Browsing by Author "Gaca, Jeffrey G"

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    Longitudinal Changes in Regional Cerebral Perfusion and Cognition Following Cardiac Surgery.
    (The Annals of thoracic surgery, 2018-09-22) Smith, Patrick J; Browndyke, Jeffrey N; Monge, Zachary A; Harshbarger, Todd B; James, Michael L; Gaca, Jeffrey G; Alexander, John H; Berger, Miles M; Newman, Mark F; Milano, Carmelo A; Mathew, Joseph P; Neurologic Outcomes Research Group (NORG)
    Cardiac surgery has been associated with increased risk of postoperative cognitive decline, as well as dementia risk in the general population. Few studies, however, have examined the impact of coronary revascularization or valve replacement / repair surgery on longitudinal cerebral perfusion changes or their association with cognitive function.We examined longitudinal changes in cerebral perfusion among 54 individuals with cardiac disease; 27 undergoing cardiac surgery and 27 matched controls. Arterial spin labeling (ASL) magnetic resonance perfusion imaging was used to quantify cerebral blood flow within the anterior communicating artery (ACA), middle cerebral artery (MCA), and posterior communicating artery (PCA) vascular territories prior to surgery and postoperatively at 6-weeks and 1-year. Cognitive performance was examined during the same intervals using a battery of tests tapping memory, executive, information processing and upper extremity motor functions. Repeated measures, mixed models were used to examine for perfusion changes and the association between perfusion changes and cognition.Significant postoperative increases in perfusion were observed at 6-weeks within the MCA vascular territory following cardiac surgery (P = .035 for interaction). Perfusion changes were most notable in distal territories of the MCA and PCA at 6-weeks, with no additional changes at 1-year. Postoperative increases in MCA perfusion at 6-weeks were associated with improved psychomotor speed (β = 0.35, P = .016); whereas, no significant differences were found between groups in vascular territory perfusion and cognition at 1-year.Cardiac surgery is associated with significant short-term increases in MCA perfusion with associated improvements in psychomotor speed.
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    Resting-State Functional Connectivity and Cognition After Major Cardiac Surgery in Older Adults without Preoperative Cognitive Impairment: Preliminary Findings.
    (J Am Geriatr Soc, 2017-01) Browndyke, Jeffrey N; Berger, Miles; Harshbarger, Todd B; Smith, Patrick J; White, William; Bisanar, Tiffany L; Alexander, John H; Gaca, Jeffrey G; Welsh-Bohmer, Kathleen; Newman, Mark F; Mathew, Joseph P
    OBJECTIVES: To look for changes in intrinsic functional brain connectivity associated with postoperative changes in cognition, a common complication in seniors undergoing major surgery, using resting-state functional magnetic resonance imaging. DESIGN: Objective cognitive testing and functional brain imaging were prospectively performed at preoperative baseline and 6 weeks after surgery and at the same time intervals in nonsurgical controls. SETTING: Academic medical center. PARTICIPANTS: Older adults undergoing cardiac surgery (n = 12) and nonsurgical older adult controls with a history of coronary artery disease (n = 12); no participants had cognitive impairment at preoperative baseline (Mini-Mental State Examination score >27). MEASUREMENTS: Differences in resting-state functional connectivity (RSFC) and global cognitive change relationships were assessed using a voxel-wise intrinsic connectivity method, controlling for demographic factors and pre- and perioperative cerebral white matter disease volume. Analyses were corrected for multiple comparisons (false discovery rate P < .01). RESULTS: Global cognitive change after cardiac surgery was significantly associated with intrinsic RSFC changes in regions of the posterior cingulate cortex and right superior frontal gyrus-anatomical and functional locations of the brain's default mode network (DMN). No statistically significant relationships were found between global cognitive change and RSFC change in nonsurgical controls. CONCLUSION: Clinicians have long known that some older adults develop postoperative cognitive dysfunction (POCD) after anesthesia and surgery, yet the neurobiological correlates of POCD are not well defined. The current results suggest that altered RSFC in specific DMN regions is positively correlated with global cognitive change 6 weeks after cardiac surgery, suggesting that DMN activity and connectivity could be important diagnostic markers of POCD or intervention targets for potential POCD treatment efforts.
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    Right Minithoracotomy Versus Median Sternotomy for Mitral Valve Surgery: A Propensity Matched Study.
    (The Annals of thoracic surgery, 2015-08) Tang, Paul; Onaitis, Mark; Gaca, Jeffrey G; Milano, Carmelo A; Stafford-Smith, Mark; Glower, Donald

    Background

    The efficacy of conventional median sternotomy versus a right minithoracotomy (RT) approach to mitral valve surgery was evaluated in a single high-volume institution.

    Methods

    A retrospective analysis of a single institution's experience was performed using propensity matching of 1,694 patients who underwent mitral valve surgery during a 15-year period. Patients who had procedures that were not usually performed through an RT approach were excluded. Using 1:1 propensity score matching, we obtained 215 matched patients in each group for outcomes analysis.

    Results

    There was no difference in the median year of operation between the two groups (2002 versus 2001; p = 0.142). The RT approach was not a predictor of postoperative mortality. Predictors of mortality included increasing age, diabetes, smoking, preoperative dialysis, lung disease, advanced congestive heart failure class, and peripheral vascular disease. The RT approach was associated with less new-onset atrial fibrillation (8% versus 16%; p = 0.018), pneumonia (1% versus 5%; p = 0.049), respiratory failure (3% versus 8%; p = 0.036), and acute renal failure (2% versus 7%; p = 0.006), lower chest tube output (350 versus 840 mL; p < 0.001), and fewer red blood transfusions (2 versus 3 units; p = 0.001).

    Conclusions

    Right minithoracotomy compared with median sternotomy for mitral valve surgery was associated with less postoperative atrial fibrillation, respiratory complications, acute renal failure, chest tube output, and use of packed red blood cells. Given study limitations, the RT approach for mitral valve surgery may have advantages over median sternotomy in selected patients.
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    Three-factor prothrombin complex concentrates for refractory bleeding after cardiovascular surgery within an algorithmic approach to haemostasis.
    (Vox sanguinis, 2019-05) Hashmi, Nazish K; Ghadimi, Kamrouz; Srinivasan, Amudan J; Li, Yi-Ju; Raiff, Robert D; Gaca, Jeffrey G; Root, Adam G; Barac, Yaron D; Ortel, Thomas L; Levy, Jerrold H; Welsby, Ian J
    BACKGROUND/OBJECTIVES:Prothrombin complex concentrates (PCC) are increasingly administered off-label in the United States to treat bleeding in cardiovascular surgical patients and carry the potential risk for acquired thromboembolic side-effects after surgery. Therefore, we hypothesized that the use of low-dose 3-factor (3F) PCC (20-30 IU/kg), as part of a transfusion algorithm, reduces bleeding without increasing postoperative thrombotic/thromboembolic complications. MATERIALS/METHODS:After IRB approval, we retrospectively analysed 114 consecutive, complex cardiovascular surgical patients (age > 18 years), between February 2014 and June 2015, that received low-dose 3F-PCC (Profilnine® ), of which seven patients met established exclusion criteria. PCC was dosed according to an institutional perioperative algorithm. Allogeneic transfusions were recorded before and after PCC administration (n = 107). The incidence of postoperative thromboembolic events was determined within 30 days of surgery, and Factor II levels were measured in a subset of patients (n = 20) as a quality control measure to avoid excessive PCC dosing. RESULTS:Total allogeneic blood product transfusion reached a mean of 12·4 ± 9·9 units before PCC and 5·0 ± 6·3 units after PCC administration (P < 0·001). The mean PCC dose was 15·8 ± 7·1 IU/kg. Four patients (3·8%) each experienced an ischaemic stroke on postoperative day 1, 2, 4 and 27. Seven patients (6·5%) had acquired venous thromboembolic disease within 10 days of surgery. Median factor II level after transfusion algorithm adherence and PCC administration was 87%. CONCLUSIONS:3F-PCC use for refractory bleeding after cardiovascular surgery resulted in reduced transfusion of allogeneic blood and blood products. Adherence to this algorithmic approach was associated with an acceptable incidence of postoperative thrombotic/thromboembolic complications.
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    Using a Regent Aortic Valve in a Small Annulus Mitral Position Is a Viable Option.
    (The Annals of thoracic surgery, 2018-04) Barac, Yaron D; Zwischenberger, Brittany; Schroder, Jacob N; Daneshmand, Mani A; Haney, John C; Gaca, Jeffrey G; Wang, Andrew; Milano, Carmelo A; Glower, Donald D
    BACKGROUND:Outcome of mitral valve replacement in extreme scenarios of small mitral annulus with the use of the Regent mechanical aortic valve is not well documented. METHODS:Records were examined in 31 consecutive patients who underwent mitral valve replacement with the use of the aortic Regent valve because of a small mitral annulus. RESULTS:Mean age was 60 ± 14 years. Mitral stenosis or mitral annulus calcification was present in 30 of 31 patients (97%). Concurrent procedures were performed in 17 of 31 patients (55%). Median valve size was 23 mm. Mean mitral gradient coming out of the operating room was 4.2 ± 1.5 mm Hg and at follow-up echocardiogram performed at a median of 32 months after the procedure was 5.8 ± 2.4 mm Hg. CONCLUSIONS:A Regent aortic mechanical valve can be a viable option with a larger orifice area than the regular mechanical mitral valve in a problematic situation of a small mitral valve annulus. Moreover, the pressure gradients over the valve are acceptable intraoperatively and over time.