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Biomedical subjects

Sary F Aranki

Publications and source records attributed to Sary F Aranki.

At least 19 recordsLinked to original sources
PubMed2006

Acute hemodynamic collapse after induction of general anesthesia for emergent pulmonary embolectomy.

Patients undergoing pulmonary embolectomy often experience hemodynamic deterioration during induction of general anesthesia (GA). Therefore, we studied the incidence and possible risk factors for hemodynamic deterioration during GA induction. Fifty-two consecutive patients undergoing emergent pulmonary embolectomy at our institution were included. Hemodynamic collapse after GA induction was defined as hypotension refractory to vasopressor, inotrope, or fluid administration, requiring cardiopulmonary resuscitation followed by urgent institution of cardiopulmonary bypass (CPB). Demographic variables, comorbidities, specific location of thromboemboli, preoperative inotropic support, and anesthetic drugs used for GA induction were evaluated as possible risk factors. After GA induction, hemodynamic collapse occurred in 19% of patients (n = 10). However, the occurrence of hemodynamic instability was not predicted by any of the evaluated risk factors. In addition, the incidence of in-hospital mortality did not differ between hemodynamically stable or unstable patients (10%; 4 of 42 versus 10%; 1 of 10 patients, respectively). In conclusion, hemodynamic deterioration after GA induction develops frequently during emergent pulmonary embolectomy. On the basis of our experience from this study and the unpredictable nature of hemodynamic deterioration, we suggest that patients undergoing pulmonary embolectomy should be prepared and draped before GA induction, and a cardiac surgical team should immediately be available for emergent institution of cardiopulmonary bypass.

Acute Disease↗
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

Balancing the benefit and risk of oral antiplatelet agents in coronary artery bypass surgery.

Concern about possible hemorrhagic complications arising from use of oral antiplatelet agents in immediate proximity to coronary artery bypass graft (CABG) surgery leads many clinicians to avoid or discontinue these agents preoperatively. Recent evidence suggests that aspirin and clopidogrel can be used with relative safety in the preoperative period; dual antiplatelet therapy in the 5 days immediately preceding CABG surgery results in a moderate and variable increase in the risk of procedural bleeding. This modest hemorrhagic risk may be acceptable, given the clinical benefits of sustained antiplatelet therapy in preventing graft occlusion and ischemic complications pre- and post-CABG. Because the bleeding risk with aspirin is dose dependent, use of a low dose is preferred post-CABG.

Administration, Oral↗
PubMed2005

Evaluation of the enclose proximal anastomosis device in coronary artery bypass grafting.

PURPOSE: Minimal manipulation of the ascending aorta during coronary artery bypass grafting may reduce the incidence of adverse perioperative events related to atheroembolic events. The objective of this study was to evaluate a new proximal anastomotic device (Novare Enclose device [Novare Surgical Systems, Cupertino, CA]). DESCRIPTION: Over a 23-month period, a total of 76 proximal anastomoses were performed in 50 patients (40 males and 10 females; mean age, 74.36 years). In 45 patients, the proximal anastomosis was constructed before the distal (25 off-pump and 20 on-pump), and in 5 patients the proximal anastomosis was constructed on cardiopulmonary bypass because of diseased ascending aortas. EVALUATION: The average time per anastomosis was <8 minutes. There were no device related complications. There were no atheroembolic complications in this cohort of patients. One patient underwent cardiac catheterization postoperatively, and the proximal vein anastomosis in this patient was widely patent. CONCLUSIONS: The Novare Enclose proximal anastomotic device (Novare Surgical Systems) appears to be safe and effective as a tool for proximal anastomosis within a reasonable time period and is comparable with accepted techniques.

Aged↗
PubMed2005

Hypothermic circulatory arrest enables aortic valve replacement in patients with unclampable aorta.

BACKGROUND: Atheroembolic complications associated with clamping a severely diseased ascending aorta during aortic valve replacement may result in unacceptable mortality and morbidity. Different management options include hypothermic circulatory arrest to replace the aortic valve, an aortic endarterectomy, or tube graft replacement of the aorta to allow safe application of cross-clamp before aortic valve replacement. METHODS: From 1998 to 2004, 70 patients who underwent aortic valve replacement had an aorta that was unclampable. Median age was 76 years; 33 (47%) were women; 46 (66%) had concomitant coronary artery bypass grafting; 9 (13%) had concomitant mitral valve surgery; and 4 (6%) were reoperations. Hypothermic circulatory arrest was used to replace the aortic valve alone, to do an aortic endarterectomy, or replace the ascending aorta with a tube graft. RESULTS: Operative mortality was 4%. There were 8 (11%) strokes and 1 (1.4%) transient ischemic attack. Statistical analysis showed no association between circulatory arrest period and occurrence of adverse cerebral events. There was no significant difference among the three groups when operative mortality and cerebral events were compared. CONCLUSIONS: Hypothermic circulatory arrest is an important adjunct that allows aortic valve replacement to be performed with an acceptable mortality but with an increased risk of cerebral event in this high-risk and elderly group of patients.

Adult↗
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↗
PubMed2004

Unrecognized left ventricular thrombus during reoperative coronary artery bypass grafting.

Left ventricular thrombus after myocardial infarction is relatively common but rarely threatening enough to warrant surgical removal at the time of coronary revascularization. The rare cases of ventricular thrombectomy described in the literature involve a pedunculated thrombus. We describe an urgent coronary revascularization procedure in a patient who had unrecognized left ventricular thrombus. The large clot was detected by transesophageal echocardiography after decannulation in a hemodynamically unstable patient. The thrombus was removed after placing the patient back on cardiopulmonary bypass emergently. He recovered and was discharged with no neurologic sequelae. Aggressive removal of clot using cardiopulmonary bypass is warranted even for the critically ill patient.

Aged↗
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

Severe argatroban-induced coagulopathy in a patient with a history of heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia is a serious complication of heparin therapy, and it remains a therapeutic challenge in the subset of patients requiring cardiopulmonary bypass. Alternative anticoagulation strategies include lepirudin, danaparoid, bivalirudin, and argatroban, or a combination of unfractionated heparin with a platelet antagonist. Argatroban is eliminated by a hepatic route, making it a practical option for patients with renal insufficiency. However, the lack of an effective antidote poses a significant problem. We present a patient with a history of heparin-induced thrombocytopenia with thrombosis who underwent a redo aortic valve replacement. Although the level of anticoagulation achieved with argatroban was initially adequate, its persistence after the completion of cardiopulmonary bypass proved to be life threatening.

Aged↗
PubMed2004

One thousand minimally invasive valve operations: early and late results.

OBJECTIVE: We sought to evaluate the potential benefits of minimally invasive approaches for treatment of isolated aortic and mitral valve disease. METHODS: From 7/96 to 04/03, we performed 1000 minimally invasive valve operations: 526 aortic (AV) procedures (64 years; mean, 25-95) and 474 mitral (MV) procedures (58 years; mean, 17-90). RESULTS: In the AV group, an upper ministernotomy was used in 492/526 patients (93%) and a right parasternal approach in 34 (7%). Sixty-three patients had reoperative aortic valve replacements. In the MV group lower sternotomy was used in 260/474 (55%), right parasternal in 200/474 (42%), and a right thoracotomy in 14 patients. MV repair was performed in 416 and MV replacement in 58 patients. Operative mortality was 12/526 (2%) in the AV and 1/474 (0.2%) in the MV group. Freedom from reoperation at 6 years was 99% and 95% in the AV and MV group, respectively. Late mortality was 5% in the AV and 3% in the MV group, respectively. CONCLUSIONS: Minimally invasive valve surgery can be performed at very low levels of morbidity and mortality, with results equal to or better than conventional techniques. All forms of valve repair and replacement operations can be performed. Long-term survival and freedom from reoperation are excellent.

Adult↗
PubMed2003

Development and validation of a simple risk score to predict the need for permanent pacing after cardiac valve surgery.

OBJECTIVES: The study objective was to develop and validate a simple risk score to predict postoperative permanent pacing (PPM) after valve surgery. BACKGROUND: Our ability to identify patients preoperatively that will require PPM is poor. A simple preoperative risk score to predict PPM after valve surgery could assist both clinical practice and research. METHODS: All valve surgery patients at our institution from 1992 to 2002 were included (n = 4,694). Two-thirds of the patients were randomly selected to form a risk score prediction group (PG), and the score was then applied to the remaining patients (validation group [VG]). RESULTS: Preoperative right bundle branch block (odds ratio [OR], 3.6; 95% confidence interval [CI], 2.3 to 5.7) and multivalve surgery that included the tricuspid valve (OR, 3.7; 95% CI, 2.3 to 6.1) were the strongest independent predictors of PPM, while multivalve surgery that did not include the tricuspid valve (OR, 2.1; 95% CI, 1.3 to 3.3), preoperative left bundle branch block (OR, 2.0; 95% CI, 1.3 to 2.9), preoperative PR interval >200 ms (OR, 1.9; 95% CI, 1.3 to 3.0), prior valve surgery (OR, 1.8, 95% CI, 1.2 to 2.7), and age >70 years (OR, 1.4; 95% CI, 1.04 to 2.0) also predicted PPM. A risk score from 0 to 6 identified patients in the VG with incidences of PPM of 1.9%, 5.2%, 8.7%, 11.5%, 21%, 36%, and 50%, respectively. CONCLUSIONS: A simple risk score incorporating preoperative conduction, age, prior valve surgery, and surgery type predicts PPM after valve surgery. This score may be useful in the perioperative management of valve surgery patients.

Aged↗
PubMed2003

Minimally invasive mitral valve repair suggests earlier operations for mitral valve disease.

OBJECTIVE: We began minimally invasive mitral valve surgery in August, 1996, to reduce hospital costs, to improve patient recovery, cosmetic appearance, and to decrease trauma, yet maintain the same quality of surgery. To validate this approach we reviewed our entire experience through May 2002. METHODS: From August 1996 to May 2002, we performed 413 minimally invasive mitral valve operations including 51 mitral valve replacements and 362 mitral valve repairs. Excluding 4 robotically assisted repairs, we evaluated 358 patients, using the mitral valve repairs as the basis for this retrospective survey. These operations were performed through a 6- to 8-cm minimally invasive incision, beginning with parasternal and, most recently, lower ministernotomy (181 patients). The mitral valve reparative techniques include repair of 94 prolapsed anterior leaflets, posterior leaflet resection, leaflet advancement, commissuroplasty, Polytetrafluoroethylene (PTFE; Gore-Tex, W. L. Gore & Associates, Inc, Flagstaff, Ariz) chordal placement, and ring annuloplasty. Cannulation sites varied but primarily utilized a miniaturized system of 24F catheters in both the inferior and superior venae cavae with assisted venous suction. The Cosgrove ring was used in 95% of the patients undergoing this procedure. RESULTS: The operative mortality was 0/358. Perioperative morbidity included a 26% incidence of new atrial fibrillation, 2% incidence of pacemaker implantation, 0.5% incidence of deep sternal wound infection, and 1.9% incidence of stroke after an operation. There were 10 arterial and 3 venous complications. The mean length of stay was 6 days and 208 patients stayed < or =5 days. Only 25% of the patients underwent homologous blood transfusion. The mean follow-up was 36 months with 1.4% lost to follow-up. There were 12 late deaths and a survival at 5 years of 95%. There were 21 valves requiring reoperation for structural valve failure of 5.8%. The probability of freedom from reoperation at 5 years was 92%. CONCLUSION: This study documents the safety of minimally invasive mitral valve repair surgery in 358 patients. It also documents a low incidence of homologous blood use, requirement for post-hospital rehabilitation, and general morbidity.

Adolescent↗
PubMed2003

Biological vs. mechanical aortic root replacement.

OBJECTIVES: Although age and co-existing coronary disease are major determining factors when deciding valve choice (mechanical vs. biological) in simple aortic valve replacement, no studies have documented selection criterion for biological (BIO) vs. mechanical (MECH) aortic root prosthesis. METHODS: Two hundred and twenty-one consecutive patients underwent elective aortic root replacement with either BIO (homograft, n=111, Freestyle, n=25) or MECH composite grafts (n=85). Median age in BIO was 53 years and in MECH 54 years (P=NS). Groups were similar in gender, NYHA class and ejection fraction (BIO, EF=59% vs. MECH, EF=55%), but the need for concomitant coronary artery bypass grafting (CABG) did differ between groups (MECH=35% vs. BIO=17%, P=0.003). Mean follow-up was 42+/-28 months for mortality and 39+/-28 months for morbidity. RESULTS: Full root replacement was performed in 213 patients (96%) and hemi-root in eight (4%). The most common underlying etiologies were annulo-aortic ectasia (n=82, 37%), calcified-degenerative (n=73, 33%) and bicuspid/congenital aortic valve disease (n=39, 18%). Operative mortality was 1.5% for BIO and 2.4% for MECH (P=0.5). By univariate analysis there was a trend towards greater 5-year survival in BIO (92.4% vs. 88.2%, P=0.068). By multivariate analysis, increasing age (HR=2.4, P=0.003), previous valve replacement (HR=4.7, P=0.024), concomitant CABG (HR=3.7, P=0.032), and perioperative stroke (HR=9.9, P=0.0005) were all independent predictors of late death. The 5-year freedom from valve-related complications was similar in both groups (BIO=93% vs. MECH=86%, P=0.5). CONCLUSIONS: Elective aortic root replacement is an exceedingly safe operation. At mean follow-up of 4 years, there is no meaningful difference in early or mid term valve-related results between BIO and MECH aortic root replacement. Continued evaluation for late valve-related complications in this cohort will be necessary to determine the advantages, if any, of one prosthesis over the other.

Adult↗