Isolated sinus of Valsalva aneurysm is a rare occurrence, with an incidence of <1.5% among con... more Isolated sinus of Valsalva aneurysm is a rare occurrence, with an incidence of <1.5% among congenital heart disease repairs in the world. We recount the case of a 64-year-old man who presented with right-sided heart failure symptoms caused by a severely dilated right coronary sinus of Valsalva aneurysm that substantially obstructed the right ventricular outflow tract. Successful surgical repair involved right ventricular outflow tract resection and subcoronary patch repair.
Journal of Nuclear Medicine Official Publication Society of Nuclear Medicine, Nov 1, 1996
SPECT has shown increasing promise as a diagnostic tool in Alzheimer's disease (AD). Recently, a ... more SPECT has shown increasing promise as a diagnostic tool in Alzheimer's disease (AD). Recently, a new SPECT brain perfusion agent, ""Tc-ethyl cysteinate dimer (""Tc-ECD) has emerged with purported advantages in image quality over the established tracer, ""Tc-hexamethylpropyleneamine oxime (""Tc-HMPAO). This re search aimed to compare cerebral images for ""Tc-HMPAO and "Tc-ECD in discriminating patients with AD from control subjects. Methods: Twenty-four AD patients (mean age ±s.d. = 68.9 ±8.2 yr) and 13 healthy subjects (68.4 ±8.0 yr) were scanned sequentially with 20 mCi of each tracer using the CERASPECT system within 1 mo. Scanning began on average 11.5 ± 2.8 min after 99mTc-HMPAO injection and 41.8 ±10.1 min after 99rTTc-ECD.A ratio, R, was derived of count densities in "typically affected" brain structures (parietal and temporal association cortices) to "unaffected" struc tures (cerebellum, basal ganglia, thalamus, occipital cortex, and sensorimotor cortex). Results: Analysis of variance revealed signif icant interaction between diagnostic group and radiopharmaceutical (F = 4.71; df = 1,35; p = 0.04), with ""Tc-ECD demonstrating better separation of R values between AD patients and control subjects than ""Tc-HMPAO. Receiver operating characteristic (ROC) analysis revealed no significant difference in the ability of the two tracers to correctly classify AD patients and control subjects. Both tracers showed high diagnostic accuracy (""Tc-ECD: sensi tivity = 100%, specificity = 92%; ""Tc-HMPAO: sensitivity = 100%, specificity = 85%). Conclusion: Technetium-99m-ECD shows greater contrast than ""Tc-HMPAO between affected and unaffected brain structures in AD when patients are compared to age-matched control subjects. Both tracers perform equally well in correctly classifying patients and control subjects.
An 83-year-old woman with a history of coronary artery disease presented with anterior ST-elevati... more An 83-year-old woman with a history of coronary artery disease presented with anterior ST-elevation myocardial infarction. During coronary intervention, she was found to have a ventricular septal rupture, but was felt not to be a surgical candidate due to advanced shock. She was offered transcatheter repair using an Amplatzer post-infarction muscular ventricular septal defect occluder and recovered completely. She was discharged, but returned four months later with chest pain. A cardiac CT and contrast-enhanced echocardiogram revealed a left ventricular pseudoaneurysm. She underwent transcatheter repair using an Amplatzer Vascular Plug II and recovered without further sequelae.
Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology, Jan 5, 2016
In animal models of heart failure (HF), myocardial metabolism shifts from high-energy fatty acid ... more In animal models of heart failure (HF), myocardial metabolism shifts from high-energy fatty acid (FA) metabolism toward glucose. However, FA (vs glucose) metabolism generates more ATP/mole; thus, FA metabolism may be especially advantageous in HF. Sex modulates myocardial blood flow (MBF) and substrate metabolism in normal humans. Whether sex affects MBF and metabolism in patients with HF is unknown. We studied 19 well-matched men and women with nonischemic HF (EF ≤ 35%). MBF and myocardial substrate metabolism were quantified using positron emission tomography. Women had higher MBF (mL/g/minute), FA uptake (mL/g/minute), and FA utilization (nmol/g/minute) (P < 0.005, P < 0.005, P < 0.05, respectively) and trended toward having higher FA oxidation than men (P = 0.09). These findings were independent of age, obesity, and insulin resistance. There were no sex-related differences in fasting myocardial glucose uptake or metabolism. Higher MBF was related to improved event-free ...
Direct aortic access for transcatheter aortic valve replacement (DA-TAVR) is an important alterna... more Direct aortic access for transcatheter aortic valve replacement (DA-TAVR) is an important alternative approach in patients with hostile ileo-femoral vessels. Planning the transaortic puncture site and an 'ideal' trajectory towards the annulus plane is important for safe and successful valve implantation. The feasibility of three-dimensional (3D) planning and real-time fluoroscopic image guidance for DA-TAVR was evaluated using pre-procedural multi-detector computed tomography (MDCT) and intra-procedural Dyna CT co-registration approaches. Between May 2012 and August 2014, a total of 44 patients (40 mini-sternotomies, four mini-thoracotomies) was selected for DA-TAVR using the authors' MDCT-Dyna CT co-registration approach (32 CoreValve, 12 SAPIEN). Pre-procedural contrast-enhanced multi-slice CT (MSCT) and intra- procedural non-contrast Dyna CT images were co-registered based on cardiac outline and aortic root calcifications. Using a prototype software, the aortic root w...
Sedation/anesthesia is critical to cardiac catheterization in the pediatric/congenital heart pati... more Sedation/anesthesia is critical to cardiac catheterization in the pediatric/congenital heart patient. We sought to identify current sedation/anesthesia practices, the serious adverse event rate related to airway, sedation, or anesthesia, and the rate of intra-procedural conversion from procedural sedation to the use of assisted ventilation or an artificial airway. Data from 13,611 patients who underwent catheterization at eight institutions were prospectively collected from 2007 to 2010. Ninety-four (0.69 %) serious sedation/airway-related adverse events occurred; events were more likely to occur in smaller patients (\4 kg, OR 4.4, 95 % CI 2.3-8.2, p \ 0.001), patients with non-cardiac comorbidities (OR 1.7, 95 % CI 1.1-26, p \ 0.01), and patients with low mixed venous oxygen saturation (OR 2.3, 95 % CI 1.4-3.6, p \ 0.001). Nine thousand three hundred and seventy-nine (69 %) patients were initially managed with general endotracheal anesthesia, LMA, or tracheostomy, whereas 4232 (31 %) were managed with procedural sedation without an artificial airway, of which 75 (1.77 %) patients were converted to assisted ventilation/general anesthesia. Young age (\12 months, OR 5.2, 95 % CI 2.3-11.4, p \ 0.001), higher-risk procedure (category 4, OR 10.1, 95 % CI 6.5-15.6, p \ 0.001), and continuous pressor/inotrope requirement (OR 11.0, 95 % CI 8.6-14.0, p \ 0.001) were independently associated with conversion. Cardiac catheterization in pediatric/congenital patients was associated with a low rate of serious sedation/airway-related adverse events. Smaller patients with non-cardiac comorbidities or low mixed venous oxygen saturation may be at higher risk. Patients under 1 year of age, undergoing high-risk procedures, or requiring continuous pressor/inotrope support may be at higher risk of requiring conversion from procedural sedation to assisted ventilation/general anesthesia.
Journal of the American College of Cardiology, 2015
Background: Atrial septal defects are common congenital heart defects encountered in adulthood th... more Background: Atrial septal defects are common congenital heart defects encountered in adulthood that in rare cases may lead to marked pulmonary artery (PA) dilatation. case: A 59-year-old woman was transferred for lung transplantation evaluation due to pulmonary hypertension. Physical exam revealed severe respiratory distress with signs of right-sided heart failure. The patient required intubation, ionotropes, tadalafil, epoprostenol, and inhaled nitric oxide for stabilization. decision Making: Echocardiography revealed a left-to-right shunt consistent with a superior sinus venosus atrial septal defect (SVASD). Preoperative evaluation revealed a severely enlarged PA with compression of the left main coronary artery (LMCA), left main bronchus (LMB) and left lung. (Figure 1) This was further complicated by partial anomalous pulmonary venous return (PAPVR) of the right aerated lung. The patient was too unstable for a more extensive surgery so underwent repair of the SVASD and PAPVR. Despite normalization of PA pressures postoperatively, compression of the LMCA and LMB persisted. Stenting of the LMCA and LMB was performed to relieve the obstruction until PA reverse remodeling could occur. She tolerated the procedures well and at 6-month follow-up was ambulatory without oxygen. conclusion: This case demonstrates a SVASD complicated by compression of adjacent structures by the PA. A novel hybrid surgical and percutaneous approach was performed and may be ideal for critically ill patients.
An 83-year-old woman with a history of coronary artery disease presented with anterior ST-elevati... more An 83-year-old woman with a history of coronary artery disease presented with anterior ST-elevation myocardial infarction. During coronary intervention, she was found to have a ventricular septal rupture, but was felt not to be a surgical candidate due to advanced shock. She was offered transcatheter repair using an Amplatzer post-infarction muscular ventricular septal defect occluder and recovered completely. She was discharged, but returned four months later with chest pain. A cardiac CT and contrast-enhanced echocardiogram revealed a left ventricular pseudoaneurysm. She underwent transcatheter repair using an Amplatzer Vascular Plug II and recovered without further sequelae.
Centrally acting cholinergic drugs have been reported to increase regional cerebral blood flow (r... more Centrally acting cholinergic drugs have been reported to increase regional cerebral blood flow (rCBF) as measured by single photon emission computed tomography (SPECT) in brain regions affected by Alzheimer&amp;amp;amp;amp;#39;s disease (AD). We studied the effects of the acetylcholine releaser linopirdine (LPD) on SPECT rCBF in patients with probable AD. Twenty-four AD patients (12 M, 12 F; mean age +/- SD = 68.9 +/- 8.2 years) and 13 healthy controls (8 M, 5 F; 68.4 +/- 8.0 years) participated. AD patients were scanned with 20 mCi of Tc99m-ECD at baseline and following 4 weeks of treatment with LPD 40 mg TID (n = 15) or placebo TID (n = 9) in a double-blind trial. Healthy subjects were scanned for comparison with baseline AD scans. Cortical/cerebellar rCBF ratios were derived for nine cortical structures. The combined parietal association cortex showed a 20.6% reduction in patients relative to controls. Patients treated with LPD showed an increase in parietal rCBF of 4.1 +/- 5.8%; whereas those treated with placebo showed a decrease of -2.0 +/- 7.4% (F = 5.13; df = 1, 22; P = 0.03). These data support the conclusion that rCBF abnormalities in AD are, in part, truly &amp;amp;amp;amp;quot;functional&amp;amp;amp;amp;quot; and can be selectively altered with pharmacological interventions. The parietal activation seen with LPD and other cholinergic AD drug therapies suggests the importance of measuring parietal lobe neuropsychological function in the course of evaluating these drugs.
Background Double-outlet right ventricle (DORV) with a restrictive ventricular septum is a rare b... more Background Double-outlet right ventricle (DORV) with a restrictive ventricular septum is a rare but highly morbid phenomenon that can be complicated by progressive left ventricular hypertrophy, arrhythmias, aneurysm formation, severe pulmonary hypertension, and death in the newborn. Surgical creation or enlargement of a ventricular septal defect (VSD) is palliative but may damage the conduction system or the atrioventricular valves in the newborn. This report presents a transcatheter approach to palliation for a newborn that had DORV with a restrictive ventricular septum. Methods/Results A full-term infant girl (2.9 kg) referred for hypoxia (80 % with room air) and murmur was found to have DORV, interrupted inferior vena cava, and restrictive VSD (95-mmHg gradient). Transhepatic access was performed, and an internal mammary (IM) catheter was advanced through the atrial septal defect and into the left ventricle. By transesophageal echocardiographic guidance, a Baylis radiofrequency perforation wire was used to cross the ventricular septum, and the defect was enlarged using a 4-mm cutting balloon. A bare metal stent then was deployed to maintain the newly created VSD. The patient did well after the procedure but required pulmonary artery banding 4 days later. She returned 5 months later with cyanosis and the development of obstructing right ventricle muscle bundles, requiring further surgical palliation. Conclusions This report describes the first transcatheter creation of VSD in DORV with a restrictive ventricular septum in a newborn infant. Use of the radiofrequency catheter in combination with cutting balloon dilation and stent implantation is an efficient method for creating a VSD in such a patient.
Continued advancements in congenital cardiac catheterization and interventions have resulted in i... more Continued advancements in congenital cardiac catheterization and interventions have resulted in increased patient and procedural complexity. Anticipation of lifethreatening events and required rescue measures is a critical component to preprocedural preparation. We sought to determine the incidence and nature of life-threatening adverse events in congenital and pediatric cardiac catheterization, risk factors, and resources necessary to anticipate and manage events. Data from 8905 cases performed at the 8 participating institutions of the Congenital Cardiac Catheterization Project on Outcomes were captured between 2007 and 2010 [median 1,095/site (range 133-3,802)]. The incidence of all life-threatening events was 2.1 % [95 % confidence interval (CI) 1.8-2.4 %], whereas mortality was 0.28 % (95 % CI 0.18-0.41 %). Fifty-seven life-threatening events required cardiopulmonary resuscitation, whereas 9 % required extracorporeal membrane oxygenation. Use of a risk adjustment model showed that age \1 year [odd ratio (OR) 1.9, 95 % CI 1.4-2.7, p \ 0.001], hemodynamic vulnerability (OR 1.6, 95 % CI 1.1-2.3, p \ 0.01), and procedure risk (category 3: OR 2.3, 95 % CI 1.3-4.1; category 4: OR 4.2, 95 % CI 2.4-7.4) were predictors of life-threatening events. Using this model, standardized life-threatening event ratios were calculated, thus showing that one institution had a lifethreatening event rate greater than expected. Congenital cardiac catheterization and intervention can be performed safely with a low rate of life-threatening events and mortality; preprocedural evaluation of risk may optimize preparation of emergency rescue and bailout procedures. Risk predictors (age \ 1, hemodynamic vulnerability, and procedure risk category) can enhance preprocedural patient risk stratification and planning.
Obesity adversely affects myocardial metabolism, efficiency, and diastolic function. Our objectiv... more Obesity adversely affects myocardial metabolism, efficiency, and diastolic function. Our objective was to determine whether weight loss can ameliorate obesity‐related myocardial metabolism and efficiency derangements and that these improvements directly relate to improved diastolic function in humans. We studied 30 obese (BMI >30 kg/m2) subjects with positron emission tomography (PET) (myocardial metabolism, blood flow) and echocardiography (structure, function) before and after marked weight loss from gastric bypass surgery (N = 10) or moderate weight loss from diet (N = 20). Baseline BMI, insulin resistance, hemodynamics, left ventricular (LV) mass, systolic function, myocardial oxygen consumption (MVO2), and fatty acid (FA) metabolism were similar between the groups. MVO2/g decreased after diet‐induced weight loss (P = 0.009). Total MVO2 decreased after dietary (P = 0.02) and surgical weight loss (P = 0.0006) and was related to decreased BMI (P = 0.006). Total myocardial FA ut...
The Journal of Thoracic and Cardiovascular Surgery, 2014
can be visualized, the procedure should be undertaken cautiously, because the aorta is located in... more can be visualized, the procedure should be undertaken cautiously, because the aorta is located in a deep place between the esophagus and thoracic vertebra. The aortas from which we harvested the adventitia were all normal tissues. Adventitia from aortas with various aortic disorders such as aortic aneurysm, aortic infection, aortic wall calcification, and rare diseases such as Marfan syndrome and Loeys-Dietz syndrome should be excluded. Constructing a no-treatment control group of patients with high BPF risk seems to be a good way to show the effectiveness of this procedure, but this is contrary to medical ethics. CONCLUSIONS Bronchial stump or anastomotic stoma reinforcement with aortic adventitia flap is a convenient and safe technique that is suitable for selected patients at potential risk of developing BPF following left pulmonary resection.
Journal of the American College of Cardiology, 2010
... 242 Authors: Chun H. Lin, Pilar Herrero, Pablo Soto, Jasdeep Sidhu, Suraj Kurup, Al Waggoner,... more ... 242 Authors: Chun H. Lin, Pilar Herrero, Pablo Soto, Jasdeep Sidhu, Suraj Kurup, Al Waggoner, Deborah L. Delano, Robert J. Gropler, Linda R. Peterson, Washington University School of Medicine, St Louis, MO Background ...
Journal of the American College of Cardiology, 2013
Background: Prediction of an optimal C-arm angle that aligns the coronary sinuses for valve deplo... more Background: Prediction of an optimal C-arm angle that aligns the coronary sinuses for valve deployment is critical during TAVR. Current solutions derive the deployment angle from multiple angiograms, reconstruction of multi-slice CT (MSCT) or C-arm CT rotational angiography (CTRA). We evaluated a method based on co-registration of MSCT and CTRA to predict deployment angle without using additional contrast agent. methods: Non-contrast CTRA (syngo DynaCT®) was acquired using a 5-sec protocol, with breath-hold and rapid-pacing. Aortic root calcifications from CTRA and MSCT were segmented and aligned with a semi-automatic rigid image registration algorithm. Optimal deployment angle was derived using prototype software (Siemens AG, Germany). This approach also accounted for differences in patient positioning. To evaluate the adequacy of the predicted angle, we compared the number of planning aortic root angiograms before and after adopting our co-registration approach. results: From Oct 2011 to Oct 1012, 10 patients underwent TAVR using predicted angle from MSCT alone, and 24 patients using co-registration. 7/10 pts (70%) in MSCT group required >2 angiograms before prosthesis insertion, compared to 3/24 pts (12.5%) in the co-registered group. conclusion: We propose a method to predict optimal C-arm angle for valve deployment based on MSCT-CTRA (non-contrast) co-registration. Such image registration strategies can potentially help in limiting contrast usage.
Journal of the American College of Cardiology, 2011
Background: We have shown previously that women exhibit a greater increase in myocardial fatty ac... more Background: We have shown previously that women exhibit a greater increase in myocardial fatty acid utilization and oxidation with the development of obesity and type 2 diabetes (T2DM) compared with men. However, whether sex impacts the intramyocellular metabolism of glucose in these conditions is unknown. Methods: Three groups-nonobese (N=10; 6 women), obese (N=26; 17 women), and T2DM subjects (N=73; 40 women) underwent positron emission tomography for quantification of myocardial utilization (MGU; nmol/g/min), and intramyocellular metabolism (nmol/g/min) using C11glucose and well-validated mathematical modeling. Results: In the men, MGU, glycolysis, glycogen synthesis, and glucose oxidation rates were different among the 3 groups (ANOVAs P<0.05). The significant post-hoc comparisons (Fischer's exact test) between any 2 of the 3 groups are shown by the P values on the Figure, left panel. In the women, there were no differences in MGU, glycolysis, glycogen storage, or glucose oxidation rates among the 3 groups. Conclusions: The detrimental effect of obesity and T2DM on myocardial glucose metabolism is more pronounced in men compared with women. When taken together with our prior observations, it appears sex impacts the myocardial metabolic response to obesity and T2DM, with fatty acid metabolism being more affected in women and glucose metabolism in men. This sexual dimorphism suggests that sex will impact any therapeutic metabolic manipulation in these patients.
Isolated sinus of Valsalva aneurysm is a rare occurrence, with an incidence of <1.5% among con... more Isolated sinus of Valsalva aneurysm is a rare occurrence, with an incidence of <1.5% among congenital heart disease repairs in the world. We recount the case of a 64-year-old man who presented with right-sided heart failure symptoms caused by a severely dilated right coronary sinus of Valsalva aneurysm that substantially obstructed the right ventricular outflow tract. Successful surgical repair involved right ventricular outflow tract resection and subcoronary patch repair.
Journal of Nuclear Medicine Official Publication Society of Nuclear Medicine, Nov 1, 1996
SPECT has shown increasing promise as a diagnostic tool in Alzheimer's disease (AD). Recently, a ... more SPECT has shown increasing promise as a diagnostic tool in Alzheimer's disease (AD). Recently, a new SPECT brain perfusion agent, ""Tc-ethyl cysteinate dimer (""Tc-ECD) has emerged with purported advantages in image quality over the established tracer, ""Tc-hexamethylpropyleneamine oxime (""Tc-HMPAO). This re search aimed to compare cerebral images for ""Tc-HMPAO and "Tc-ECD in discriminating patients with AD from control subjects. Methods: Twenty-four AD patients (mean age ±s.d. = 68.9 ±8.2 yr) and 13 healthy subjects (68.4 ±8.0 yr) were scanned sequentially with 20 mCi of each tracer using the CERASPECT system within 1 mo. Scanning began on average 11.5 ± 2.8 min after 99mTc-HMPAO injection and 41.8 ±10.1 min after 99rTTc-ECD.A ratio, R, was derived of count densities in "typically affected" brain structures (parietal and temporal association cortices) to "unaffected" struc tures (cerebellum, basal ganglia, thalamus, occipital cortex, and sensorimotor cortex). Results: Analysis of variance revealed signif icant interaction between diagnostic group and radiopharmaceutical (F = 4.71; df = 1,35; p = 0.04), with ""Tc-ECD demonstrating better separation of R values between AD patients and control subjects than ""Tc-HMPAO. Receiver operating characteristic (ROC) analysis revealed no significant difference in the ability of the two tracers to correctly classify AD patients and control subjects. Both tracers showed high diagnostic accuracy (""Tc-ECD: sensi tivity = 100%, specificity = 92%; ""Tc-HMPAO: sensitivity = 100%, specificity = 85%). Conclusion: Technetium-99m-ECD shows greater contrast than ""Tc-HMPAO between affected and unaffected brain structures in AD when patients are compared to age-matched control subjects. Both tracers perform equally well in correctly classifying patients and control subjects.
An 83-year-old woman with a history of coronary artery disease presented with anterior ST-elevati... more An 83-year-old woman with a history of coronary artery disease presented with anterior ST-elevation myocardial infarction. During coronary intervention, she was found to have a ventricular septal rupture, but was felt not to be a surgical candidate due to advanced shock. She was offered transcatheter repair using an Amplatzer post-infarction muscular ventricular septal defect occluder and recovered completely. She was discharged, but returned four months later with chest pain. A cardiac CT and contrast-enhanced echocardiogram revealed a left ventricular pseudoaneurysm. She underwent transcatheter repair using an Amplatzer Vascular Plug II and recovered without further sequelae.
Journal of nuclear cardiology : official publication of the American Society of Nuclear Cardiology, Jan 5, 2016
In animal models of heart failure (HF), myocardial metabolism shifts from high-energy fatty acid ... more In animal models of heart failure (HF), myocardial metabolism shifts from high-energy fatty acid (FA) metabolism toward glucose. However, FA (vs glucose) metabolism generates more ATP/mole; thus, FA metabolism may be especially advantageous in HF. Sex modulates myocardial blood flow (MBF) and substrate metabolism in normal humans. Whether sex affects MBF and metabolism in patients with HF is unknown. We studied 19 well-matched men and women with nonischemic HF (EF ≤ 35%). MBF and myocardial substrate metabolism were quantified using positron emission tomography. Women had higher MBF (mL/g/minute), FA uptake (mL/g/minute), and FA utilization (nmol/g/minute) (P < 0.005, P < 0.005, P < 0.05, respectively) and trended toward having higher FA oxidation than men (P = 0.09). These findings were independent of age, obesity, and insulin resistance. There were no sex-related differences in fasting myocardial glucose uptake or metabolism. Higher MBF was related to improved event-free ...
Direct aortic access for transcatheter aortic valve replacement (DA-TAVR) is an important alterna... more Direct aortic access for transcatheter aortic valve replacement (DA-TAVR) is an important alternative approach in patients with hostile ileo-femoral vessels. Planning the transaortic puncture site and an 'ideal' trajectory towards the annulus plane is important for safe and successful valve implantation. The feasibility of three-dimensional (3D) planning and real-time fluoroscopic image guidance for DA-TAVR was evaluated using pre-procedural multi-detector computed tomography (MDCT) and intra-procedural Dyna CT co-registration approaches. Between May 2012 and August 2014, a total of 44 patients (40 mini-sternotomies, four mini-thoracotomies) was selected for DA-TAVR using the authors' MDCT-Dyna CT co-registration approach (32 CoreValve, 12 SAPIEN). Pre-procedural contrast-enhanced multi-slice CT (MSCT) and intra- procedural non-contrast Dyna CT images were co-registered based on cardiac outline and aortic root calcifications. Using a prototype software, the aortic root w...
Sedation/anesthesia is critical to cardiac catheterization in the pediatric/congenital heart pati... more Sedation/anesthesia is critical to cardiac catheterization in the pediatric/congenital heart patient. We sought to identify current sedation/anesthesia practices, the serious adverse event rate related to airway, sedation, or anesthesia, and the rate of intra-procedural conversion from procedural sedation to the use of assisted ventilation or an artificial airway. Data from 13,611 patients who underwent catheterization at eight institutions were prospectively collected from 2007 to 2010. Ninety-four (0.69 %) serious sedation/airway-related adverse events occurred; events were more likely to occur in smaller patients (\4 kg, OR 4.4, 95 % CI 2.3-8.2, p \ 0.001), patients with non-cardiac comorbidities (OR 1.7, 95 % CI 1.1-26, p \ 0.01), and patients with low mixed venous oxygen saturation (OR 2.3, 95 % CI 1.4-3.6, p \ 0.001). Nine thousand three hundred and seventy-nine (69 %) patients were initially managed with general endotracheal anesthesia, LMA, or tracheostomy, whereas 4232 (31 %) were managed with procedural sedation without an artificial airway, of which 75 (1.77 %) patients were converted to assisted ventilation/general anesthesia. Young age (\12 months, OR 5.2, 95 % CI 2.3-11.4, p \ 0.001), higher-risk procedure (category 4, OR 10.1, 95 % CI 6.5-15.6, p \ 0.001), and continuous pressor/inotrope requirement (OR 11.0, 95 % CI 8.6-14.0, p \ 0.001) were independently associated with conversion. Cardiac catheterization in pediatric/congenital patients was associated with a low rate of serious sedation/airway-related adverse events. Smaller patients with non-cardiac comorbidities or low mixed venous oxygen saturation may be at higher risk. Patients under 1 year of age, undergoing high-risk procedures, or requiring continuous pressor/inotrope support may be at higher risk of requiring conversion from procedural sedation to assisted ventilation/general anesthesia.
Journal of the American College of Cardiology, 2015
Background: Atrial septal defects are common congenital heart defects encountered in adulthood th... more Background: Atrial septal defects are common congenital heart defects encountered in adulthood that in rare cases may lead to marked pulmonary artery (PA) dilatation. case: A 59-year-old woman was transferred for lung transplantation evaluation due to pulmonary hypertension. Physical exam revealed severe respiratory distress with signs of right-sided heart failure. The patient required intubation, ionotropes, tadalafil, epoprostenol, and inhaled nitric oxide for stabilization. decision Making: Echocardiography revealed a left-to-right shunt consistent with a superior sinus venosus atrial septal defect (SVASD). Preoperative evaluation revealed a severely enlarged PA with compression of the left main coronary artery (LMCA), left main bronchus (LMB) and left lung. (Figure 1) This was further complicated by partial anomalous pulmonary venous return (PAPVR) of the right aerated lung. The patient was too unstable for a more extensive surgery so underwent repair of the SVASD and PAPVR. Despite normalization of PA pressures postoperatively, compression of the LMCA and LMB persisted. Stenting of the LMCA and LMB was performed to relieve the obstruction until PA reverse remodeling could occur. She tolerated the procedures well and at 6-month follow-up was ambulatory without oxygen. conclusion: This case demonstrates a SVASD complicated by compression of adjacent structures by the PA. A novel hybrid surgical and percutaneous approach was performed and may be ideal for critically ill patients.
An 83-year-old woman with a history of coronary artery disease presented with anterior ST-elevati... more An 83-year-old woman with a history of coronary artery disease presented with anterior ST-elevation myocardial infarction. During coronary intervention, she was found to have a ventricular septal rupture, but was felt not to be a surgical candidate due to advanced shock. She was offered transcatheter repair using an Amplatzer post-infarction muscular ventricular septal defect occluder and recovered completely. She was discharged, but returned four months later with chest pain. A cardiac CT and contrast-enhanced echocardiogram revealed a left ventricular pseudoaneurysm. She underwent transcatheter repair using an Amplatzer Vascular Plug II and recovered without further sequelae.
Centrally acting cholinergic drugs have been reported to increase regional cerebral blood flow (r... more Centrally acting cholinergic drugs have been reported to increase regional cerebral blood flow (rCBF) as measured by single photon emission computed tomography (SPECT) in brain regions affected by Alzheimer&amp;amp;amp;amp;#39;s disease (AD). We studied the effects of the acetylcholine releaser linopirdine (LPD) on SPECT rCBF in patients with probable AD. Twenty-four AD patients (12 M, 12 F; mean age +/- SD = 68.9 +/- 8.2 years) and 13 healthy controls (8 M, 5 F; 68.4 +/- 8.0 years) participated. AD patients were scanned with 20 mCi of Tc99m-ECD at baseline and following 4 weeks of treatment with LPD 40 mg TID (n = 15) or placebo TID (n = 9) in a double-blind trial. Healthy subjects were scanned for comparison with baseline AD scans. Cortical/cerebellar rCBF ratios were derived for nine cortical structures. The combined parietal association cortex showed a 20.6% reduction in patients relative to controls. Patients treated with LPD showed an increase in parietal rCBF of 4.1 +/- 5.8%; whereas those treated with placebo showed a decrease of -2.0 +/- 7.4% (F = 5.13; df = 1, 22; P = 0.03). These data support the conclusion that rCBF abnormalities in AD are, in part, truly &amp;amp;amp;amp;quot;functional&amp;amp;amp;amp;quot; and can be selectively altered with pharmacological interventions. The parietal activation seen with LPD and other cholinergic AD drug therapies suggests the importance of measuring parietal lobe neuropsychological function in the course of evaluating these drugs.
Background Double-outlet right ventricle (DORV) with a restrictive ventricular septum is a rare b... more Background Double-outlet right ventricle (DORV) with a restrictive ventricular septum is a rare but highly morbid phenomenon that can be complicated by progressive left ventricular hypertrophy, arrhythmias, aneurysm formation, severe pulmonary hypertension, and death in the newborn. Surgical creation or enlargement of a ventricular septal defect (VSD) is palliative but may damage the conduction system or the atrioventricular valves in the newborn. This report presents a transcatheter approach to palliation for a newborn that had DORV with a restrictive ventricular septum. Methods/Results A full-term infant girl (2.9 kg) referred for hypoxia (80 % with room air) and murmur was found to have DORV, interrupted inferior vena cava, and restrictive VSD (95-mmHg gradient). Transhepatic access was performed, and an internal mammary (IM) catheter was advanced through the atrial septal defect and into the left ventricle. By transesophageal echocardiographic guidance, a Baylis radiofrequency perforation wire was used to cross the ventricular septum, and the defect was enlarged using a 4-mm cutting balloon. A bare metal stent then was deployed to maintain the newly created VSD. The patient did well after the procedure but required pulmonary artery banding 4 days later. She returned 5 months later with cyanosis and the development of obstructing right ventricle muscle bundles, requiring further surgical palliation. Conclusions This report describes the first transcatheter creation of VSD in DORV with a restrictive ventricular septum in a newborn infant. Use of the radiofrequency catheter in combination with cutting balloon dilation and stent implantation is an efficient method for creating a VSD in such a patient.
Continued advancements in congenital cardiac catheterization and interventions have resulted in i... more Continued advancements in congenital cardiac catheterization and interventions have resulted in increased patient and procedural complexity. Anticipation of lifethreatening events and required rescue measures is a critical component to preprocedural preparation. We sought to determine the incidence and nature of life-threatening adverse events in congenital and pediatric cardiac catheterization, risk factors, and resources necessary to anticipate and manage events. Data from 8905 cases performed at the 8 participating institutions of the Congenital Cardiac Catheterization Project on Outcomes were captured between 2007 and 2010 [median 1,095/site (range 133-3,802)]. The incidence of all life-threatening events was 2.1 % [95 % confidence interval (CI) 1.8-2.4 %], whereas mortality was 0.28 % (95 % CI 0.18-0.41 %). Fifty-seven life-threatening events required cardiopulmonary resuscitation, whereas 9 % required extracorporeal membrane oxygenation. Use of a risk adjustment model showed that age \1 year [odd ratio (OR) 1.9, 95 % CI 1.4-2.7, p \ 0.001], hemodynamic vulnerability (OR 1.6, 95 % CI 1.1-2.3, p \ 0.01), and procedure risk (category 3: OR 2.3, 95 % CI 1.3-4.1; category 4: OR 4.2, 95 % CI 2.4-7.4) were predictors of life-threatening events. Using this model, standardized life-threatening event ratios were calculated, thus showing that one institution had a lifethreatening event rate greater than expected. Congenital cardiac catheterization and intervention can be performed safely with a low rate of life-threatening events and mortality; preprocedural evaluation of risk may optimize preparation of emergency rescue and bailout procedures. Risk predictors (age \ 1, hemodynamic vulnerability, and procedure risk category) can enhance preprocedural patient risk stratification and planning.
Obesity adversely affects myocardial metabolism, efficiency, and diastolic function. Our objectiv... more Obesity adversely affects myocardial metabolism, efficiency, and diastolic function. Our objective was to determine whether weight loss can ameliorate obesity‐related myocardial metabolism and efficiency derangements and that these improvements directly relate to improved diastolic function in humans. We studied 30 obese (BMI >30 kg/m2) subjects with positron emission tomography (PET) (myocardial metabolism, blood flow) and echocardiography (structure, function) before and after marked weight loss from gastric bypass surgery (N = 10) or moderate weight loss from diet (N = 20). Baseline BMI, insulin resistance, hemodynamics, left ventricular (LV) mass, systolic function, myocardial oxygen consumption (MVO2), and fatty acid (FA) metabolism were similar between the groups. MVO2/g decreased after diet‐induced weight loss (P = 0.009). Total MVO2 decreased after dietary (P = 0.02) and surgical weight loss (P = 0.0006) and was related to decreased BMI (P = 0.006). Total myocardial FA ut...
The Journal of Thoracic and Cardiovascular Surgery, 2014
can be visualized, the procedure should be undertaken cautiously, because the aorta is located in... more can be visualized, the procedure should be undertaken cautiously, because the aorta is located in a deep place between the esophagus and thoracic vertebra. The aortas from which we harvested the adventitia were all normal tissues. Adventitia from aortas with various aortic disorders such as aortic aneurysm, aortic infection, aortic wall calcification, and rare diseases such as Marfan syndrome and Loeys-Dietz syndrome should be excluded. Constructing a no-treatment control group of patients with high BPF risk seems to be a good way to show the effectiveness of this procedure, but this is contrary to medical ethics. CONCLUSIONS Bronchial stump or anastomotic stoma reinforcement with aortic adventitia flap is a convenient and safe technique that is suitable for selected patients at potential risk of developing BPF following left pulmonary resection.
Journal of the American College of Cardiology, 2010
... 242 Authors: Chun H. Lin, Pilar Herrero, Pablo Soto, Jasdeep Sidhu, Suraj Kurup, Al Waggoner,... more ... 242 Authors: Chun H. Lin, Pilar Herrero, Pablo Soto, Jasdeep Sidhu, Suraj Kurup, Al Waggoner, Deborah L. Delano, Robert J. Gropler, Linda R. Peterson, Washington University School of Medicine, St Louis, MO Background ...
Journal of the American College of Cardiology, 2013
Background: Prediction of an optimal C-arm angle that aligns the coronary sinuses for valve deplo... more Background: Prediction of an optimal C-arm angle that aligns the coronary sinuses for valve deployment is critical during TAVR. Current solutions derive the deployment angle from multiple angiograms, reconstruction of multi-slice CT (MSCT) or C-arm CT rotational angiography (CTRA). We evaluated a method based on co-registration of MSCT and CTRA to predict deployment angle without using additional contrast agent. methods: Non-contrast CTRA (syngo DynaCT®) was acquired using a 5-sec protocol, with breath-hold and rapid-pacing. Aortic root calcifications from CTRA and MSCT were segmented and aligned with a semi-automatic rigid image registration algorithm. Optimal deployment angle was derived using prototype software (Siemens AG, Germany). This approach also accounted for differences in patient positioning. To evaluate the adequacy of the predicted angle, we compared the number of planning aortic root angiograms before and after adopting our co-registration approach. results: From Oct 2011 to Oct 1012, 10 patients underwent TAVR using predicted angle from MSCT alone, and 24 patients using co-registration. 7/10 pts (70%) in MSCT group required >2 angiograms before prosthesis insertion, compared to 3/24 pts (12.5%) in the co-registered group. conclusion: We propose a method to predict optimal C-arm angle for valve deployment based on MSCT-CTRA (non-contrast) co-registration. Such image registration strategies can potentially help in limiting contrast usage.
Journal of the American College of Cardiology, 2011
Background: We have shown previously that women exhibit a greater increase in myocardial fatty ac... more Background: We have shown previously that women exhibit a greater increase in myocardial fatty acid utilization and oxidation with the development of obesity and type 2 diabetes (T2DM) compared with men. However, whether sex impacts the intramyocellular metabolism of glucose in these conditions is unknown. Methods: Three groups-nonobese (N=10; 6 women), obese (N=26; 17 women), and T2DM subjects (N=73; 40 women) underwent positron emission tomography for quantification of myocardial utilization (MGU; nmol/g/min), and intramyocellular metabolism (nmol/g/min) using C11glucose and well-validated mathematical modeling. Results: In the men, MGU, glycolysis, glycogen synthesis, and glucose oxidation rates were different among the 3 groups (ANOVAs P<0.05). The significant post-hoc comparisons (Fischer's exact test) between any 2 of the 3 groups are shown by the P values on the Figure, left panel. In the women, there were no differences in MGU, glycolysis, glycogen storage, or glucose oxidation rates among the 3 groups. Conclusions: The detrimental effect of obesity and T2DM on myocardial glucose metabolism is more pronounced in men compared with women. When taken together with our prior observations, it appears sex impacts the myocardial metabolic response to obesity and T2DM, with fatty acid metabolism being more affected in women and glucose metabolism in men. This sexual dimorphism suggests that sex will impact any therapeutic metabolic manipulation in these patients.
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