Publications by authors named "Dominic Emerson"

37 Publications

Long-term outcomes after heart transplantation using ex vivo allograft perfusion in standard risk donors: A single-center experience.

Clin Transplant 2022 Jan 14:e14591. Epub 2022 Jan 14.

Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA.

Introduction: The Organ Care System (OCS) is an ex vivo perfusion platform for donor heart preservation. Short/mid-term post-transplant outcomes after its use are comparable to standard cold storage (CS). We evaluated long-term outcomes following its use.

Methods: Between 2011 and 2013, 38 patients from a single center were randomized as a part of the PROCEED II trial to receive allografts preserved with CS (n = 19) or OCS (n = 19). Endpoints included 8-year survival, survival free from graft-related deaths, freedom from cardiac allograft vasculopathy (CAV), non-fatal major adverse cardiac events (NF-MACE), and rejections.

Results: Eight-year survival was 57.9% in the OCS group and 73.7% in the CS group (p = .24). Freedom from CAV was 89.5% in the OCS group and 67.8% in the CS group (p = .13). Freedom from NF-MACE was 89.5% in the OCS group and 67.5% in the CS group (p = .14). Eight-year survival free from graft-related death was equivalent between the two groups (84.2% vs. 84.2%, p = .93). No differences in rejection episodes were observed (all p > .5).

Conclusions: In select patients receiving OCS preserved allografts, late post-transplant survival trended lower than those transplanted with an allograft preserved with CS. This is based on a small single-center series, and larger numbers are needed to confirm these findings.
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http://dx.doi.org/10.1111/ctr.14591DOI Listing
January 2022

Diagnosing heparin-induced thrombocytopenia in mechanical circulatory support device patients.

J Heart Lung Transplant 2022 Jan 17;41(1):80-85. Epub 2021 Sep 17.

Pathology, Cedars Sinai Medical Center, Los Angeles, California. Electronic address:

Background: Mechanical circulatory support device (MCSD) patients with positive heparin-induced thrombocytopenia (HIT) screening pose a unique challenge, as clinicians must make rapid decisions about their anticoagulation and whether they can safely undergo cardiopulmonary bypass. We identified screening practices at our institution and other institutions nationwide that differed from American Society of Hematology (ASH) guidelines. This discovery prompted a data review to confirm the applicability of guidelines to this unique population and to highlight complications of "gestalt" screening.

Methods: Our study included MCSD patients with HIT testing from April 2014 to August 2020. We evaluated 510 PF4 IgG ELISA results.

Results: HIT was confirmed in 4.2% of patients. There was an increased prevalence of HIT in patients with nondurable (5.3%) vs durable devices (2.9%) or those in the preimplantation setting (1.3%), however this difference was not statistically significant (p = 0.26). None of the patients with a low probability 4T Score had HIT. All patients with a high probability 4T Score and PF4 immunoassay OD >2.0 had HIT. False positive results occurred in 22% of assays ordered for patients with a low probability 4T Score. Twelve patients with a low probability 4T Score and a false positive immunoassay were switched to a direct thrombin inhibitor (DTI) while awaiting confirmatory results. Two patients experienced clinically significant bleeding after conversion to a DTI. An organ was refused in one patient with false positive HIT screening.

Conclusions: Our findings demonstrate that an opportunity exists to improve clinical outcomes by re-emphasizing the utility of established guidelines and highlighting their safe use in the MCSD patient population.
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http://dx.doi.org/10.1016/j.healun.2021.09.006DOI Listing
January 2022

Contemporary Left Ventricular Assist Device Outcomes in an Aging Population: An STS INTERMACS Analysis.

J Am Coll Cardiol 2021 08;78(9):883-894

Kirklin Institute for Research in Surgical Outcomes (KIRSO), Department Surgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.

Background: Survival, functional outcomes, and quality of life after left ventricular assist device (LVAD) are ill-defined in elderly patients, and with new-generation devices.

Objectives: This study sought to evaluate survival, functional outcomes, and quality of life after LVAD in contemporary practice.

Methods: Adults receiving durable LVADs between January 1, 2010, and March 1, 2020, were identified from the INTERMACS (Interagency Registry for Mechanically Assisted Circulatory Support) database. The primary outcome was adjusted survival; secondary outcomes included quality of life rated using a visual analogue scale (where 0 represents "worst health" and 100 "best health"); 6-minute walk distance; stroke; device malfunction; and rehospitalization, stratified by patient age. Median follow-up was 15 months (IQR: 6-32 months).

Results: The cohort comprised 68.9% (n = 16,808) patients aged <65 years, 26.3% (n = 6,418) patients aged 65-75 years, and 4.8% (n = 1,182) patients aged >75 years, who were predominantly male (n = 19,119, 78%) and on destination therapy (n = 12,425, 51%). Competing outcomes analysis demonstrated mortality (70% CIs) of 34% (33%-34%), 54% (54%-55%), and 66% (64%-68%) for patients aged <65, 65-75, and >75 years, respectively, which improved during the study in patients aged >75 years. Newer-generation devices were associated with reduced late mortality (HR: 0.35; 95% CI: 0.25-0.49). Stroke, device malfunction or thrombosis, and rehospitalizations decreased with increasing age (all P < 0.01). Median 6-minute walk distance increased from 0 feet (IQR: 0-665 feet) to 1,065 feet (IQR: 642-1,313 feet) (P < 0.001), and quality of life improved from 40 (IQR: 15-60) to 75 (IQR: 60-90) (P < 0.001) after LVAD in all age groups.

Conclusions: In elderly patients, LVADs are associated with increased functional capacity, similar improvements in quality of life, and fewer complications compared with younger patients.
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http://dx.doi.org/10.1016/j.jacc.2021.06.035DOI Listing
August 2021

Durable Robotic Mitral Repair of Degenerative Primary Regurgitation With Long-Term Follow-Up.

Ann Thorac Surg 2021 Aug 23. Epub 2021 Aug 23.

Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California. Electronic address:

Background: Variation in degenerative mitral morphology may contribute to suboptimal repair rates. This study evaluates outcomes of a standardized mitral repair technique.

Methods: An institutional clinical registry was used to identify 1036 consecutive patients undergoing robotic mitral surgery between 2005 and 2020: 87% (n = 902) had degenerative disease. Calcification, failed transcatheter repair, and endocarditis were excluded, leaving 582 (68%) patients with isolated posterior leaflet and 268 (32%) with anterior or bileaflet prolapse. Standardized repair comprised triangular resection and true-sized flexible band in posterior leaflet prolapse. Freedom from greater than 2+ moderate mitral regurgitation stratified by prolapse location was assessed using competing risk analysis with death as a competing event. Median follow-up was 5.5 (range 0-15) years.

Results: Of patients with isolated posterior leaflet prolapse, 87% (n = 506) had standardized repairs and 13% (n = 76) had additional or nonresectional techniques vs 24% (n = 65) and 76% (n = 203), respectively, for anterior or bileaflet prolapse (P < .001). Adjunctive techniques in the isolated posterior leaflet group included chordal reconstruction (8.6%, n = 50) and commissural sutures (3.4%, n = 20). Overall, median clamp time was 80 (interquartile range, 68-98) minutes, 17 patients required intraoperative re-repair, and 6 required mitral replacement. Freedom from greater than 2+ regurgitation or reintervention at 10 years was 92% for posterior prolapse (vs 83% for anterior or bileaflet prolapse). Anterior or bileaflet prolapse was associated with late greater than 2+ regurgitation (hazard ratio, 3.0; 95% confidence interval, 1.3-7.0).

Conclusions: Posterior leaflet prolapse may be repaired in greater than 99% of patients using triangular resection and band annuloplasty, with satisfactory long-term durability. Increased risk of complex repairs and inferior durability highlights the value of identifying anterior and bileaflet prolapse preoperatively.
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http://dx.doi.org/10.1016/j.athoracsur.2021.07.060DOI Listing
August 2021

Commentary: Mechanical bridge over troubled waters.

J Thorac Cardiovasc Surg 2021 Jun 29. Epub 2021 Jun 29.

Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2021.06.046DOI Listing
June 2021

Recipient and surgical factors trigger severe primary graft dysfunction after heart transplant.

J Heart Lung Transplant 2021 09 10;40(9):970-980. Epub 2021 Jun 10.

Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.

Background: Primary graft dysfunction (PGD) is a major cause of early mortality following heart transplant (HT). The International Society for Heart and Lung Transplantation (ISHLT) subdivides PGD into 3 grades of increasing severity. Most studies have assessed risk factors for PGD without distinguishing between PGD severity grade. We sought to identify recipient, donor and surgical risk factors specifically associated with mild/moderate or severe PGD.

Methods: We identified 734 heart transplant recipients at our institution transplanted between January 1, 2012 and December 31, 2018. PGD was defined according to modified ISHLT criteria. Recipient, donor and surgical variables were analyzed by multinomial logistic regression with mild/moderate or severe PGD as the response. Variables significant in single variable modeling were subject to multivariable analysis via penalized logistic regression.

Results: PGD occurred in 24% of the cohort (n = 178) of whom 6% (n = 44) had severe PGD. One-year survival was reduced in recipients with severe PGD but not in those with mild or moderate PGD. Multivariable analysis identified 3 recipient factors: prior cardiac surgery, recipient treatment with ACEI/ARB/ARNI plus MRA, recipient treatment with amiodarone plus beta-blocker, and 3 surgical factors: longer ischemic time, more red blood cell transfusions, and more platelet transfusions, that were associated with severe PGD. We developed a clinical risk score, ABCE, which provided acceptable discrimination and calibration for severe PGD.

Conclusions: Risk factors for mild/moderate PGD were largely distinct from those for severe PGD, suggesting a differing pathophysiology involving several biological pathways. Further research into mechanisms underlying the development of PGD is urgently needed.
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http://dx.doi.org/10.1016/j.healun.2021.06.002DOI Listing
September 2021

Robotic mitral valve repair following failed transcatheter edge-to-edge repair.

Ann Thorac Surg 2021 Jun 28. Epub 2021 Jun 28.

Department of Cardiac Surgery, Cedars-Sinai, Los Angeles, USA. Electronic address:

Mitral valve repair is infrequently performed in patients undergoing corrective surgery for failed mitral transcatheter edge-to-edge repair (TEER) in current US practice. This article describes surgical techniques for reconstructive surgery following failed TEER. A total of nine patients underwent robotic-assisted mitral surgery following failed TEER between 2010 and 2020 at a single center. Repair was completed in 88.9% (n=8) patients and freedom from >2+ mitral regurgitation was 87.5% (n=7) at a median follow up of 1.9 years.
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http://dx.doi.org/10.1016/j.athoracsur.2021.05.083DOI Listing
June 2021

Multi-institutional collaborative mock oral (mICMO) examination for cardiothoracic surgery trainees: Results from the pilot experience.

JTCVS Open 2020 Sep 25;3:128-135. Epub 2020 Jul 25.

Department of Thoracic and Cardiovascular Surgery, UT MD Anderson Cancer Center, Houston, Tex.

Objective: The American Board of Thoracic Surgery-certifying examination is challenging for applicants. Single institutions have reported good results with a mock oral examination (MOE) for trainees. General surgery literature has demonstrated success with in-person multi-institutional MOE examinations. Due to small numbers of cardiothoracic training programs and significant geographic variability, we hypothesized that a multi-institutional, collaborative remotely administered MOE (mICMO) pairing faculty with trainees from different institutions would provide an important educational experience.

Methods: mICMOs were conducted via the Zoom virtual platform across 6 institutions. Descriptive results via post-experience survey were analyzed and reported.

Results: In total, 100% of trainees found mICMO useful. The majority would recommend to a peer, and 100% of faculty examiners found mICMO useful and would participate in another examination.

Conclusions: Faculty and trainees found the experience to be effective with respect to creating a high-stakes environment, educationally beneficial, and productive. These results support the continued use of mICMO and encourage expansion and collaboration with additional institutions across the country.
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http://dx.doi.org/10.1016/j.xjon.2020.07.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7381400PMC
September 2020

Mitral Valve Replacement: Still a Durable Option.

Ann Thorac Surg 2021 Jun 21. Epub 2021 Jun 21.

Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S San Vicente Blvd., Los Angeles, CA 90048.

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http://dx.doi.org/10.1016/j.athoracsur.2021.05.066DOI Listing
June 2021

Aortic Endocarditis: Further Evidence for Early Surgical Intervention.

Ann Thorac Surg 2022 02 26;113(2):543-544. Epub 2021 May 26.

Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 S San Vicente Blvd, Los Angeles, CA 90048.

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http://dx.doi.org/10.1016/j.athoracsur.2021.05.003DOI Listing
February 2022

A case of a pregnant patient with COVID-19 infection treated with emergency c-section and extracorporeal membrane oxygenation.

J Card Surg 2021 Aug 11;36(8):2982-2985. Epub 2021 May 11.

Department of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California, USA.

Coronavirus disease 2019 (COVID-19) causes the development of severe acute respiratory distress syndrome. Pregnant women may be at increased risk for the development of severe disease. We present the case of a pregnant patient who developed respiratory failure due to COVID-19 and rapidly decompensated requiring intubation. Despite mechanical ventilation, the patient's respiratory status continued to worsen. At bedside, cardiothoracic surgeons, obstetricians, intensivists, and neonatologists discussed balancing the risk of COVID-19 and respiratory failure to the patient, premature delivery to the neonate, potential coagulopathy associated with COVID-19, and the need for anticoagulation with mechanical circulatory support. Ultimately, the decision was to proceed with emergency cesarean section delivery in the intensive care unit followed by peri-partum veno-venous extracorporeal membrane oxygenation initiation. The patient and neonate were both discharged home in stable condition.
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http://dx.doi.org/10.1111/jocs.15623DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8242885PMC
August 2021

Multi-parametric approach to predict prosthetic valve size using CMR and clinical data: insights from SAVR.

Int J Cardiovasc Imaging 2021 Jul 10;37(7):2269-2276. Epub 2021 Mar 10.

Section of Cardiothoracic Surgery, Heart Center, Veterans Affairs Medical Center, Washington, DC, USA.

The purpose of this investigation was to characterize the CMR and clinical parameters that correlate to prosthetic valve size (PVS) determined at SAVR and develop a multi-parametric model to predict PVS. Sixty-two subjects were included. Linear/area measurements of the aortic annulus were performed on cine CMR images in systole/diastole on long/short axis (SAX) views. Clinical parameters (age, habitus, valve lesion, valve morphology) were recorded. PVS determined intraoperatively was the reference value. Data were analyzed using Spearman correlation. A prediction model combining imaging and clinical parameters was generated. Imaging parameters had moderate to moderately strong correlation to PVS with the highest correlations from systolic SAX mean diameter (r = 0.73, p < 0.0001) and diastolic SAX area (r = 0.73, p < 0.0001). Age was negatively correlated to PVS (r = - 0.47, p = 0.0001). Weight was weakly correlated to PVS (r = 0.27, p = 0.032). AI and bicuspid valve were not predictors of PVS. A model combining clinical and imaging parameters had high accuracy in predicting PVS (R = 0.61). Model predicted mean PVS was 23.3 mm (SD 1.1); actual mean PVS was 23.3 mm (SD 1.3). The Spearman r of the model (0.80, 95% CI 0.683-0.874) was significantly higher than systolic SAX area (0.68, 95% CI 0.516-0.795). Clinical parameters like age and habitus impact PVS; valve lesion/morphology do not. A multi-parametric model demonstrated high accuracy in predicting PVS and was superior to a single imaging parameter. A multi-parametric approach to device sizing may have future application in TAVR.
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http://dx.doi.org/10.1007/s10554-021-02203-5DOI Listing
July 2021

Outcomes of Heart Transplantation in Cardiac Amyloidosis Patients: A Single Center Experience.

Transplant Proc 2021 Jan-Feb;53(1):329-334. Epub 2020 Sep 8.

Cedars-Sinai Smidt Heart Institute, Los Angeles, Calif, United States; Division of Cardiac Surgery, Cedars-Sinai Medical Center, Los Angeles, Calif, United States. Electronic address:

Background: Indications for heart transplantation are expanding to include amyloid light chain (AL) and transthyretin-related (TTR) amyloidosis. Previously, AL amyloid had been a contraindication to heart transplantation given inferior outcomes. These patients typically have biventricular failure requiring mechanical circulatory support (MCS). We report the outcomes of patients with end-stage cardiac amyloidosis who underwent cardiac transplantation, including some who were bridged to transplantation with a durable biventricular MCS METHODS: The records for patients with cardiac amyloidosis who underwent cardiac transplant between 2010 and 2018 were reviewed. Primary endpoint was post-transplant 1-year survival. Secondary endpoints included 1-year freedom from cardiac allograft vasculopathy (as defined by stenosis ≥ 30% by angiography), nonfatal major adverse cardiac events (myocardial infarction, new congestive heart failure, percutaneous coronary intervention, implantable cardioverter defibrillator/pacemaker implant, stroke), and any rejection.

Results: A total of 46 patients received heart transplantation with a diagnosis of either AL or TTR amyloidosis. Of these, 7 patients were bridged to transplantation with a durable biventricular MCS device (6 AL, 1 TTR) and 39 patients were transplanted without MCS bridging. The MCS group consisted of 5 total artificial hearts and 2 biventricular assist devices. The 1-year survival was 91% for the entire cohort, 83% for those with AL amyloidosis, 94% for those with TTR amyloidosis, and 86% for those who received MCS bridging.

Conclusions: Cardiac transplantation can be safely performed in selected amyloidosis patients with reasonable short-term outcomes. Those bridged to transplantation with biventricular MCS appear to have short-term outcomes similar to those transplanted without MCS. Larger numbers and longer observation are required to confirm these findings.
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http://dx.doi.org/10.1016/j.transproceed.2020.08.020DOI Listing
April 2021

Clinical Relevance and Statistical Significance.

Ann Thorac Surg 2021 02 6;111(2):535-536. Epub 2020 Sep 6.

Cedars-Sinai Medical Center, Department of Cardiac Surgery, Smidt Heart Institute, 127 S San Vicente Blvd, Los Angeles, CA 90048.

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http://dx.doi.org/10.1016/j.athoracsur.2020.06.103DOI Listing
February 2021

Heart transplantation in the era of the SARS-CoV-2 pandemic: Is it safe and feasible?

Clin Transplant 2020 10 24;34(10):e14029. Epub 2020 Jul 24.

Cedars-Sinai Smidt Heart Institute, Los Angeles, California, USA.

As the SARS-CoV-2-pandemic continues to unfold, the number of heart transplants completed in the United States has been declining steadily. The current case series examines the immediate short-term outcomes of seven heart transplant recipients transplanted during the SARS-CoV-2 pandemic. We hope to illustrate that with proper preparation, planning, and testing, heart transplantation can be continued during a pandemic. We assessed 7 patients transplanted from March 4, 2020, to April 15, 2020. The following endpoints were noted: in-hospital survival, in-hospital freedom from rejection, in-hospital nonfatal major cardiac adverse events (NF-MACE), severe primary graft dysfunction, hospital length of stay, and ICU length of stay. There were no expirations throughout the hospital admission. In addition, there were no patients with NF-MACE or treated rejection, and 1 patient developed severe primary graft dysfunction. Average length of stay was 17.2 days with a standard deviation of 5.9 days. ICU length of stay was 7.7 days with a standard deviation of 2.3 days. Despite the decreasing trend in completed heart transplants due to SARS-CoV-2, heart transplantation appears to be feasible in the immediate short term. Further follow-up is needed, however, to assess the impact of SARS-CoV-2 on post-heart transplant outcomes months after transplantation.
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http://dx.doi.org/10.1111/ctr.14029DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7361065PMC
October 2020

Aortic Root Dilation and Testosterone Use: Are They Associated?

J Cardiothorac Vasc Anesth 2020 Dec 15;34(12):3395-3397. Epub 2020 May 15.

Department of Anesthesiology, Cedars-Sinai Medical Center, Los Angeles, CA. Electronic address:

Aortic root dilation and thoracic aortic aneurysms are relatively rare in young and healthy patient populations. However, a number of observed incidental cases regarding young males and testosterone use raises suspicion of a potential risk factor for aortic root dilation. The authors' patient, a healthy 40-year-old man with a significant history of testosterone use who developed a massively dilated aortic root, is sufficiently alarming to report. Notwithstanding anecdotal cases, there exists a well-known association between elite strength athletes and aortic root dilation. Nevertheless, very little clinical research exists on the relationship between testosterone use and aortic root dilation and/or thoracic aortic aneurysms. Furthermore, a small number of animal studies showed a relationship between testosterone and vascular dilation, particularly the aorta. Although testosterone may play a role in the development of aortic pathologies, further research is necessary to clarify the possible relationship if cases such as these are to be prevented.
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http://dx.doi.org/10.1053/j.jvca.2020.05.003DOI Listing
December 2020

Commentary: Lessons from 1000 robotic mitral repairs.

J Thorac Cardiovasc Surg 2020 Mar 27. Epub 2020 Mar 27.

Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif.

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http://dx.doi.org/10.1016/j.jtcvs.2019.12.133DOI Listing
March 2020

Total artificial heart: surgical technique in the patient with normal cardiac anatomy.

Ann Cardiothorac Surg 2020 Mar;9(2):81-88

Advanced Heart Program, Banner University Medical Group, Phoenix, Arizona, USA.

Heart failure is a complex, growing problem with significant morbidity and mortality. Though heart transplantation remains the gold standard treatment for end-stage heart failure, there remains a national shortage of donor hearts. Mechanical circulatory support has provided an additional option for clinicians to support patients for the purposes of bridging patients to transplantation or to be used for destination therapy purposes. Despite generally favorable outcomes with univentricular support, in a subset of patients with biventricular heart failure, an isolated left ventricular assist device is not sufficient. Right ventricular failure has a negative impact on patient survival if not identified and treated promptly. The Total Artificial Heart (TAH) is the only Food and Drug Administration (FDA) approved artificial heart used for bridging patients to transplantation. Outcomes in patients who undergo implantation of the TAH at experienced centers have been good and reproducible.
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http://dx.doi.org/10.21037/acs.2020.02.09DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7160624PMC
March 2020

Successful robotic resection of a primary cardiac synovial sarcoma.

JTCVS Tech 2020 Jun 24;2:104-106. Epub 2020 Feb 24.

Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif.

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http://dx.doi.org/10.1016/j.xjtc.2020.02.005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8298838PMC
June 2020

Commentary: Biomarkers and magical thinking.

J Thorac Cardiovasc Surg 2020 11 11;160(5):1247-1248. Epub 2019 Nov 11.

Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif.

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http://dx.doi.org/10.1016/j.jtcvs.2019.10.126DOI Listing
November 2020

A New Paradigm in Mechanical Circulatory Support: 100-Patient Experience.

Ann Thorac Surg 2020 05 26;109(5):1370-1377. Epub 2019 Sep 26.

Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California.

Background: Acutely decompensated heart failure presents a complicated challenge. Established temporary support measures have significant adverse effects. A minimally invasive temporary left ventricular assist device (LVAD), the Impella 5.0 (Abiomed, Danvers, MA), has been developed to support these patients.

Methods: Patients with acutely decompensated heart failure in whom medical management had failed and who required additional support using an Impella 5.0 device were evaluated from January 2014 to September 2018 at a single center in a retrospective manner using a prospectively maintained database. Patients were treated with the device as a bridge to recovery (BTR; n = 30), bridge to durable device (BTDD; n = 23), or bridge to transplantation (BTT; n = 47). All devices were placed using an axillary artery approach. Demographic features and outcomes were evaluated for each group and compared.

Results: A total of 100 patients underwent insertion of an axillary Impella 5.0 LVAD. Patients had an average age of 56.7 ± 13.2 years, were predominantly male (84%), and had a severely depressed left ventricular ejection fraction (average 16%), and most had an Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) profile 1 (57%) or 2 (33%) score. When divided into groups, there was no difference in age or INTERMACS score, but a statistical difference was noted in baseline left ventricular ejection fraction (20%, 14%, 15%) and creatinine level (1.0, 2.0, 1.6), in the BTR, BTDD, or BTT group, respectively (all P < .05). Survival was 64% overall, and it was 50%, 48%, and 81% for BTR, BTDD, and BTT, respectively (P = .007). Survival improved during this experience and was 90% overall in the most recent 30 patients.

Conclusions: Use of this minimally invasive LVAD system is an attractive strategy to support patients with acute decompensated heart failure to recovery, durable LVAD, or heart transplantation.
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http://dx.doi.org/10.1016/j.athoracsur.2019.08.041DOI Listing
May 2020

Combined Heart and Kidney Transplantation: Clinical Experience in 100 Consecutive Patients.

J Am Heart Assoc 2019 02;8(4):e010570

1 Division of Cardiology Cedars-Sinai Smidt Heart Institute the Multiorgan Transplant Program Cedars-Sinai Medical Center Los Angeles CA.

Background Combined heart and kidney transplantation ( HKT x) is performed in patients with severe heart failure and advanced renal insufficiency. We analyzed the long-term survival after HKT x, the influence of age and dialysis status, the rates of cardiac rejection, and the influence of sensitization. Methods and Results From June 1992 to December 2016, we performed 100 HKT x procedures. We compared older (≥60 years, n=53) with younger (<60 years, n=47) recipients, and recipients on preoperative dialysis (n=49) and not on dialysis (n=51). We analyzed actuarial freedom from any cardiac rejection, acute cellular rejection, and antibody-mediated rejection, and survival rates by sensitized status with panel-reactive antibody levels <10%, 10% to 50%, and >50%, and compared these survival rates with those from the United Network for Organ Sharing database. There was no difference in 15-year survival between the 2 age groups (35±12.4% and 49±17.3%, ≥60 versus <60 years; P=0.45). There was no difference in 15-year survival between the dialysis and nondialysis groups (44±13.4% and 37±15.2%, P=0.95). Actuarial freedom from any cardiac rejection ( acute cellular rejection >0 or antibody-mediated rejection >0) was 92±2.8% and 84±3.8%, acute cellular rejection (≥2R/3A) 98±1.5% and 94±2.5%, and antibody-mediated rejection (≥1) 96±2.1% and 93±2.6% at 30 days and 1 year after HKT x. There was no difference in the 5-year survival among recipients by sensitization status with panel-reactive antibody levels <10%, 10% to 50%, and >50% (82±5.9%, 83±10.8%, and 92±8.0%; P=0.55). There was no difference in 15-year survival after HKT x between the United Network for Organ Sharing database and our center (38±3.2% and 40±10.1%, respectively; P=0.45). Conclusions HKT x is safe to perform in patients 60 years and older or younger than 60 years and with or without dialysis dependence, with excellent outcomes. The degree of panel-reactive antibody sensitization did not appear to affect survival after HKT x.
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http://dx.doi.org/10.1161/JAHA.118.010570DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6405671PMC
February 2019

Functional status as a predictor of outcomes in open and endovascular abdominal aortic aneurysm repair.

J Vasc Surg 2017 Jan 25;65(1):40-45. Epub 2016 Jul 25.

Division of Vascular Surgery, Washington DC Veteran's Affairs Medical Center, Washington, D.C.. Electronic address:

Background: Functional status is a simple and rapidly assessable metric that may be used as a predictor for surgical outcomes. This study examined the association of functional status with short-term mortality after abdominal aortic aneurysm (AAA) repair in octogenarians to characterize the utility of functional status as a means of preoperative risk assessment.

Methods: All patients who underwent endovascular and open AAA repair from 2002 to 2010 within the Veterans Affairs Surgical Quality Improvement Program (VASQIP) database were identified. Functional status, defined as an ordinal scale from 1 to 3 (1, independent; 2, partially dependent; 3, totally dependent), was examined using multivariate regression models with 30-day mortality as the primary outcome. For the purpose of analysis, this 3-point scale was converted into a binomial scale of function, with "normal" including 1 (completely independent) and "abnormal" including 2 or 3 (partially to totally dependent).

Results: We identified 9030 patients who underwent AAA repair (46.6% open and 53.4% endovascular). Mortality at 30 days was 2.8% for the entire cohort (4.2% open, 1.7% endovascular; P < .001). There were 1340 patients aged ≥80 years, of which 67.3% underwent endovascular AAA repair. Among all age groups, functional status was a significant predictor of 30-day mortality (<80 years, P < .001; ≥80 years, P < .001). The ≥80 cohort with abnormal function status also demonstrated increased operative mortality (P = .002), length of stay (P = .001), and incidence of pulmonary complications (P = .025) compared with the cohort with normal functional status. Multivariate logistic regression demonstrated that within the ≥80-year-old cohort, only functional status remained a significant predictor of mortality (P < .001). In addition, the strength of the association between functional status and mortality was greater in the older cohort than in the younger one (Cox regression hazard ratio: 3.13 vs 2.18).

Conclusions: Functional status is a simple and rapidly applicable predictor of mortality within AAA patients and may be a useful tool to help preoperatively risk-stratify elderly patients presenting with AAA in need of repair. Further studies are needed to understand how best to apply these data to the clinical setting to guide preoperative decision making.
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http://dx.doi.org/10.1016/j.jvs.2016.05.079DOI Listing
January 2017

Video-assisted thoracoscopic surgery for complex mediastinal mass resections.

Ann Cardiothorac Surg 2015 Nov;4(6):509-18

1 Division of Thoracic Surgery, Department of Surgery, 2 Department of Anesthesia, MedStar Georgetown University Hospital, Washington, DC 2007, USA.

Minimally invasive surgery has changed the way operative procedures are performed in many specialties. As surgeons have become progressively facile with these techniques, the opportunities to use them have expanded. In thoracic surgery, many surgeons now use minimally invasive techniques to resect small, uncomplicated pathologies of the mediastinum as well as to perform thymectomy for myasthenia gravis. Experience with these techniques has allowed new knowledge to be gained and expansion of the use of these techniques for more complicated mediastinal pathology. This keynote address will outline the instrumentation and techniques that we have adopted over a decade of using these techniques for more complicated mediastinal pathology.
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http://dx.doi.org/10.3978/j.issn.2225-319X.2015.11.01DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4669254PMC
November 2015

Coronary Artery Bypass Grafting During Acute Coronary Syndrome: Outcomes and Comparison of Off-Pump to Conventional Coronary Artery Bypass Grafting at a Veteran Affairs Hospital.

Innovations (Phila) 2015 May-Jun;10(3):157-62

From the *Veterans Affairs Medical Center; †Georgetown University Hospital; and ‡The George Washington University Hospital, Washington, DC USA.

Objective: The management of acute coronary syndrome (ACS) has evolved dramatically over the last 50 years. Currently, management includes a multidisciplinary approach potentially including catheter-based therapy, surgery, or purely medical management. Where surgical therapy is indicated, data regarding long-term outcomes are limited. In particular, little data exist regarding on-pump (conventional coronary artery bypass grafting, cCABG) versus off-pump (OPCABG) outcomes for this group.

Methods: A retrospective review of prospectively collected data was undertaken. Patients undergoing isolated CABG from January 2000 to December 2011 with ACS were identified (n = 271); non-ACS patients (n = 854) were established as a control. Data were analyzed with a χ or a t test, where appropriate. Survival was compared using Kaplan-Meier analysis and Cox proportional hazards model.

Results: Thirty-day mortality between the ACS and the control groups was similar; however, long-term mortality was worse for the ACS group (P = 0.032; median follow-up, 5.5 years). Length of stay and composite morbidity were higher in the ACS group (P < 0.01). Subgroup analysis of ACS patients (OPCABG vs cCABG) demonstrated worse preoperative comorbidities in the OPCABG group, but similar 30-day and long-term mortality. However, the cCABG group had higher rates of reoperation (P = 0.034) and longer length of stay (P = 0.017) and operative time (P < 0.0001). Cox proportional hazards model was applied. Risk factors for the non-ACS cohort included age, diabetes, OPCABG, and ACS (P < 0.05). Among the ACS cohort, only age remained a statistically significant factor (P < 0.0001).

Conclusions: ACS appears to negatively impact long-term, but not short-term, mortality. Within the ACS group, OPCABG compares favorably to cCABG in the long-term and also improves short-term morbidity.
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http://dx.doi.org/10.1097/IMI.0000000000000159DOI Listing
May 2016

Long-term outcomes after off-pump or conventional coronary artery bypass grafting within a veteran population.

Innovations (Phila) 2015 Mar-Apr;10(2):133-7

From the *Veterans Affairs Medical Center; †Georgetown University Hospital; and ‡The George Washington University Hospital, Washington, DC USA.

Objective: Recently published data indicate that outcomes for off-pump coronary artery bypass grafting (OPCABG) may be inferior to conventional CABG (cCABG) within the Veteran population, but this has been only partly addressed within high-volume off-pump centers. Here, we seek to examine the long-term outcomes for these patients within the Veteran population at a single institution well experienced with OPCABG.

Methods: With the use of a preexisting in-house database, all patients who had undergone isolated CABG from 2000 to 2011 (n = 1125) were identified. From these data, 18 demographic and risk factors were compared and used to create a propensity score, which was used for matching between groups (OPCABG vs cCABG). The primary end point examined was death. Survival was analyzed using the Kaplan-Meier method and the log-rank test. Groups were compared using a Student t test or Fisher exact test, where appropriate.

Results: Unmatched OPCABG and cCABG groups were found to have significant differences in risk factors, with the OPCABG being a higher-risk population by ejection fraction, chronic obstructive pulmonary disease status, age, and renal function, among others (all P < 0.05). Kaplan-Meier analysis of the unmatched groups demonstrated an increased mortality rate within the higher-risk OPCABG group (P = 0.0002). With the use of propensity score matching, 337 OPCABG patients were then matched to 337 cCABG controls. Comparison of demographic and risk factors between these matched groups did not demonstrate any statistically significant difference. When Kaplan-Meier analysis was performed for the matched groups, there was no statistically significant difference in survival. In addition, in the matched data set, OPCABG patients had a shorter average length of stay (8.2 vs 9.7 days, P = 0.022), shorter operative time (205 vs 270 minutes, P < 0.001), and lower rate of bleeding complications (0.9% vs 3.6%, P = 0.032).

Conclusions: In this high-volume off-pump center, matched OPCABG survival is similar to cCABG. Although recent data indicate that OPCABG survival may be worse than that of cCABG within the entire Veteran population, in centers well experienced with OPCABG, this does not seem to hold true. In addition, the benefit of decreased length of stay and lower morbidity rates seems to be significant. Further study of the long-term outcomes of OPCABG in high-volume Veteran's centers is warranted.
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http://dx.doi.org/10.1097/IMI.0000000000000131DOI Listing
December 2015

Using cardiac magnetic resonance imaging to evaluate cardiac function and predict outcomes in patients with valvular heart disease.

Innovations (Phila) 2015 Jan-Feb;10(1):63-7

From the Divisions of *Cardiothoracic Surgery and †Cardiology, Veterans Affairs Medical Center; ‡Department of Surgery, Georgetown University Hospital; and Divisions of §Cardiothoracic Surgery and ∥Cardiology, The George Washington University Hospital, Washington, DC, USA.

Objective: In valvular heart disease, elevated left atrial and pulmonary pressures contribute to right ventricular strain and, ultimately, right ventricle failure. Elevated pulmonary artery (PAP) and left ventricular end diastolic pressures are used as markers of right ventricle dysfunction and correlate with poor outcomes. Using cardiac magnetic resonance imaging (CMR), it is possible to directly quantify both left and right ventricular ejection function (LVEF and RVEF), and here, we compare CMR with traditional markers as outcome predictors.

Methods: A retrospective review of prospectively collected data was performed for patients from January 2004 to February 2008 at a single center (n = 103). Patients were divided into those receiving CMR (n = 56) and those receiving only catheterization (n = 47). Univariate and multivariate logistic regression models were applied to determine predictors of mortality. Finally, predictive models for mortality using PAP, mean PAP, and left ventricular end diastolic pressure were compared to models using LVEF and RVEF obtained from CMR.

Results: Preoperative average CMR LVEF and RVEF were 57% and 46%, respectively. Only age emerged as an isolated predictor of mortality (P = 0.01) within the univariate models. Stepwise regression models were created using the catheterization or CMR data. When compared, the CMR model has a slightly better R, c (prediction accuracy), and sensitivity/specificity (0.22 vs 0.28, 0.77 vs 0.82, and 0.63/0.62 vs 0.69/0.64, respectively).

Conclusions: Within our population, LVEF and RVEF predict mortality as least as well as traditional catheterization values. Additionally, CMR may identify of elevated PAPs caused by right ventricle dysfunction and those due to other causes, allowing these other causes to be addressed preoperatively.
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http://dx.doi.org/10.1097/IMI.0000000000000119DOI Listing
September 2015

Cardiac surgery in patients chronically infected with hepatitis C virus: long-term outcomes and comparison to historical controls and human immunodeficiency virus infection.

J Cardiovasc Surg (Torino) 2016 Aug 16;57(4):598-605. Epub 2014 Oct 16.

Veterans Affairs Medical Center, Washington, DC, USA -

Background: Approximately 2-4 million individuals are chronically infected with hepatitis C (HCV) in the United States. Though several studies have previously examined short and mid-term outcomes for patients with cirrhosis requiring cardiac surgery, no study to date has examined the long-term outcomes of individuals chronically infected with HCV.

Methods: A retrospective review of 75 patients with HCV and/or HIV infection who underwent cardiac surgery between 1999 and 2011 was undertaken. A control dataset, consisting of all non-HCV or HIV infected individuals from this same time period (N.=1499) was also assembled, and both matched and unmatched data were examined. Propensity matching was used to compare groups. Long-term mortality and short-term morbidity were examined.

Results: Within the HIV and HCV cohorts baseline demographics were generally similar to historic controls. Average MELD Score in the HCV group was 10.1. In comparison with the matched control, the HCV group's survival is significantly worse (P=0.02), a trend not observed in the HIV group. Short-term morbidity was not noted to be different.

Conclusions: Though carefully selected prior to surgery, and having MELD scores that averaged 10.1, patients with chronic HCV infection tend to do worse than both patients with HIV or matched historical controls following cardiac surgery.
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August 2016
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