Publications by authors named "Gonzalo V Gonzalez-Stawinski"

73 Publications

High-quality cardiac surgery through teamwork.

Proc (Bayl Univ Med Cent) 2020 Sep 14;34(1):215-220. Epub 2020 Sep 14.

Department of Cardiothoracic Surgery, Baylor University Medical Center and Baylor Scott & White Heart and Vascular Hospital - Dallas, Dallas, Texas.

The high-quality cardiothoracic surgery program is primed for mindful effective surgery. The challenge lies in attaining mindful skills and efficiency. Herein is one journey toward high departmental quality over two decades.
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http://dx.doi.org/10.1080/08998280.2020.1811057DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7785160PMC
September 2020

A system-wide extracorporeal membrane oxygenation quality collaborative improves patient outcomes.

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

Baylor University Medical Center, Baylor Scott & White Health, Dallas, Tex. Electronic address:

Objective: Extracorporeal membrane oxygenation (ECMO) use in adult patient populations has grown rapidly with wide variation in practices and outcomes. We evaluated the impact on patient outcomes, resource use, and costs of an initiative to coordinate and standardize best practices across ECMO programs within a large integrated health care system.

Methods: The ECMO Collaborative Project brought clinicians and service-line leaders from 4 programs within a single health care system together with operational subject matter experts tasked with developing and implementing standardized guidelines, order sets, and an internal database to support an automated quarterly report card. Patient outcomes, resource use, and financial measures were compared for the 16 months before (January 2017 to April 2018; "precollaborative," n = 185) versus the 14 months after (November 2018 to December 2019, "postcollaborative," n = 243) a 6-month implementation and blanking period. Subset analyses were performed for venoarterial ECMO, venovenous ECMO, and extracorporeal cardiopulmonary resuscitation.

Results: Survival to discharge/transfer increased significantly (in-hospital mortality hazard ratio, 0.75; 95% confidence interval [95% CI], 0.58-0.99) for the postcollaborative versus the precollaborative period (107/185, 57.8% vs 113/243, 46.5%, P = .03), predominantly due to improvement among patients receiving venoarterial ECMO (hazard ratio, 0.61; 95% CI, 0.41-0.91). The percentage of patients successfully weaned from ECMO increased from 58.9% (109/185) to 70% (170/243), P = .02. Complication rates decreased by 40% (incidence rate ratio, 0.60; 95% CI, 0.49-0.72). No significant changes were observed in ECMO duration, intensive care unit or hospital length of stay, or cost-per-case; payment-per-case and contribution-margin-per-case both decreased significantly.

Conclusions: The ECMO Collaborative Project improved survival to discharge/transfer, weaning rates and complications, without additional costs, through coordination and standardization across ECMO programs within a health care system.
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http://dx.doi.org/10.1016/j.jtcvs.2020.10.079DOI Listing
October 2020

Outcomes of orthotopic heart transplantation and left ventricular assist device in patients aged 65 years or more with end-stage heart failure.

Proc (Bayl Univ Med Cent) 2019 Apr 28;32(2):177-180. Epub 2019 Mar 28.

Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research InstituteDallasTexas.

Age has traditionally been a limiting factor for advanced heart failure (HF) therapies. Orthotopic heart transplantation (OHT) age guidelines have become less restrictive, and left ventricular assist devices (LVADs) are increasingly utilized as destination therapy for patients ≥65 years. Although indications differ, we assessed outcomes for both modalities in this older population. We reviewed charts of consecutive advanced HF therapy recipients aged ≥65 years at our center from 2012 to 2016. Of 118 patients evaluated, 46 (39%) received an LVAD and 72 (61%) received OHT. Gender, body mass index, and rate of prior sternotomy were similar between groups; OHT recipients were younger, less likely to have diabetes mellitus, and more likely to have HF due to ischemic etiology. Forty-six percent of patients receiving LVADs were urgent need (Interagency Registry for Mechanically Assisted Circulatory Support [INTERMACS] profile 1-2), compared to 29% of patients receiving OHT (United Network for Organ Sharing 1A criteria;  = 0.068). OHT recipients had shorter lengths of stay and better 1-year survival compared to LVAD recipients. Although many centers do not offer advanced HF therapy to patients aged ≥65 years, our results indicate that age alone should not be prohibitive for advanced HF therapy, particularly OHT.
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http://dx.doi.org/10.1080/08998280.2019.1576095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6541055PMC
April 2019

Salvage of severe primary graft dysfunction following heart transplantation using extracorporeal life support.

Proc (Bayl Univ Med Cent) 2018 10 18;31(4):482-486. Epub 2018 Oct 18.

Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research InstituteDallasTexas.

Primary graft dysfunction (PGD) is the leading cause of early mortality after heart transplantation. Typically, mechanical circulatory support is necessary to provide hemodynamic support and to enable graft recovery. However, both the reported incidence of PGD and the reported salvage rates with extracorporeal membrane oxygenation (ECMO) vary widely. This may partly be due to variations in the definition of PGD and its levels of severity. We analyzed a prospectively maintained database of 255 transplant recipients at our institution to determine the effectiveness of ECMO support in those who develop severe PGD as defined by the International Society for Heart and Lung Transplantation consensus guidelines. Nineteen (7.5%) patients (aged 32-69 years) developed severe PGD and were treated with veno-arterial (VA) ECMO, which was initiated in the operating room at the time of transplant in most patients. The majority received VA ECMO through femoral cannulation. Two patients required veno-venous ECMO for respiratory support after VA ECMO separation. The 30-day in-hospital survival rate following transplantation was 63% ( = 12). In conclusion, ECMO proved to be a viable option for early hemodynamic support in patients with severe PGD and has become our preferred modality for mechanical circulatory support in these patients.
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http://dx.doi.org/10.1080/08998280.2018.1498724DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6413990PMC
October 2018

Extracorporeal membrane oxygenation as a salvage therapy for patients with severe primary graft dysfunction after heart transplant.

Clin Transplant 2019 05 14;33(5):e13538. Epub 2019 Apr 14.

Department of Cardiothoracic Surgery, Mayo Clinic, Jacksonville, Florida.

Background: Severe primary graft dysfunction (PGD) is the leading cause of early death after heart transplant.

Aim: To examine the outcomes of heart transplant recipients who received venoarterial extracorporeal membrane oxygenation (VA-ECMO) for severe PGD.

Methods: We reviewed electronic health records of adult patients who underwent heart transplant from November 2005 through June 2015. We defined severe PGD according to International Society for Heart and Lung Transplantation consensus statements.

Results: Of 1030 heart transplant patients, 31 (3%) had severe PGD and required VA-ECMO. The mean (range) age was 59 (43-69) years. Fifteen patients (48%) underwent prior sternotomy and 10 (32%) received a left ventricular assist device as a bridge to transplant. Severe PGD manifested as failure to wean from cardiopulmonary bypass in 20 patients (65%) and as severe hemodynamic instability in the immediate postoperative period in 10 (32%), including cardiac arrest in 3 (10%). Twenty-five patients (81%) were successfully weaned from VA-ECMO, and 19 (61%) were discharged; the other 12 (39%) died.

Conclusions: Although VA-ECMO is a common method for providing mechanical circulatory support to patients with PGD, multicenter studies are needed to assess factors associated with successful outcomes and improved survival of these patients.
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http://dx.doi.org/10.1111/ctr.13538DOI Listing
May 2019

Outcomes of Moderate-to-Severe Acute Kidney Injury following Left Ventricular Assist Device Implantation.

Cardiorenal Med 2019 23;9(2):100-107. Epub 2019 Jan 23.

Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, Texas, USA,

Background: Although acute kidney injury (AKI) is a common complication following cardiac surgery, less is known about the occurrence and consequences of moderate/severe AKI following left ventricular assist device (LVAD) implantation.

Methods: All patients who had an LVAD implanted at our center from 2008 to 2016 were reviewed to determine the incidence of, and risk factors for, moderate/severe (stage 2/3) AKI and to compare postoperative complications and mortality rates between those with and those without moderate/severe AKI.

Results: Of 246 patients, 68 (28%) developed moderate/severe AKI. A multivariable logistic regression comprising body mass index and prior sternotomy had fair predictive ability (area under the curve = 0.71). A 1-unit increase in body mass index increased the risk of moderate/severe AKI by 7% (odds ratio = 1.07; 95% confidence interval: 1.03-1.11); a prior sternotomy increased the risk more than 3-fold (odds ratio = 3.4; 95% confidence interval: 1.84-6.43). The group of patients with moderate/severe AKI had higher rates of respiratory failure and death than the group of patients with mild/no AKI. Patients with moderate/severe AKI were at 3.2 (95% confidence interval: 1.2-8.2) times the risk of 30-day mortality compared to those without. Even after adjusting for age and Interagency Registry for Mechanically Assisted Circulatory Support profile, those with moderate/severe AKI had 1.75 (95% confidence interval: 1.03-3.0) times the risk of 1-year mortality compared to those without.

Discussion: Risk-stratifying patients prior to LVAD placement in regard to AKI development may be a step toward improving surgical outcomes.
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http://dx.doi.org/10.1159/000492476DOI Listing
June 2019

Relation of Vasoplegia in the Absence of Primary Graft Dysfunction to Mortality Following Cardiac Transplantation.

Am J Cardiol 2018 12 8;122(11):1902-1908. Epub 2018 Sep 8.

Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, Texas; Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, Texas. Electronic address:

Vasoplegia following cardiac transplantation is associated with increased morbidity and mortality. Previous studies have not accounted for primary graft dysfunction (PGD). The definition of vasoplegia is based on pressor requirement at 48 hours, many PGD parameters may have normalized after the initial 24 hours on inotropes. We surmised that the purported negative effects of vasoplegia following transplantation may in part be driven by PGD. We reviewed 240 consecutive adult cardiac transplants at our center between 2012 and 2016. The severity of vasoplegia was evaluated as a risk factor for 1-year survival, and the analysis was repeated for the subgroup of 177 patients who did not develop PGD. Overall, 63 (26%) of patients developed mild, moderate, or severe PGD. In those without PGD, vasoplegia was associated with length of stay but not with short- or long-term mortality. Moderate and/or severe vasoplegia occurred in 35 (15%) patients and was associated with higher short-term mortality, length of stay, and PGD. Multivariate logistic regression identified body mass index ≥35 kg/m, left ventricular assist device before transplantation, and use of extracorporeal membrane oxygenation as joint risk factors for vasoplegia. In patients without PGD, only left ventricular assist device before transplantation was associated with vasoplegia. In conclusion, our results show that, in the sizeable subgroup of patients with no signs of PGD, vasoplegia had a much more modest impact on post-transplant morbidity and no significant effect on 1- and 3-year survival. This suggests that PGD may be a confounder when assessing vasoplegia as a risk factor for adverse outcomes.
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http://dx.doi.org/10.1016/j.amjcard.2018.08.035DOI Listing
December 2018

Durable left ventricular assist device implantation in extremely obese heart failure patients.

Artif Organs 2019 Mar 3;43(3):234-241. Epub 2019 Jan 3.

Baylor University Medical Center, Center for Advanced Heart and Lung, Dallas, TX.

Left ventricular assist devices (LVADs) have improved clinical outcomes and quality of life for those with end-stage heart failure. However, the costs and risks associated with these devices necessitate appropriate patient selection. LVAD candidates are becoming increasingly more obese and there are conflicting reports regarding obesity's effect on outcomes. Hence, we sought to evaluate the impact of extreme obesity on clinical outcomes after LVAD placement. Consecutive LVAD implantation patients at our center from June 2008 to May 2016 were studied retrospectively. We compared patients with a body mass index (BMI) ≥40 kg/m (extremely obese) to those with BMI < 40 kg/m with respect to patient characteristics and surgical outcomes, including survival. 252 patients were included in this analysis, 30 (11.9%) of whom met the definition of extreme obesity. We found that patients with extreme obesity were significantly younger (47[33, 57] vs. 60[52, 67] years, P < 0.001) with fewer prior sternotomies (16.7% vs. 36.0%, P = 0.04). They had higher rates of pump thrombosis (30% vs. 9.0%, P = 0.003) and stage 2/3 acute kidney injury (46.7% vs. 27.0%, P = 0.003), but there were no differences in 30-day or 1-year survival, even after adjusting for age and clinical factors. Extreme obesity does not appear to place LVAD implantation patients at a higher risk for mortality compared to those who are not extremely obese; however, extreme obesity was associated with an increased risk of pump thrombosis, suggesting that these patients may require additional care to reduce the need for urgent device exchange.
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http://dx.doi.org/10.1111/aor.13380DOI Listing
March 2019

Donor predicted heart mass as predictor of primary graft dysfunction.

J Heart Lung Transplant 2018 07 17;37(7):826-835. Epub 2018 Mar 17.

Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, Texas, USA; Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, Texas, USA.

Background: Concern over the hazards associated with undersized donor hearts has impeded the utilization of otherwise viable allografts for transplantation. Previous studies have indicated predicted heart mass (PHM) may provide better size matching in cardiac transplantation than total body weight (TBW). We investigated whether size-matching donor hearts by PHM is a better predictor of primary graft dysfunction (PGD) than matching by TBW.

Methods: Records of consecutive adult cardiac transplants performed between 2012 and 2016 at a single-center academic hospital were reviewed. We compared patients implanted with hearts undersized by ≥30% with those implanted with donor hearts matched for size (within 30%), and performed the analysis both for undersizing by PHM and for undersizing by TBW. The primary outcome was moderate/severe PGD within 24 hours, according to the 2014 International Society for Heart and Lung Transplantation consensus. Secondary outcome was 1-year survival.

Results: Of 253 patients, 21 (8%) and 30 (12%) received hearts undersized by TBW and PHM, respectively. The overall rate of moderate/severe PGD was 13% (33 patients). PGD was associated with undersizing if performed by PHM (p = 0.007), but not if performed by TBW (p = 0.49). One-year survival was not different between groups (log-rank, p > 0.8). Multivariate analysis confirmed that undersizing donor hearts by PHM, but not by TBW, was predictive of moderate/severe PGD (OR 3.3, 95% CI 1.3 to 8.6).

Conclusions: Undersized donor hearts by ≥30% by PHM may increase rates of PGD after transplantation, confirming that PHM provides more clinically appropriate size matching than TBW. Better size matching may ultimately allow for expanding the donor pool.
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http://dx.doi.org/10.1016/j.healun.2018.03.009DOI Listing
July 2018

Reoperative sternotomy is associated with primary graft dysfunction following heart transplantation.

Interact Cardiovasc Thorac Surg 2018 09;27(3):343-349

Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, TX, USA.

Objectives: Prior sternotomy is associated with increased morbidity and mortality following heart transplantation. However, its effect on primary graft dysfunction (PGD), a major contributor to early mortality, is unknown. Herein, this effect is studied using the International Society for Heart and Lung Transplantation consensus definition for PGD.

Methods: Medical records of consecutive adult cardiac transplants between 2012 and 2016 were reviewed. Baseline characteristics, postoperative findings and 1-year survival were compared between patients with and without prior sternotomy.

Results: Among 255 total patients included, 139 (55%) had undergone prior sternotomy; these recipients were older, more often male, had higher body mass index, higher frequencies of united network for organ sharing (UNOS) 1A status and ischaemic cardiomyopathy and experienced longer waitlist times when compared with those without prior sternotomy (all P < 0.018). Postoperatively, the prior sternotomy group exhibited higher rates of mild to severe PGD (32% vs 18%; P = 0.015) and higher short-term mortality (P = 0.017) and 1-year mortality (P = 0.047). They required more blood transfusions, had more postoperative pneumonia, wound infection and longer hospital stays. A stepwise multivariable regression model identified prior sternotomy as a predictor of PGD (odds ratio 2.7). Multiple prior sternotomies was associated with even more UNOS 1A status, ischaemic cardiomyopathy and pneumonia. However, logistic modelling did not show a difference in the rate of PGD between those with 1 or ≥2 prior sternotomies.

Conclusions: Our data suggest that prior sternotomy is a risk factor for PGD. Consistent with previous reports, prior sternotomy is associated with increased morbidity, blood product utilization and 1-year mortality following cardiac transplantation.
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http://dx.doi.org/10.1093/icvts/ivy084DOI Listing
September 2018

Major Adverse Renal and Cardiac Events After Coronary Angiography and Cardiac Surgery.

Ann Thorac Surg 2018 06 2;105(6):1724-1730. Epub 2018 Feb 2.

Department of Internal Medicine, Texas A&M University College of Medicine Health Science Center, Dallas, Texas; Department of Cardiology, Baylor University Medical Center, Dallas, Texas; Department of Cardiology, The Heart Hospital Baylor Plano, Plano, Texas; Department of Cardiology, Baylor Jack and Jane Hamilton Heart and Vascular Hospital, Dallas, Texas; Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas. Electronic address:

Background: Patients at high risk for having postprocedural complications may receive iodixanol, an iso-osmolar contrast, during coronary angiography to minimize the risk of renal toxicity. For those who also require cardiac surgery, the wait time between angiography and surgery may be a modifiable factor capable of mitigating poor surgical outcomes; however, there have been inconsistent reports regarding the optimal wait time. We sought to determine the effects of wait time between angiography and cardiac surgery, as well as contrast-induced acute kidney injury on the development of major adverse renal and cardiac events (MARCE).

Methods: We merged datasets to identify adults who underwent coronary angiography with iodixanol and subsequent cardiac surgery.

Results: Of 965 patients, 126 (13.1%) had contrast-induced acute kidney injury; 133 (13.8%) had MARCE within 30 days and 253 (26.2%) within 1 year of surgery. After adjusting for contrast-induced acute kidney injury, age, and Thakar acute renal failure score, the effect of wait time lost significance for the full cohort, but remained for the subgroup of 654 who had coronary artery bypass graft surgery. Patients undergoing coronary artery bypass graft surgery within 1 day of coronary angiography had an approximate twofold increase in risk of MARCE (30-day hazard ratio 2.13, 95% confidence interval: 1.16 to 3.88, p = 0.014; 1-year hazard ratio 2.07, 95% confidence interval: 1.32 to 3.23, p = 0.002) compared with patients who waited 5 or more days.

Conclusions: Patients who had contrast-induced acute kidney injury and had cardiac surgery within 1 day of angiography had an increased risk of MARCE.
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http://dx.doi.org/10.1016/j.athoracsur.2018.01.010DOI Listing
June 2018

Comparison of Clinical Characteristics, Complications, and Outcomes in Recipients Having Heart Transplants <65 Years of Age Versus ≥65 Years of Age.

Am J Cardiol 2017 Dec 15;120(12):2207-2212. Epub 2017 Sep 15.

Annette C. and Harold C. Simmons Transplant Institute, Baylor Scott & White Research Institute, Dallas, Texas; Department of Cardiac and Thoracic Surgery, Baylor University Medical Center, Dallas, Texas. Electronic address:

Advanced recipient age remains a limiting factor for heart transplant candidacy, with many centers reluctant to transplant older patients. Here, we report our experience with recipients aged ≥65 years compared with younger recipients in terms of baseline characteristics, intraoperative and immediate postoperative experiences, and post-transplant morbidity and survival. The main study outcome was primary graft dysfunction (PGD), which has not been widely studied in this population. Donor and recipient data from 255 heart transplantations performed between 2012 and 2016 were reviewed. Seventy (27%) recipients were ≥65 years and 185 were younger. The older group had a higher frequency of ischemic cardiomyopathy and more frequently had a previous sternotomy than the younger recipients (all p <0.007). We found no significant differences in post-transplant morbidity (intensive care unit and hospital stay, pneumonia, infections, reoperation for bleeding, stroke, renal failure, or in-hospital mortality; all p >0.12). One-year survival was also similar in the 2 groups (p = 0.88). The incidence of moderate or severe PGD was lower in the older group (6%) than in the younger group (16%; p = 0.037). Multivariate logistic regression found pretransplant creatinine and donor undersizing by predicted heart mass to be predictors of moderate to severe PGD, whereas recipient age ≥65 years was identified as protective against PGD in this cohort. In conclusion, our study showed comparable survival and outcomes in recipients ≥65 years of age with otherwise similar nutritional status and body mass composition.
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http://dx.doi.org/10.1016/j.amjcard.2017.08.043DOI Listing
December 2017

Utilization of high donor sequence number grafts in cardiac transplantation.

Clin Transplant 2018 01 4;32(1). Epub 2017 Dec 4.

Department of Cardiac and Thoracic Surgery, Baylor University Medical Center, Dallas, TX, USA.

Donor sequence number (DSN) represents the number of candidates to whom a graft was offered and declined prior to acceptance for transplantation. We sought to investigate the outcomes of patients receiving high DSN grafts. Consecutive isolated adult cardiac transplantations performed at a single-center were reviewed. Recipients were grouped into standard (≤75th percentile) DSN and high (>75th percentile) DSN. A previously validated donor risk index was used to quantify the risk associated with donor grafts, and recipient outcomes were assessed. Overall, 254 patients were included: 194 standard DSN (range 1-79) and 60 high DSN (range 82-1723). High DSN grafts were harvested at greater distance (P < .001) with increased ischemia time (P < .001), resulting in a modest increase in donor risk index (1 point median difference, P = .014). High DSN recipients were less frequently listed as UNOS status 1A (P < .001). Despite a nonsignificant trend toward increased in-hospital/30-day mortality in high DSN recipients, there were no differences in primary graft dysfunction or 1-year survival (high DSN 89% vs standard DSN 88%, P = .82). After adjustment for risk factors, high DSN was not associated with increased 1-year mortality (hazard ratio 1.18, 95%-CI 0.54-2.58, P = .68).
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http://dx.doi.org/10.1111/ctr.13128DOI Listing
January 2018

Rational Heart Transplant From a Hepatitis C Donor: New Antiviral Weapons Conquer the Trojan Horse.

J Card Fail 2017 Oct 8;23(10):765-767. Epub 2017 Aug 8.

Baylor University Medical Center, Dallas, Texas; Baylor Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas; Baylor Center for Advanced Heart and Lung Disease, Baylor University Medical Center, Dallas, Texas; Department of Internal Medicine, Texas A&M Health Science Center, Dallas, Texas.

Background: Donors with hepatitis C (HCV) viremia are rarely used for orthotopic heart transplantation (HT) owing to post-transplantation risks. New highly effective HCV antivirals may alter the landscape.

Methods: An adult patient unsuitable for bridging mechanical support therapy accepted a heart transplant offer from a donor with HCV viremia. On daily logarithmic rise in HCV viral load and adequate titers to ensure successful genotyping, once daily sofosbuvir (400 mg)-velpatasvir (100 mg) (Epclusa; Gilead) was initiated empirically pending HCV genotype (genotype 3a confirmed after initiation of therapy).

Results: We report the kinetics of acute hepatitis C viremia and therapeutic response to treatment with a new pangenotypic antiviral agent after donor-derived acute HCV infection transmitted incidentally with successful cardiac transplantation to an HCV-negative recipient. Prompt resolution of viremia was noted by the 1st week of a 12 week course of antiviral therapy. Sustained virologic remission continued beyond 12 weeks after completion of HCV therapy (SVR-12).

Conclusions: The availability of effective pangenotypic therapy for HCV may expand donor availability. The feasibility of early versus late treatment of HCV remains to be determined through formalized protocols. We hypothesize pharmacoeconomics to be the greatest limitation to widespread availability of this promising tool.
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http://dx.doi.org/10.1016/j.cardfail.2017.08.448DOI Listing
October 2017

Novel Cardiac Coordinate Modeling System for Three-Dimensional Quantification of Inflow Cannula Malposition of HeartMate II LVADs.

ASAIO J 2018 Mar/Apr;64(2):154-158

Optimal function of left ventricular assist devices (LVADs) depends on proper alignment of the inflow cannula (IC). Quantitative guidelines for IC angulation are lacking because of variation in cardiac geometry and difficulty in analyzing three-dimensional (3D) cannula orientation relative to the left ventricle (LV). Based on contrast-enhanced computed tomography images from five normal and five clinically malpositioned IC cases in patients with HeartMate II LVADs, we developed a method for 3D quantification of IC malpositioning. Using Mimics image software (Materialise, Leuven, Belgium), the native heart, major arteries, and LVAD were segmented to create patient-specific 3D models, allowing LV cavity volume and long-axis length to be measured directly. The deviation of the IC was quantified in a cylindrical coordinate system at the IC insertion point relative to the mitral valve and septum, and IC occlusion was assessed by the distance between cannula inlet and the proximal endocardium. Compared with normal cases, patients with malpositioned pumps had shorter LV length (p = 0.03) and reduced pump pocket depth (p = 0.009). Malpositioned pumps may experience greater obstruction by the nearby myocardium. This quantitative 3D modeling tool may help identify different modes of pump malalignment and migration and may facilitate preoperative planning and minimally invasive approaches via virtual LVAD implantation.
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http://dx.doi.org/10.1097/MAT.0000000000000628DOI Listing
February 2019

Ambulatory extracorporeal membrane oxygenation with subclavian venoarterial cannulation to increase mobility and recovery in a patient awaiting cardiac transplantation.

Proc (Bayl Univ Med Cent) 2017 Apr;30(2):224-225

Department of Cardiac and Thoracic Surgery (Jacob, MacHannaford, Chamogeorgakis, Gonzalez-Stawinski, Rafael, Malyala, Lima) and the Annette C. and Harold C. Simmons Transplant Institute (MacHannaford, Chamogeorgakis, Gonzalez-Stawinski, Felius, Rafael, Malyala, Lima), Baylor University Medical Center at Dallas, Texas.

Venoarterial extracorporeal membrane oxygenation (ECMO) can provide temporary cardiopulmonary support for patients in hemodynamic extremis or refractory heart failure until more durable therapies-such as cardiac transplantation or a left ventricular assist device-can be safely implemented. Conventional ECMO cannulation strategies commonly employ the femoral artery and vein, constraining the patients to the supine position for the duration of ECMO support. We have recently adopted a modified cannulation approach to promote patient mobility, rehabilitation, and faster recovery and to mitigate complications associated with femoral arterial cannulation, such as limb ischemia and compartment syndrome. This technique involves cannulation of the subclavian artery and vein. The current case report details our recent experience with this approach in a critically ill patient awaiting cardiac transplantation.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349837PMC
http://dx.doi.org/10.1080/08998280.2017.11929596DOI Listing
April 2017

Application of the International Society for Heart and Lung Transplantation (ISHLT) criteria for primary graft dysfunction after cardiac transplantation: outcomes from a high-volume centre†.

Eur J Cardiothorac Surg 2017 02;51(2):263-270

Department of Cardiac and Thoracic Surgery, Baylor University Medical Center, Dallas, TX, USA.

Objectives: A standardized definition for primary graft dysfunction (PGD) after cardiac transplantation was recently proposed by the International Society of Heart and Lung Transplantation (ISHLT). We sought to characterize the outcomes associated with and identify risk factors for PGD following cardiac transplantation using these criteria at a high volume centre.

Methods: Donor and recipient medical records of 201 consecutive adult cardiac transplantations performed between November 2012 and March 2015 were retrospectively reviewed. Patients undergoing isolated heart transplantation were diagnosed with none, mild, moderate, or severe PGD using ISHLT criteria. Cumulative survival was calculated according to the Kaplan–Meier method. Associations of risk factors for combined moderate/severe PGD were assessed with univariate and multivariate analyses.

Results: A total of 191 consecutive patients underwent isolated heart transplantation, and 59 (30%) met ISHLT criteria for PGD: 35 (18%) mild, 8 (4%) moderate and 16 (8%) severe. Thirty-day/in-hospital mortality occurred in six (3%) patients, all of whom were diagnosed with severe PGD. Patients with moderate/severe PGD also had significantly increased intensive care unit length of stay (LOS), total LOS, reoperations for bleeding and postoperative infections. Survival at 1-year was diminished with increasing severity of PGD (none 93%, mild 94%, moderate 75% and severe 44%; log-rank P < 0.001). Elevated preoperative creatinine, pretransplantation hospitalized recipient and undersized donor were independently predictive of moderate/severe PGD.

Conclusions: A diagnosis of PGD portends worse outcomes including increased 30-day and 1-year mortality. The ISHLT diagnostic criteria for moderate and severe PGD identify and discriminate patients with PGD in a clinically relevant manner.
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http://dx.doi.org/10.1093/ejcts/ezw271DOI Listing
February 2017

How to Do It: The Commando Operation for Reconstruction of the Fibrous Skeleton with Double Valve Replacement.

Heart Surg Forum 2016 12 21;19(6):E308-E310. Epub 2016 Dec 21.

Department of Cardiac and Thoracic Surgery, Baylor University Medical Center, Dallas, Texas, USA.

Infiltrative processes that extend into the intervalvular fibrosa, such as infection or calcification, often mandate a complex reconstructive procedure known as the Commando operation. First described less than 20 years ago, this operation is not widely implemented, with experience limited to a few select centers. This report provides a detailed summary of our approach to this intricate procedure.
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http://dx.doi.org/10.1532/hsf.1514DOI Listing
December 2016

HeartMate II Left Ventricular Assist Device Pump Exchange: A Single-Institution Experience.

Thorac Cardiovasc Surg 2017 Aug 30;65(5):410-414. Epub 2016 Nov 30.

Department of Cardiac and Thoracic Surgery, Baylor University Medical Center, Dallas, Texas, United States.

 Left ventricular assist devices (LVADs) have revolutionized the treatment of patients with end-stage heart failure. These devices are replaced when pump complications arise if heart transplant is not possible. We present our experience with HeartMate II (HMII (Thoratec, Plesanton, California, United States)) LVAD pump exchange.  We retrospectively reviewed all cases that required pump exchange due to LVAD complication from November 2011 until June 2016 at a single high-volume institution. The indications, demographics, and outcome were extracted and analyzed.  Of 250 total patients with implanted HMII LVADs, 16 (6%) required pump exchange during the study period. The initial indications for LVAD placement in these patients were bridge to transplantation ( = 6 [37.5%]) or destination therapy ( = 10 [62.5%]). Fifteen patients (93.8%) required pump exchange due to pump thrombosis and 1 (6.2%) due to refractory driveline infection. Nine patients (56.2%) underwent repeat median sternotomy while a left subcostal approach was used in the remaining seven patients. Fifteen patients (93.7%) survived until hospital discharge. During the follow-up period (median, 155 days), 11 patients remained alive and 4 of these underwent successful cardiac transplantation.  HMII LVAD pump exchange can be safely performed for driveline infection or pump thrombosis when heart transplantation is not an option.
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http://dx.doi.org/10.1055/s-0036-1593867DOI Listing
August 2017

Using extracorporeal membrane oxygenation support preoperatively and postoperatively as a successful bridge to recovery in a patient with a large infarct-induced ventricular septal defect.

Proc (Bayl Univ Med Cent) 2016 Jul;29(3):301-4

Department of Cardiac and Thoracic Surgery (Jacob, Patel, Lima, Malyala, Chamogeorgakis, MacHannaford, Gonzalez-Stawinski, Rafael) and the Annette C. and Harold C. Simmons Transplant Institute (Lima, Felius, Chamogeorgakis, Gonzalez-Stawinski), Baylor University Medical Center at Dallas.

Rupture of the ventricular septum during acute myocardial infarction usually occurs within the first week. The event is usually followed by low cardiac output, heart failure, and multiorgan failure. Despite the many advances in the nonoperative treatment of heart failure and cardiogenic shock, including the intra-aortic balloon pump and a multitude of new inotropic agents and vasodilators, these do not supplant the need for operative intervention in these critically ill patients. This article describes the successful use of extracorporeal membrane oxygenation support as a bridge to recovery postoperatively in a patient with a large infarct-produced ventricular septal defect.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4900776PMC
http://dx.doi.org/10.1080/08998280.2016.11929443DOI Listing
July 2016

Comparison of Characteristics of Patients Undergoing Heart Transplantation at the Same Hospital in Two Different Time Periods (1997-2012 and 2013-2015).

Am J Cardiol 2016 Jul 5;118(2):288-91. Epub 2016 May 5.

Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas.

Heart transplantation (HT) increases at some centers each year and decreases at others. We examined characteristics of patients having HT at the same hospital in 2 different time periods (1997-2012 and 2013-2015) by 2 different surgical groups. We compared certain clinical and morphological finding in 291 patients having HT 1997 to 2012 to finding in 228 other patients having HT from 2013 to 2015. Several significant (p <0.05) differences were found: in the most recent time period (2013-2015) compared to the earlier time period (1997-2012), the mean ages of the men were older (57 years -vs- 55 years); diabetes mellitus was more frequent (37% -vs- 21%); systemic hypertension (by history) was more frequent (59% -vs- 32%); the mean body mass index was higher (29.2 kg/m(2) -vs- 26.5 kg/m(2)), and mean heart weight was lower in both men (509 g -vs- 549 g) and women (422 g -vs- 454 g). There were insignificant (p >0.05) differences in gender, frequency of massive cardiac adiposity, underlying cardiac condition, frequency of coronary heart disease, and frequency of previous insertion of a left ventricular assist device. In conclusion, certain characteristics of patients having HT at one Texas hospital changed in several respects in 2 time periods corresponding to changes in surgeons doing the HTs.
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http://dx.doi.org/10.1016/j.amjcard.2016.04.031DOI Listing
July 2016

Impact of donor age on cardiac transplantation outcomes and on cardiac function.

Interact Cardiovasc Thorac Surg 2016 10 31;23(4):580-3. Epub 2016 May 31.

Department of Thoracic and Cardiac Surgery, Baylor University Medical Center at Dallas, Dallas, TX, USA.

Objectives: Although the impact of older donors on heart transplant outcomes has been previously published, the survival results are conflicting. We herein analyse the impact of older donors on transplant survival and myocardial function.

Methods: The records of the patients who underwent heart transplant at Baylor University Medical Center at Dallas from November 2012 until March 2015 were reviewed and the data were extracted. The heart recipients were divided into two groups based on donors age; 50 years of age was the division point. The two groups were compared with regard to the following transplant outcomes: in-hospital and 1-year survival, severe (3R) rejection, primary graft dysfunction, myocardial performance as reflected by the inotropic score, left ventricular ejection fraction, intensive care unit and overall length of stay.

Results: Anoxia was more common cause of death in younger donors (43.9%), whereas intracranial bleeding was more frequent in older donors (48.1%, P = 0.016). The in-hospital survival and 1-year survival were the same between the two groups. Additionally, cardiac transplantation from older donors was not associated with higher incidence of graft dysfunction, higher inotropic support score, longer intensive care unit and total hospital length of stay or more frequent severe rejection episodes. The left ventricular ejection fraction was similar between the two groups.

Conclusions: Heart transplant from older donors is not associated with lower in-hospital and mid-term survival if donors are carefully selected; furthermore, the graft function is comparable. The use of hearts from donors older than 50 years of age can be expanded beyond critically ill recipients in carefully selected recipients.
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http://dx.doi.org/10.1093/icvts/ivw172DOI Listing
October 2016

Effectiveness and Safety of the Impella 5.0 as a Bridge to Cardiac Transplantation or Durable Left Ventricular Assist Device.

Am J Cardiol 2016 05 4;117(10):1622-1628. Epub 2016 Mar 4.

Division of Cardiology, Department of Internal Medicine, Baylor University Medical Center, Dallas, Texas.

Many patients with end-stage heart failure require mechanical circulatory support as a temporizing measure to enable multidisciplinary assessment for the most suitable therapeutic strategy. Impella 5.0 can be used as a bridge to decision to evaluate patients for potential recovery or bridge to next therapy (bridge to heart transplantation [BTHT] or bridge to durable left ventricular assist device or VAD [BLVAD]. Our goal was to examine single-center outcomes with the Impella 5.0 device as a bridge to next therapy (BTHT or BTLVAD). Forty patients underwent Impella 5.0 support from December 2009 to December 2015 with the intent of BTHT (n = 20) or BTLVAD (n = 20). The primary end point was survival to next therapy. Secondary end points included hemodynamic assessments and in-hospital/30-day complications. All patients were inotrope-dependent, with severely depressed left ventricular ejection fraction (12%) and renal insufficiency (creatinine 2.0 mg/dl). Most were Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 2 (66%) with biventricular failure (65%). Thirty patients (75%) survived to next therapy, including transplant (n = 13), durable LVAD (n = 15), and recovery of native heart function (n = 2). No strokes or major bleeding events requiring surgery were observed. Acute renal dysfunction, bleeding requiring transfusion, hemolysis, device malfunction, limb ischemia occurred in 13 (33%), 11 (28%), 3 (8%), 4 (10%), and 1 (3%) patients, respectively. Survival rate to discharge and/or 30 days was 68% (27 of 40). Temporary support with the Impella 5.0 allows for an effective bridge to decision strategy for hemodynamic stabilization and multidisciplinary heart team assessment of critically ill patients with heart failure. In conclusion, many of these patients can be subsequently bridged to the next therapy with favorable outcomes.
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http://dx.doi.org/10.1016/j.amjcard.2016.02.038DOI Listing
May 2016

Donor Hearts: Time to Look at Them in a Different Light?

J Card Fail 2016 05 4;22(5):383-4. Epub 2016 Apr 4.

Baylor University Medical Center, Dallas, Texas. Electronic address:

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http://dx.doi.org/10.1016/j.cardfail.2016.04.002DOI Listing
May 2016

Frequency of Massive Cardiac Adiposity (Floating Heart) in the Native Hearts of Patients Having Heart Transplantation at a Single Texas Hospital (2013 to 2015) and Comparison of Various Clinical and Morphologic Variables in the Patients With Massive Versus Nonmassive Cardiac Adiposity.

Am J Cardiol 2016 Apr 29;117(8):1375-80. Epub 2016 Jan 29.

Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas.

Body weight continues to increase worldwide due primarily to the increase in body fat. This study analyzes the frequency of massive adiposity at hearts of patients who underwent heart transplantation (HT) determined by the ability of the heart to float in a container of 10% formaldehyde (because adipose tissue is lighter than myocardium) and compares certain characteristics of those patients with and without floating hearts. The hearts studied at HT during a 3-year period (2013 to 2015) at Baylor University Medical Center were carefully "cleaned" and weighed by the same individual and tested as to their ability to float in a container of formaldehyde, an indication of severe cardiac adiposity. Of the 220 hearts studied, 84 (38%) floated in a container of formaldehyde and 136 (62%) did not. Comparison of the 84 patients with floating hearts to the 136 with nonfloating hearts showed a significant difference in ages, but a nonsignificant difference in gender, body mass index, frequency of systemic hypertension, or diabetes mellitus. The odds of a heart being a floating one was increased in patients with a diagnosis of ischemic cardiomyopathy (unadjusted odds ratio 2.12, 95% CI 1.21 to 3.70). The frequency of massive cardiac adiposity in the native hearts of patients having HT (38%) is striking and appears to have increased in frequency in the recent decades.
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http://dx.doi.org/10.1016/j.amjcard.2016.01.035DOI Listing
April 2016

Heart transplantation in the Ehlers-Danlos syndrome.

Proc (Bayl Univ Med Cent) 2015 Oct;28(4):492-3

Texas A&M Health Science Center College of Medicine (Reinhold); the Division of Cardiology (Khalid, Stoler, Hall) and the Department of Cardiovascular and Thoracic Surgery (Lima, Gonzalez-Stawinski, Chamogeorgakis), Baylor University Medical Center at Dallas and the Baylor Hamilton Heart and Vascular Hospital, Dallas, Texas.

We describe a woman with Ehlers-Danlos syndrome and aortic aneurysm who experienced a myocardial infarction due to spontaneous left circumflex coronary artery dissection 3 weeks postpartum. She developed end-stage heart failure and subsequently underwent a successful orthotopic heart transplantation. To our knowledge, this is the first report of a heart transplant performed in an individual with Ehlers-Danlos syndrome.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4569234PMC
http://dx.doi.org/10.1080/08998280.2015.11929319DOI Listing
October 2015

Replacement of the aortic valve with a bioprosthesis at the time of continuous flow ventricular assist device implantation for preexisting aortic valve dysfunction.

Proc (Bayl Univ Med Cent) 2015 Oct;28(4):454-6

Department of Cardiac Surgery, Baylor University Medical Center at Dallas, Dallas, Texas (Lima, Chamogeorgakis), and the Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio (Mountis, Gonzalez-Stawinski). Dr. Gonzalez-Stawinski is now affiliated with Baylor University Medical Center at Dallas.

Left ventricular assist device (LVAD) implantation has become a mainstay of therapy for advanced heart failure patients who are either ineligible for, or awaiting, cardiac transplantation. Controversy remains over the optimal therapeutic strategy for preexisting aortic valvular dysfunction in these patients at the time of LVAD implant. In patients with moderate to severe aortic regurgitation, surgical approaches are center specific and range from variable leaflet closure techniques to concomitant aortic valve replacement (AVR) with a bioprosthesis. In the present study, we retrospectively analyzed our outcomes in patients who underwent simultaneous AVR and LVAD implantation secondary to antecedent aortic valve pathology. Between January 2004 and June 2010, 144 patients underwent LVAD implantation at a single institution. Of these, 7 patients (4.8%) required concomitant AVR. Five of the 7 patients (71%) survived to hospital discharge and suffered no adverse events in the perioperative period. One-year survival for the discharged patients was 80%, and no prosthetic valve-related adverse events were observed in long-term follow-up. Given our experience, we conclude that bioprosthetic AVR is a plausible alternative for end-stage heart failure patients at the time of LVAD implantation.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4569222PMC
http://dx.doi.org/10.1080/08998280.2015.11929306DOI Listing
October 2015

Utility of cardiac computed tomography for inflow cannula patency assessment and prediction of clinical outcome in patients with the HeartMate II left ventricular assist device.

Interact Cardiovasc Thorac Surg 2015 Nov 29;21(5):590-3. Epub 2015 Jul 29.

Department of Heart Transplantation and Mechanical Circulatory Support, Baylor University Medical Center, Dallas, TX, USA National and Kapodistrian University of Athens, Athens, Greece

Objectives: Proper inflow cannula orientation during implantation of the HeartMate II (HMII) left ventricular assist device (LVAD) is important for optimal pump function. This article describes our experience with cardiac computed tomography (CCT) to evaluate inflow cannula patency and predict future adverse outcomes (AE) after HMII LVAD implantation.

Methods: Ninety-three patients underwent HMII LVAD implantation for end-stage cardiomyopathy from January 2010 until March 2014. A total of 25 consecutive patients had CCT after the implantation; 3 patients were excluded from the analysis due to associated abnormality of the outflow graft. The 22 patients with CCT after HMII LVAD were censored for adverse events related to LVAD malfunction after HMII LVAD implantation. The maximum percentage of inflow cannula obstruction on CCT was recorded. We analysed the predictive value of CCT in addition to other clinical and diagnostic variables for future AEs.

Results: Seven of the 22 patients (32%) experienced AEs after HMII LVAD implantation. The degree of inflow cannula obstruction was higher in the group of patients who experienced an AE (70 vs 14%; P < 0.001). Inflow cannula obstruction >30% showed excellent correlation with AE longitudinally based on receiver operating curve (0.829). The group with AEs more frequently experienced CHF symptoms (P = 0.054).

Conclusions: Inflow cannula obstruction >30% on CCT predicts future adverse events in patients with HMII LVAD; the need for surgical intervention in terms of LVAD exchange or urgent listing for heart transplantation should be considered in good surgical risk patients. Cardiac computed tomography should be considered routinely postoperatively in patients with HMII LVAD.
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http://dx.doi.org/10.1093/icvts/ivv205DOI Listing
November 2015

Ventricular assist devices: The future is now.

Trends Cardiovasc Med 2015 May 20;25(4):360-9. Epub 2014 Nov 20.

Department of Cardiac Surgery, Baylor University Medical Center, Dallas, TX. Electronic address:

Heart failure has become a global epidemic. For advanced heart failure, a broad assortment of device options have been introduced for both acute and prolonged intervals of hemodynamic assistance. Durable implantable ventricular assist devices (VADs) in particular play a key role in the management of advanced heart failure. This review focuses specifically on the current outcomes with VAD therapy, highlights the results from pivotal clinical trials, and summarizes the various device options on the market and those in preclinical development.
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http://dx.doi.org/10.1016/j.tcm.2014.11.008DOI Listing
May 2015

The two extremes of cardiac sarcoidosis and the effect of Prednisone therapy.

Am J Cardiol 2015 Jan 13;115(1):150-3. Epub 2014 Oct 13.

Department of Pathology, Baylor University Medical Center, Dallas, Texas; Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas; Department of Internal Medicine (Division of Cardiology), Baylor University Medical Center, Dallas, Texas. Electronic address:

Described herein are clinical and morphologic findings in 2 patients who underwent heart transplantation because of severe heart failure resulting from cardiac sarcoidosis. Although the explanted hearts in each patient had characteristic gross changes of cardiac sarcoidosis, one patient who had been treated with prednisone, had no residual sarcoid granulomas in the myocardium, whereas the other patient, in whom diagnosis was not made until heart transplantation, had innumerable sarcoid granulomas in her heart. This report suggests that prednisone can eliminate sarcoid granulomas in the heart but that their replacement is by dense fibrous tissue, something also likely the result of the granulomas themselves, creating a situation where the treated (prednisone) and the non-treated sarcoid heart may appear similar by gross examination.
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http://dx.doi.org/10.1016/j.amjcard.2014.10.003DOI Listing
January 2015
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