Gloverhiggins2588

Background The presence of significant atrioventricular valve (AVV) regurgitation results in unfavorable conditions that affect the success of single ventricle (SV) multistage palliation. We report our institution's AVV repair experience. Methods We examined incidence of AVV repair in 603 infants who underwent initial SV palliation surgery from 2002-12. We explored patients' characteristics, anatomic and operative details associated with death, transplantation and AVV reoperation. Results Sixty patients received AVV repair during first-stage (n=10), Glenn (n=27), Fontan (n=23). Median age at AVV repair was 6.9 months (IQR 4.2-24.1). Underlying SV anomaly was HLHS (n=30), heterotaxy (n=15), other (n=15). The AVV was tricuspid (n=34), mitral (n=6), common (n=20). Pre-operatively, all patients had AVV regurgitation ≥ moderate and 7 (12%) had ventricular dysfunction ≥ moderate. Post-repair, AVV regurgitation was none/trivial (n=21, 35%), mild (n=21, 35%), ≥ moderate (n=17, 30%). Competing risks analysis showed that 10-years following AVV repair, 18% of patients had undergone AVV reoperation, 26% had died or undergone transplantation, and 56% were alive without subsequent reoperation. Transplant-free survival was 38%, 65% and 100% for AVV repair at first-stage, Glenn or Fontan (p=0.0011) and was 74%, 83% and 56% for tricuspid, mitral and common AVV repair (p=0.344). Factors associated with transplant-free survival were timing of AVV repair, underlying SV anomaly, and systemic ventricle function. Conclusions AVV repair at first-stage surgery and reduced systemic ventricle function are associated with poor outcomes. In those high-risk patients, different approaches that involve initial palliation mode, timing of AVV repair or listing for transplantation might be warranted.Background Venous-arterial extracorporeal membrane oxygenation (VA-ECMO) undoubtedly saves many lives, but is associated with a high degree of patient morbidity, mortality, and resource utilization. We aimed to develop a machine learning algorithm to augment clinical decision making related to VA-ECMO. Methods Patients supported by VA-ECMO at a single institution from May 2011 to October 2018 were retrospectively reviewed. Laboratory values from only the initial 48 hours of VA-ECMO support were used. Data were split into 70% for training, 15% validation and 15% withheld for testing. Feature importance was estimated and dimensionality reduction techniques were utilized. A deep neural network was trained to predict survival to discharge and the final model was assessed using the independent testing cohort. Model performance was compared to that of the SAVE score using a receiver operator characteristic curve. Results Of the 282 eligible adult VA-ECMO patients, 117 (41%) survived to discharge. A total of 1.96 million laboratory values were extracted from the electronic medical record, from which 270 different summary variables were derived for each patient. The most important variables in predicting the primary outcome included lactate, age, total bilirubin, and creatinine. For the testing cohort, the final model achieved 82% overall accuracy and a greater area under the curve (AUC) than the SAVE score (0.92 vs 0.65, p=0.01) in predicting survival to discharge. Conclusions This proof of concept study demonstrates the potential for machine learning models to augment clinical decision making for VA-ECMO patients. Further development with multi-institutional data is warranted.Complete surgical resection is the most critical factor to achieve better long-term outcomes in treating primary cardiac sarcomas, however, it is oftentimes hampered when there is extensive tumor involvement into important cardiac apparatus. Here, we report a case of successful complete resection of a cardiac sarcoma infiltrating the right atrio-ventricle, tricuspid valve and right coronary artery.Background The objective of the present study was to characterize practical utilization trends and outcomes for intra-aortic balloon pump (IABP) and percutaneous left ventricular assist device (pVAD) in cardiogenic shock at a national level. Methods An analysis of all adult patients admitted non-electively for cardiogenic shock from January 2008 through December 2017 was performed using the National Inpatient Sample (NIS). Trends of inpatient IABP and pVAD use were analyzed using survey weighted estimates and the modified Cochran-Armitage test for significance. Multivariable regression models and inverse probability of treatment weights (IPTW) were used to perform risk-adjusted analyses of pVAD mortality a composite of adverse events (AE), and resource utilization, with IABP as reference. Results Of an estimated 774,310 patients admitted with cardiogenic shock, 143,051received a device IABP= 127,792 (16.5%) or pVAD=15,259 (2.0%). The usage of IABP decreased (23.8 to 12.7%, p-for-trend less then 0.001), while pVAD implantation increased significantly during the study period (0.2 to 4.5%, p-for-trend less then 0.001). IPTW demonstrated significantly higher odds of mortality with pVAD (OR 1.9, 95% CI 1.7-2.2), but not AE (OR 1.1 95% CI 0.96-1.27) compared to IABP. Mitoubiquinone solubility dmso After risk-adjustment, pVAD use was associated with an additional $15,202 (P less then 0.001) for survivors and $29,643 for non-survivors (P less then 0.001). Conclusions Over the study period, the rate of pVAD utilization for cardiogenic shock has significantly increased. Compared to IABP, pVAD use was associated with increased mortality, costs and several adverse events. Multi-institutional clinical trials with rigorous inclusion criteria are warranted to evaluate the clinical utility of pVADs in the modern era.Aortic injuries are notoriously lethal particularly when associated with concomitant injuries. We describe the evaluation and management of a polytrauma patient with transverse arch transection which was complicated by dissection of both common carotid arteries. He was managed with aortic arch replacement and reimplanatation of innominate and left common carotid arteries with an additional graft from ascending aorta to the right common carotid artery.Background Aortic valve neo-cuspidization (AVNeo, Ozaki procedure) has excellent mid-term results in adults. Outcomes in patients with a small native aortic annulus are unknown. We report early outcomes in young patients with small native aortic valve annuli. Methods Retrospective review of patients undergoing AVNeo between 2015-2019 were reviewed. Patients with native aortic annulus ≤21 mm undergoing 3-leaflet AVNeo were included. Results 51 patients were identified (median age 7.9 years, weight 21 kg). 80% patients were ≤12 years age. Pre-operative indication was AR (n=23), AS (n=22) or AS/AR (n=6). Baseline anatomy was quadricuspid (n=1), tricuspid (n=23), bicuspid (n=15) or unicuspid (n=12) valve. Pre-operative peak gradient for AS and AS/AR patients was 55.36 mmHg. Median native annulus diameter was 17 mm; sinus and annular enlargements were required in 22 and 9 patients, respectively. Median ICU and hospital length of stay were 2.0 and 7.2 days, respectively. There were no re-interventions and one hospital mortality unrelated to aortic valve. At discharge, 94% of patients had ≤mild AR and median peak gradient was 18 mmHg. At mean follow-up of 11.9 months, 80% and 82% of patients had 0 at follow-up. Conclusions The Ozaki procedure has acceptable short-term results in young patients with small aortic annuli. A larger aortic annulus can be achieved with surgical annular enlargement. Long-term follow-up is necessary to determine late valve function and potential continued annular growth.Background While literature shows rigid plate fixation has superior outcomes over wire cerclage techniques, a patient population clearly benefitting from initial sternal plating over standard closure has not been identified. Data on plating as primary sternal closure in the morbidly obese patient remains sparse. Methods A single-center retrospective study was performed on 564 consecutive patients undergoing complete median sternotomy from July 2014 to July 2017. Post-operative outcomes of patients with a body mass index ≥ 35kg/m2 were compared between sternotomies with standard wire cerclage closure and those with sternal plate reinforcement. The primary endpoint was postoperative sternal complication defined as deep sternal wound infection, acute sternal dehiscence, chronic sternal disunion, or non-infectious sternal wound complication requiring operative intervention. Results 32.6% of sternotomies (184/564) were performed on patients with a body mass index ≥ 35kg/m2. Of this group, 31.5% (58/184) underwent sternal closure with titanium plate reinforcement and 68.5% (126/184) underwent traditional chest closure. The overall sternal complication rate was 4.9% (9/184), consisting of 6/126 non-plated patients and 3/58 plated patients (4.8 vs. 5.2%, P=0.80). Conclusions Sternal plate reinforcement for sternotomy closure of patients with a body mass index ≥ 35kg/m2 produced no difference in post-operative sternal complication rates.The development of amphipathic polymers, including various formulations of styrene-maleic acid (SMA) copolymers, has allowed the purification of increasing sizes and complexities of biological membrane protein assemblies in native nanodiscs. However, the factors determining the sizes and shapes of the resulting bio-nano particles remain unclear. Here, we show how grafting on short alkyl amine sidechains onto the polar residues leads to a broad set of nanoparticle sizes with improved solution behavior. link2 The solubilization of lipid vesicles occurs over a wide range of pH levels and calcium concentrations, providing utility across the physiologically relevant range of solution conditions. Furthermore, the active SMA derivatives can contain strictly alternating monomers, which have inherently lower sequence polydispersity. Pronounced differences in the shapes of native nanoparticles were formed from Escherichia coli bacterial outer membrane containing PagP protein using methyl, ethyl and propylamine derivatives of styrene-maleic anhydride. In particular, the methylamine-substituted polymer forms smaller, monodispersed nanodiscs, while the longer alkyl derivatives form worm-like nanostructures. Thus the introduction of hydrophobicity onto the polar sidechains of amphipathic polymers has profound effects on morphology of native nanodisc, with shorter methyl moieties offering more uniformity and utility for structural biology studies.Polyunsaturated phospholipids in plasma membranes modulate order and dynamics of the lipid bilayer and influence integral membrane protein function. In this study, we investigate the effects of polyunsaturated fatty acid (PUFA) chains in phosphatidylcholine (PC) on osmotic water permeability and packing characteristics, using a droplet interface bilayer (DIB) as a model cell membrane. The lipid bilayer system is composed of mixtures of PC lipids with varying ratio of 1-stearoyl-2-oleoylphosphatidylcholine (SOPC, 18 0-181 PC) to 1-stearoyl-2-docosahexaenoylphosphatidylcholine (SDPC, 180-226 PC). link3 Water permeability coefficients (Pf) were derived from the kinetics of osmotic filtration across the DIB. Confocal Raman microspectroscopy probed the structural and packing properties of the mixtures. The water transport parameters and Raman spectral analyses together indicate that Pf and aggregate ordering of a lipid bilayer are significantly influenced by the progressive addition of PUFA chains to a bilayer. The permeability rates across bilayers of the mixtures are a linear function of SDPC mol%.