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Biomedical subjects

James D Rawn

Publications and source records attributed to James D Rawn.

At least 19 recordsLinked to original sources
PubMed2006

Predicting survival in patients requiring renal replacement therapy after cardiac surgery.

BACKGROUND: We sought to develop and internally validate a prediction score for all-cause in-hospital mortality in patients who have acute renal failure and require renal replacement therapy after cardiac surgery. METHODS: From January 1992 to July 2001, 136 of 14,000 patients (0.9%) had acute renal failure requiring renal replacement therapy after cardiac surgery. Multivariate logistic regression analysis, based on pre-renal replacement therapy variables, was used to construct a predictive score for all causes of in-hospital mortality. Subsequently, the score was validated in 27 patients who underwent surgery between August 2001 and March 2003. RESULTS: In-hospital mortality was 58% (79 of 136). From the logistic regression model, we assigned a score (range, 0 to 6) based on the presence of independent predictors of operative mortality (preoperative creatinine < or = 1.5 mg/dL [odds ratio (OR) = 5.0], hypertension [OR = 4.4], predialysis coma [OR = 9.6], sepsis [OR = 6.4], and total bilirubin > or = 2 mg/dL [OR = 5.6]). Higher scores strongly predicted mortality: patients who scored 3 or higher before the initiation dialysis (n = 54), had a mortality rate of 94% (51 of 54). In contrast, patients who scored 1 or less on this scale (n = 36), had a mortality of 16% (6 of 36). In the validation cohort, the sensitivity of the new score at the cutoff of 2 or fewer points versus 3 or more points was 0.71, the specificity was 0.90, the positive predictive value was 0.92, and the negative predictive value was 0.64. CONCLUSIONS: The prediction score represents a simple and accurate tool for predicting in-hospital mortality associated with renal replacement therapy for cardiac surgery patients before the institution of this resource-intensive treatment.

Acute Kidney Injury↗
PubMed2005

Staged initial percutaneous coronary intervention followed by valve surgery ("hybrid approach") for patients with complex coronary and valve disease.

OBJECTIVES: The goal of this study was to determine if a "hybrid" approach to the treatment of complex combined coronary and valve disease is superior to the results predicted by a Society of Thoracic Surgeons' (STS) algorithm with conventional coronary artery bypass graft (CABG)/valve surgery in high-risk patients. BACKGROUND: With advancements in percutaneous coronary interventions (PCIs), some patients requiring coronary revascularization and valve surgery may benefit from a hybrid approach involving initial planned PCI followed by valve surgery, rather than conventional CABG/valve surgery. METHODS: We retrospectively analyzed 26 consecutive patients with coronary artery and valve disease who underwent planned initial PCI followed by valve surgery during the same hospital stay between September 1997 and August 2003. We calculated the predicted mortality at the time of PCI and compared it with the observed mortality. RESULTS: There were 12 male and 14 female patients with a median age of 72 years (range 53 to 91 years). Balloon angioplasty was performed in all patients, followed by stenting in 22 (85%) patients. Within a median of 5 days (range 0 to 14 days), 15 patients (58%) underwent primary and 11 patients (42%) underwent re-operative valve surgery. Operative mortality was 1 of 26 patients (3.8%), dramatically lower than the STS-predicted mortality of 22%. Median blood loss was 900 ml, and 22 patients (85%) required blood transfusions. Survival at 1, 3, and 5 years was 78%, 56%, and 44%, respectively. CONCLUSIONS: Hybrid initial PCI followed by staged valve surgery represents an excellent alternative to conventional CABG/valve surgery in some high-risk patients, particularly those who present in shock after myocardial infarction. Lower mortality rates come at the cost of more bleeding and transfusion requirements.

Aged↗
PubMed2005

Risk factors and outcomes of pancreatitis after open heart surgery.

BACKGROUND: We sought to analyze the risk factors and natural history associated with post-cardiac surgery acute pancreatitis. METHODS: Retrospective analysis of all patients having undergone cardiac surgery at our hospital between January 1, 1992, and October 1, 2001. RESULTS: A total of 10,249 cardiac operations were performed. Thirty-nine (0.4%) patients developed postoperative pancreatitis. There was a higher incidence during the period spanning 1992 through 1996 than 1997 through 2001 (0.6% versus 0.2%, P< .05). Patients with pancreatitis had longer postoperative length of stay (51+/-5 days versus 10+/-1 days, P<.05) and a greater in-hospital mortality rate (28% versus 4%, P<.05) than patients who did not develop pancreatitis. A history of alcohol abuse, cardiac surgery performed during 1992 to 1996, increased cardiopulmonary bypass time, and increased cross-clamp time were independent risk factors for the development of pancreatitis. Multiple-organ failure was an independent predictor for death among patients with pancreatitis. CONCLUSIONS: Although the frequency of post-cardiac surgery pancreatitis is diminishing, it is still associated with significant mortality.

Acute Disease↗
PubMed2005

Impact of concomitant coronary artery bypass grafting on hospital survival after aortic root replacement.

BACKGROUND: We examined the impact of concomitant coronary artery bypass grafting (CABG) on hospital survival after aortic root replacement. We sought to determine whether CABG procedures that were not originally planned but rather added after the aortic root procedure was completed (CABG/bailout) skewed the results to shift patients with bad outcomes to the CABG group, making the non-CABG group appear undeservedly low risk. METHODS: Between May 1992 and January 2001, 369 consecutive patients underwent aortic root replacement. Concomitant CABG was required in 95 patients (26%). Indications for CABG were significant coronary artery disease in 73 patients (20%), active endocarditis or acute aortic dissection involving the coronary orifices in 14 patients (4%), and difficulty weaning from bypass because of regional wall motion abnormality from presumed but unconfirmed coronary artery disease or technical error at coronary ostial reimplantation (CABG/bailout) in 8 patients (2%). RESULTS: Operative mortality for the entire cohort was 5.7% (21 patients). The operative mortality rate for the non-CABG group was 0.4% (1 of 274 patients), and for the CABG group, 21% (20 of 95 patients; p < 0.001). Independent predictors of operative mortality in the CABG group were New York Heart Association functional class III or IV (odds ratio, 3.9; 95% confidence interval, 1.07 to 14.5), active endocarditis (odds ratio, 9.2; 95% confidence interval, 2.06 to 41.5), acute aortic dissection (odds ratio, 7.6; 95% confidence interval, 1.81 to 32.0), and failure to use retrograde cardioplegia (odds ratio, 6.4; 95% confidence interval, 1.06 to 38.8). The use of CABG/bailout was not a predictor. CONCLUSIONS: Adding CABG at the end of an aortic root procedure is a rare event, and because it is rare, there is no significant shift of risk as a result of the CABG/bailout patients on the overall CABG group.

Adult↗
PubMed2005

Massachusetts cardiac surgery report card: implications of statistical methodology.

BACKGROUND: Choice of statistical methodology may significantly impact the results of provider profiling, including cardiac surgery report cards. Because of sample size and clustering issues, logistic regression may overestimate systematic interprovider variability, leading to false outlier classification. Theoretically, the use of hierarchical models should result in more accurate representation of provider performance. METHODS: Extensively validated and audited data were available for all 4,603 isolated coronary artery bypass grafting procedures performed at 13 Massachusetts hospitals during 2002. To produce the official Massachusetts cardiac surgery report card, a 19-variable predictor set and a hierarchical generalized linear model were employed. For the current study, this same analysis was repeated with the 14 predictors used in the New York Cardiac Surgery Reporting System. Two additional analyses were conducted using each set of predictor variables and applying standard logistic regression. For each of the four combinations of predictors and models, the point estimates of risk-adjusted 30-day mortality, 95% confidence or probability intervals, and outlier status were determined for each hospital. RESULTS: Overall unadjusted mortality for coronary bypass operations was 2.19%. For most hospitals, there was wide variability in the point estimates and confidence or probability intervals of risk-adjusted mortality depending on statistical model, but little variability relative to the choice of predictors. There were no hospital outliers using hierarchical models, but there was one outlier using logistic regression with either predictor set. CONCLUSIONS: When used to compare provider performance, logistic regression increases the possibility of false outlier classification. The use of hierarchical models is recommended.

Aged↗
PubMed2005

Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after rapid diagnosis and aggressive surgical approach.

OBJECTIVES: This study retrospectively reviews an aggressive multidisciplinary approach to the treatment of massive pulmonary embolism, centering on rapid diagnosis with contrast-enhanced computed tomography of the chest to define the location and degree of clot burden and transthoracic echocardiography to document right ventricular strain followed by immediate surgical intervention when appropriate. METHODS: Between October 1999 through February 2004, 47 patients (30 men and 17 women; median age, 58 years; age range, 24-86 years) underwent emergency surgical embolectomy for massive central pulmonary embolism. The indications for surgical intervention were (1) contraindications to thrombolysis (21/47 [45%]), (2) failed medical treatment (5/47 [10%]), and (3) right ventricular dysfunction (15/47 [32%]). Preoperatively, 12 (26%) of 47 patients were in cardiogenic shock, and 6 (11%) of 47 were in cardiac arrest. RESULTS: There were 3 (6%) operative deaths, 2 with preoperative cardiac arrest; 2 of these 3 patients required a right ventricular assist device. In 38 (81%) patients a caval filter was placed intraoperatively. Median length of stay was 11 days (range, 3-75 days). Median follow-up was 27 months (range, 2-50 months); follow-up was 100% complete in surviving patients. There were 6 (12%) late deaths, 5 of which were from metastatic cancer. Actuarial survival at 1 and 3 years' follow-up was 86% and 83%, respectively. CONCLUSION: An aggressive approach to large pulmonary embolus, including rapid diagnosis and prompt surgical intervention, has improved results with surgical embolectomy. We now perform surgical pulmonary embolectomy not only in patients with large central clot burden and hemodynamic compromise but also in hemodynamically stable patients with right ventricular dysfunction documented by means of echocardiography.

Actuarial Analysis↗
PubMed2005

Valve replacement in women of childbearing age: influences on mother, fetus and neonate.

BACKGROUND AND AIM OF THE STUDY: Currently, there is no clear consensus on the optimal type of cardiac valve prosthesis that should be placed in women of childbearing age. The risks of reoperative surgery for bioprosthetic valves must be weighed against those of anticoagulation therapy required for mechanical valves. Bioprosthetic valves placed in women of childbearing age are not necessarily superior to mechanical valves in terms of maternal or fetal outcomes. METHODS: A retrospective analysis was performed of early and late outcome in 103 women of childbearing age (mean age 28.3 +/- 5.1 years; range: 18-35 years) who underwent mechanical (n = 63) or biological (n = 40) valve replacement between January 1982 and July 2002. RESULTS: Eleven of the 40 women (28%) with biological valves had 19 pregnancies (13 vaginal births; three caesarean sections). Twelve of the 63 women (19%) with mechanical valves had 37 pregnancies (nine vaginal births, four caesarean sections). All of the women with mechanical valves became pregnant while receiving warfarin, and were subsequently placed on heparin or enoxaparin. No bleeding complications or birth defects were observed in either group. The incidence of miscarriages (32% (12/37) versus 11% (2/19), p = 0.09) and therapeutic abortions (32.4% (12/37) versus 5.3% (1/19), p = 0.06) were greater in the group with mechanical valves than with bioprosthetic valves. Freedom from reoperation at five and 10 years for biological versus mechanical valves was 79% versus 90%, and 38% versus 82%, respectively (p < 0.01), with no reoperative mortality. CONCLUSION: Biological valves are recommended in women of childbearing age, despite the fact that no birth defects were seen in children born to women with mechanical valves on warfarin, because the teratogenic effects of warfarin may be masked by the high rate of miscarriages and therapeutic abortions in this group.

Adolescent↗
PubMed2004

Outcomes in patients with normal serum creatinine and with artificial renal support for acute renal failure developing after coronary artery bypass grafting.

This retrospective study of cardiac surgical patients with normal serum creatinine who developed acute renal failure requiring artificial renal support was undertaken to (1) determine the prevalence of acute renal failure and hospital mortality in this subgroup, (2) identify the independent predictors of early mortality, and (3) determine long-term survival and prognosis.

Acute Kidney Injury↗
PubMed2004

Left anterior descending coronary endarterectomy: early and late results in 196 consecutive patients.

BACKGROUND: With advances in percutaneous coronary interventions, many patients now referred for coronary artery bypass grafting have diffuse coronary artery disease. We undertook this retrospective study to determine whether left anterior descending (LAD) coronary endarterectomy is a safe and effective long-term adjunct to coronary artery bypass grafting in patients who cannot otherwise be completely revascularized. METHODS: Between January 1992 and March 2000, 196 of 7,633 (2.5%) consecutive patients underwent LAD coronary endarterectomy with coronary artery bypass grafting. Median age was 67 years (range, 33 to 97 years), 101 patients (52%) had unstable angina, and 182 (93%) were in New York Heart Association class III or IV. Thirty-three patients (17%) had ongoing myocardial infarction; another 17 (9%) had myocardial infarction less than 1 month. Thirty patients (15%) required intraaortic balloon pump preoperatively and 19 (10%) were reoperations. RESULTS: All patients underwent LAD endarterectomy with coronary artery bypass grafting to the LAD. The left internal mammary artery was grafted to the LAD in 151 patients (77%), and 46 of 151 (30%) of these required an additional vein patch to the endarterectomized bed. Concomitant valve procedures were performed in 8 (4%) patients. Overall hospital mortality was 3% (6 of 196). Perioperative myocardial infarction in the LAD territory was 3%. One-year survival was 94% (95% confidence interval, 90% to 97%), whereas 5-year survival was 74% (95% confidence interval, 66% to 80%). Freedom from cardiac events (angina, myocardial infarction, congestive heart failure, percutaneous coronary interventions) was 90% (95% confidence interval, 84% to 94%) at 1 year and 84% (95% confidence interval, 75% to 90%) at 5 years. CONCLUSIONS: Despite the presence of diffuse coronary artery disease, coronary artery bypass grafting with LAD endarterectomy offers excellent results with very low hospital mortality and morbidity, and favorable long-term survival.

Adult↗
PubMed2004

Severity of intraoperative tricuspid regurgitation predicts poor late survival following cardiac transplantation.

BACKGROUND: This study evaluates the significance of tricuspid regurgitation (TR) on long-term survival as detected by intraoperative transesophageal echocardiography at the time of orthotopic heart transplantation. Although significant (2+ to 4+) TR after orthotopic heart transplantation is rare, its influence on long-term survival is unknown, warranting further investigation. METHODS: Between January 1992 and July 2001, 181 consecutive patients underwent orthotopic heart transplantation. Tricuspid regurgitation was graded by intraoperative transesophageal echocardiography after final separation from cardiopulmonary bypass in 130 of 181 patients (72%). RESULTS: Although 80% (104/130) of patients had either no (0, n = 77) or trace (1+, n = 27) TR, 9% (12/130 patients) had mild (2+), 10% (13/130 patients) had moderate (3+), and 0.8% (1/130 patients) had severe (4+) TR. The severity correlated strongly with the presence of right ventricular dysfunction (p < 0.001). In a multivariate regression model, gender mismatch (p = 0.002) and right ventricular dysfunction (p < 0.001) were independent predictors for equal to or greater than mild (2+ to 4+) TR (p = 0.015). Although the degree of recipient pulmonary vascular resistance did not influence the grade (p = 0.600), higher pulmonary vascular resistance tended to increase the severity of TR in the setting of prolonged donor ischemic times (p = 0.054). Proportional hazards regression analysis demonstrated significantly decreased survival for patients with mild or greater (2+ to 4+) TR detected by transesophageal echocardiography at the time of transplantation (p < 0.001) and RV dysfunction (p = 0.023). CONCLUSIONS: Even mild (> or = 2+) TR identified by transesophageal echocardiography at the time of orthotopic heart transplant predicts poor late survival, suggesting a possible role for concomitant tricuspid valve repair at the time of transplant. Whether or not tricuspid valve repair will improve long-term survival is unknown.

Acute Kidney Injury↗
PubMed2004

Risk factors and outcomes for 'vasoplegia syndrome' following cardiac transplantation.

OBJECTIVE: Vasoplegia syndrome after orthotopic heart transplantation (OHT) is a rare but highly lethal syndrome of unknown etiology, characterized by severe refractory hypotension, metabolic acidosis, and decreased systemic vascular resistance (SVR). The objective of this retrospective study was to identify the risk factors contributing to the development of vasoplegia syndrome after OHT in order to provide potential algorithms for its management. METHODS: Between October 1992 and July 2001, 187 consecutive patients underwent OHT. Complete pre- and post-data were available in 147 patients (78%). Mean age was 49+/-11 years, 82% (120/147) were male, and donor ischemic time was 117+/-62 min. Twenty-eight of 147 (19%) developed vasoplegia syndrome, defined as SVR <800 dyns per cm(5) with serum bicarbonate <20 mEq/l. RESULTS: Patients who developed vasoplegia syndrome demonstrated greater hospital mortality (25 vs. 9%, P=0.031) compared to those who did not. Multivariate logistic regression identified pre-operative use of intravenous heparin (OR 2.8, CI 1-7.4, P=0.039) and body surface area >1.9 m(2) (OR 7, CI 0.98-50, P=0.052) as independent predictors for the development of post-operative vasoplegia syndrome. Pre-operative use of inotropic support conferred protection against the development of post-operative vasoplegia syndrome (OR 0.25, CI 0.08-0.79, P=0.018). Pre-operative use of ACE inhibitors was not associated with increased risk (55 vs. 59%, P=0.441). CONCLUSIONS: Vasoplegia syndrome following OHT is associated with high early mortality. The development of a risk stratification profile may help in patient selection as well as the post-operative management of vasoplegia syndrome following OHT.

Acidosis↗
PubMed2004

Delayed presentation of totally avulsed right superior vena cava after extraction of permanent pacemaker lead.

Pacemaker lead extraction has been shown to be an effective and safe treatment for infected permanent pacemaker leads, however, they may lead to potentially serious complications, usually occurring during the extraction procedure. This report describes a case of a 48-year-old woman with a patent persistent left SVC and an infected permanent pacemaker lead of a DDD pacing system who underwent transvenous laser-assisted lead extraction using a combined SVC and femoral approach. Two days after the procedure the patient developed symptoms of SVC obstruction requiring surgical intervention. The right SVC was found to be almost completely destroyed with only a thin strip of the lateral wall intact and active bleeding. The probable causative mechanisms and surgical management are discussed.

Device Removal↗
PubMed2004

Aortic valve replacement in patients with severely reduced left ventricular function.

Aortic valve replacement (AVR) can be done safely in patients with severe aortic stenosis (AS) and depressed ventricular function (ejection fraction < or =35%). Dobutamine echocardiography is useful to identify AS patients with contractile reserve who will benefit from AVR and can be used for risk stratification of these patients. AVR can also be undertaken in patients with severe aortic regurgitation and depressed ventricular function with an acceptable operative mortality. AVR in both groups results in a 5-year survival of approximately 70%, which is similar to that of orthotopic heart transplantation. Due to the comorbidities of immunosuppression and limited donor organ supply, AVR should be attempted prior to transplantation in both these high-risk groups.

Aortic Valve↗
PubMed2004

Tailored surgical therapy for acute native mitral valve endocarditis.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair has been shown superior to valve replacement for the treatment of non-infectious valve disease. The criteria and results of valve repair for native valve endocarditis are still being defined. The study aim was to examine the short- and long-term results of mitral valve repair and replacement for acute infective endocarditis and to define criteria for the use of each technique. METHODS: A total of 53 consecutive patients who presented with acute native mitral valve infective endocarditis (diagnosed less than six weeks before surgery) between January 1992 and June 2002 was retrospectively analyzed. RESULTS: Twenty-one patients (40%) underwent mitral valve repair, and 32 (60%) underwent valve replacement. Operative mortality was 0% for the repair group and 13% (4/32) for the replacement group (p = 0.14). Median follow up was 4 years (range: 6-108 months). At five years follow up, a median ejection fraction (EF) of 60% and mitral regurgitation (MR) grade of 1/4 was observed, with an overall late survival of 85% (19/21), in the repair group, while the replacement group had a median EF of 55% and an overall late survival of 73% (p = 0.73). Recurrent endocarditis occurred in 2/21 (10%) in the repair group and 1/32 (3%) in the replacement group (p = 0.34). CONCLUSION: Mitral valve repair is a safe and effective technique to treat acute native mitral valve infective endocarditis with favorable short- and long-term morbidity and mortality. Patients with advanced endocarditis and annular destruction require valve replacement. Mitral valve repair should be performed when technically feasible.

Acute Disease↗
PubMed2003

Robotic mammary takedown and off-pump bypass surgery for single-vessel disease of the left anterior descending coronary artery.

Robotic takedown of the left internal mammary artery and direct off-pump anastomosis to the left anterior descending artery through small thoracotomy incisions can be done safely with minimal morbidity and is associated with decreased blood loss, decreased ventilatory requirements, less intensive care unit stay, and less overall length of stay. It should be considered as an alternative to percutaneous angioplasty and stenting for those with isolated left anterior descending artery disease.

Adult↗