine patients were randomized to placebo or ramipiril in this double-blind study. There was a significant reduction in the composite endpoint of cardiac death, nonfatal acute myocardial infarction, or clinical heart failure (8 vs 18 patients, p ϭ 0.031) [4]. Interestingly, ramipiril significantly reduced the incidence of cardiac death, but not the incidence of heart failure, and the treatment effect was not related to degree of left ventricular dysfunction, suggesting another effect than just improving left ventricular function. The AVERT, MERIT-HF, and APRES studies had in common reporting good tolerance and few side effects of the studied drugs. In addition to Dr Roberts editorial, these investigations suggest that: (1) aggressive lowering of serum-cholesterol may even further improve graft patency; (2) treatment with a selective -blocker may be implicated not only to those patients that have sustained a myocardial infarction, but also to those suffering from heart failure postoperatively; and (3) ACEI treatment is probably indicated for a large subgroup of CABG patients: those with asymptomatic, moderately reduced left ventricular function.
J Cardiothorac Vasc Anesth, 2000
Pediatrics, Nov 1, 1994
We determined whether inhaled nitric oxide (NO) could improve systemic oxygenation in human neona... more We determined whether inhaled nitric oxide (NO) could improve systemic oxygenation in human neonates with hypoplastic lungs. A multicenter nonrandomized investigation was performed to study the efficacy of short-term NO inhalation. Inhaled NO was administered at 80 ppm to nine neonates without evidence of structural cardiac disease by echocardiography. Lung hypoplasia was due to congenital diaphragmatic hernia (CDH) in eight patients and to oligohydramnios in one patient. A total of 15 trials of NO inhalation were performed in these nine patients. Eight trials in seven patients were performed before extracorporeal membrane oxygenation ((ECMO); one patient had two trials) and seven trials were performed in five patients after decannulation from ECMO (two patients had two trials each). NO inhalation before ECMO did not change postductal PaO2 (42 +/- 3 mmHg vs 42 +/- 4 mmHg), oxygen saturation (SpO2; 89% vs 88%) or oxygenation index (31 +/- 4 cm H2O/torr vs 31 +/- 4 cm H2O/torr) for the group. All patients required ECMO support, which lasted from 5 to 17 days (mean 9). After decannulation from ECMO, NO inhalation increased postductal PaO2 from a median of 56 mm Hg (range 41 to 94) to a median of 113 mm Hg (range 77 to 326), P &lt; .05. It decreased the oxygenation index from a median of 23 cm H2O/torr (range 11 to 7) to a median of 11 cm H2O/torr (range 4 to 21), P &lt; .05. It increased SpO2 from 91% to 96% (P &lt; .05) and pH from 7.48 +/- .03 to 7.50 +/- .03. In our patients with hypoplastic lungs, inhaled NO was effective only after ECMO. This could be due to maturational changes such as activating the endogenous surfactant system. Inhaled NO may be effective in neonates with hypoplastic lungs who have recurrent episodes of pulmonary hypertension after ECMO, even if they were previously unresponsive.
The Heart Surgery Forum, 2003
... Surgery 90:1075-83. Shaw PJ, Bates D, Cartlidge NE, Heaviside D, Julian DG, Shaw DA. 1985. ... more ... Surgery 90:1075-83. Shaw PJ, Bates D, Cartlidge NE, Heaviside D, Julian DG, Shaw DA. 1985. ... J Am Coll Cardiol 20:70-7. Lynn GM, Stefanko K, Reed JF 3rd, Gee W, Nicholas G. 1992. Risk factors for stroke after coronary artery bypass. ...
Interactive Cardiovascular and Thoracic Surgery, 2003
The aim of this study was to compare flow characteristics of LIMA-LAD anastomoses constructed usi... more The aim of this study was to compare flow characteristics of LIMA-LAD anastomoses constructed using two different techniques. Thirty patients underwent MIDCAB using either simple continuous suture (20) or separate nitinol U-clips (10). Intraoperative transit time flow measurements were recorded. Preoperative variables were similar in the two groups. Anastomosis time was significantly higher in the Uclipped group (9.9^1.5 min. vs.11.4^1.5 min; P ¼ 0:016). Average flow value in the 20 continuous suture LIMA-LAD anastomoses was 26.7^8.8 ml/min versus 36.3^10.6 ml/min in the 10 U-clipped grafts (P ¼ 0:014). Pulsatility Index value was significantly lower in the U-clipped group (3.1^0.9 vs. 1.8^0.3, P ¼ 0:0001) and diastolic flow index was significantly higher (0.7^0.04 vs. 0.8^0.03, P ¼ 0:046). Perioperative results were similar in the two groups (P ¼ ns). No mortality was reported. Postoperative trans-thoracic Doppler confirmed patency of the LIMA in all 30 patients. At short-term clinical follow-up (60^4 days), all patients were in CCSI. Nitinol U-clips can be used to construct LIMA-LAD anastomoses on the beating heart. Flow dynamics of these anastomoses are superior to those of grafts constructed using continuous suture technique. Particularly, total flow is higher and diastolic flow may reach values of 80% of the total measured flow. q
The heart surgery forum, 2003
The primary goal of this study was to (1) determine patients' access to and use of the Intern... more The primary goal of this study was to (1) determine patients' access to and use of the Internet for healthrelated information before and after endoscopic atraumatic coronary artery bypass (Endo-ACAB) surgery, (2) investigate patients' methods of searching for such information, and (3) suggest future improvements for Internet-based patient education. The secondary goal of this study was to determine (1) patients' health-related quality of life and (2) degree of satisfaction following the Endo-ACAB procedure. A follow-up study was conducted of 50 consecutive patients who had undergone Endo-ACAB procedures at the Center for Less Invasive Cardiac Surgery and Robotic Heart Surgery in Buffalo, New York. Study surveys were designed cooperatively by a communication scientist specializing in Internet studies and cardiac surgeons. Patients completed surveys over a period of 18 months, from January 2001 to June 2002. All 50 patients (100%) in the targeted study group completed the ...
The heart surgery forum, 2003
The heart surgery forum, 2002
We investigated the present use of integrated coronary revascularization (ICR) by interviewing a ... more We investigated the present use of integrated coronary revascularization (ICR) by interviewing a sample of United States invasive cardiologists and cardiac surgeons. Both groups still favor left internal mammary artery (LIMA) grafting to revascularize the left anterior descending (LAD) coronary artery. There remains a lack of exposure to and acceptance of ICR, especially for surgeons. We report the findings of this national survey of 180 cardiologists and 160 surgeons, as they may serve as an indicator of the current opinions about ICR and its future applicability as a standard method of coronary artery revascularization. We discuss the limited popularity of minimally invasive hybrid procedures and the importance of further exposing cardiologists and surgeons to ICR.
The American surgeon, 2002
Robotics has been recognized as a major driving force in the advancement of minimally invasive su... more Robotics has been recognized as a major driving force in the advancement of minimally invasive surgery. However, the extent to which General Surgery residents are being trained to use robotic technology has never been assessed. A survey was sent to program directors of accredited General Surgery training programs to determine the prevalence and application of robotics in surgical training programs. Responses were tabulated and analyzed. Thirty-three per cent indicated interest in minimally invasive surgery. Twelve per cent of responders have used robotics in their practice, and 65 per cent felt robotics will play an important role in the future of General Surgery. Currently residents from 14 per cent of the responding training programs have exposure to robotic technology, and residents from an additional 4 per cent of these programs have limited didactic exposure. Program directors from 23 per cent of responding programs identified plans to incorporate robotics into their program. R...
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Papers by Hratch Karamanoukian