Browsing by Author "Nicoara, Alina"

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Open Access
Abdominal Gunshot Causing Ventricular Septal Injury Without Perforation into the Pericardium.
(Journal of Cardiothoracic and Vascular Anesthesia, 2019-03-01) Sigurdsson, Martin I; Brockbank, Benjamin; Haney, John C; Andrews, Jon; MacLeod, David B; Vaslef, Steven N; Brooks, Kelli R; Manning, Erin L; Nicoara, Alina
Open Access
Assessment of Coronary Blood Flow by Transesophageal Echocardiography.
(J Cardiothorac Vasc Anesth, 2016-01) Maxwell, Cory; Cherry, Anne; Daneshmand, Mani; Swaminathan, Madhav; Nicoara, Alina
Open Access
Discordance in Grading Methods of Aortic Stenosis by Pre-Cardiopulmonary Bypass Transesophageal Echocardiography.
(Anesth Analg, 2016-04) Whitener, George; McKenzie, Jeff; Akushevich, Igor; White, William D; Dhakal, Ishwori B; Nicoara, Alina; Swaminathan, Madhav
BACKGROUND: Current guidelines define severe aortic valve stenosis (AS) as an aortic valve area (AVA) ≤1.0 cm by the continuity equation and mean gradient (ΔPm) ≥ 40 mm Hg. However, these measurements can be discordant when classifying AS severity. Approximately one-third of patients with normal ejection fraction and severe AS by AVA have nonsevere AS by ΔPm when measured by preoperative transthoracic echocardiography (TTE). Given the use of positive pressure ventilation and general anesthesia in the pre-cardiopulmonary bypass (pre-CPB) period, we hypothesized that discordance between ΔPm and AVA during pre-CPB transesophageal echocardiography (TEE) would be higher than previously reported by TTE. METHODS: We retrospectively examined pre-CPB TEE data for patients who had aortic valve replacement, with or without coronary artery bypass grafting, from 2000 to 2012. Patients were excluded if they had ejection fraction <55%, emergency surgery, repeat sternotomy, moderate or severe mitral regurgitation, or severe aortic regurgitation. Only patients with both pre-CPB AVA and ΔPm measurements were included. Patients were grouped according to severity (mild, moderate, and severe) by AVA or ΔPm. Discordance was defined as disagreement between severities based on either parameter. RESULTS: A total of 277 patients met inclusion criteria. There were 227 patients with AVA ≤ 1.0 cm. The proportion of these patients with a ΔPm < 40 mm Hg was 54% (95% confidence interval, 47%-61%). The rate of discordance was significantly higher than the rate (37%; P < 0.001) found in previously reported analyses using TTE. Of the patients with a ΔPm ≥ 40 mm Hg, only 8% (n = 9/113) had a discordant AVA. In contrast, of the patients with ΔPm < 40 mm Hg, 80% (n = 131/164) had a discordant AVA. CONCLUSIONS: We confirmed our hypothesis that grading AS by ΔPm and AVA during pre-CPB TEE exhibits higher discordance than reported for TTE by others. It remains unclear whether these discrepancies reflect the effect of general anesthesia, imaging modality (TTE versus TEE) differences, inaccuracies in AS grading cutoffs when applied to pre-CPB TEE, or selection bias of the surgical population.
Open Access
Durability and Efficacy of Tricuspid Valve Repair in Patients Undergoing Left Ventricular Assist Device Implantation.
(JACC. Heart failure, 2019-12-03) Barac, Yaron D; Nicoara, Alina; Bishawi, Muath; Schroder, Jacob N; Daneshmand, Mani A; Hashmi, Nazish K; Velazquez, Eric; Rogers, Joseph G; Patel, Chetan B; Milano, Carmelo A
OBJECTIVES:This study sought to determine the durability of tricuspid valve repair (TVr) performed concurrently with left ventricular assist device (LVAD) implantation and its association with the development of late right heart failure (RHF). BACKGROUND:Surgical management of tricuspid regurgitation (TR) at the time of LVAD implantation is performed in an attempt to reduce the occurrence of postoperative RHF. Limited data exist regarding the durability of TVr in patients with LVAD as well as its impact on development of late RHF. METHODS:A retrospective review was conducted of consecutive adult patients who underwent durable LVAD implantation and concurrent TVr at the authors' institution between 2009 and 2017. Late RHF was defined as readmission for HF requiring inotropic or diuretic therapy. TVr failure was defined as moderate or severe TR at any follow-up echocardiographic examination after LVAD implantation. RESULTS:A total of 156 patients underwent LVAD and concurrent TVr during the study. Of the total, 59 patients (37.8%) had a failed TVr. The mean duration of echocardiographic follow-up was 23 ± 22 months. Of the 146 patients who were discharged after the index hospitalization, 53 patients (36.3%) developed late RHF. Multivariate Cox proportional hazard analysis demonstrated that TVr failure was an independent predictor of late RHF development (hazard ratio: 2.62; 95% confidence interval: 1.38 to 4.96; p = 0.003). CONCLUSION:Failure of TVr in this cohort occurred at a significant rate. Failure of TVr is an independent risk factor for development of late RHF. Future studies should investigate strategies to reduce recurrence of significant TR.
Open Access
Frailty in the End-Stage Lung Disease or Heart Failure Patient: Implications for the Perioperative Transplant Clinician.
(Journal of cardiothoracic and vascular anesthesia, 2019-05) Bottiger, Brandi A; Nicoara, Alina; Snyder, Laurie D; Wischmeyer, Paul E; Schroder, Jacob N; Patel, Chetan B; Daneshmand, Mani A; Sladen, Robert N; Ghadimi, Kamrouz
The syndrome of frailty for patients undergoing heart or lung transplantation has been a recent focus for perioperative clinicians because of its association with postoperative complications and poor outcomes. Patients with end-stage cardiac or pulmonary failure may be under consideration for heart or lung transplantation along with bridging therapies such as ventricular assist device implantation or venovenous extracorporeal membrane oxygenation, respectively. Early identification of frail patients in an attempt to modify the risk of postoperative morbidity and mortality has become an important area of study over the last decade. Many quantification tools and risk prediction models for frailty have been developed but have not been evaluated extensively or standardized in the cardiothoracic transplant candidate population. Heightened awareness of frailty, coupled with a better understanding of distinct cellular mechanisms and biomarkers apart from end-stage organ disease, may play an important role in potentially reversing frailty related to organ failure. Furthermore, the clinical management of these critically ill patients may be enhanced by waitlist and postoperative physical rehabilitation and nutritional optimization.
Open Access
Intraoperative renal resistive index with adjustment for aortic insufficiency for acute kidney injury prediction in cardiac surgery patients
Merchant, Akeel; Andrew, ben; Nicoara, Alina; Stafford-Smith, MARK; Hauck, Jennifer; Li, yi; Cherry, Anne
Open Access
Use of mobile tablet devices and reduction in time to perioperative transesophageal echocardiography reporting: a historical cohort study
(Canadian Journal of Anesthesia, 2015-01-01) Bottiger, Brandi; McCartney, Sharon; Akushevich, Igor; Nicoara, Alina; Yanamadala, Mamata; Swaminathan, Madhav
© 2014, Canadian Anesthesiologists' Society.Purpose: Timely communication of intraoperative transesophageal echocardiography (TEE) findings to the postoperative care team is critical to optimizing patient care. We compared the use of a personal computer (PC) system with the use of a mobile tablet device (MTD) system for point-of-care TEE data entry and hypothesized that the MTD-based system would reduce the time to preliminary TEE reporting and decrease the incidence of delinquent reporting by 50%. Methods: In this historical cohort study, we reviewed 508 perioperative TEE reports entered by cardiothoracic anesthesia fellows. Reports were grouped based on whether data were entered on a PC (PC group) or a MTD (MTD group). Time to TEE reporting was defined as the time from the patient leaving the operating room to the time the TEE report was generated. Delinquent reports were defined as those generated >24 hr after the initial exam. Time to TEE reporting and incidence of delinquent reports were compared between the two groups. Results: Mean (SD) time to TEE reporting was significantly improved with MTD data entry vs PC data entry [233 (676) min vs 1,103 (3,830) min, respectively; mean difference 870 min; 95% confidence interval (CI) 293 to 1,448; P = 0.003], and median (IQR) time was also significantly improved [46 (163) min vs 126 (1,000) min, respectively; median difference 80 min; P = 0.0002]. The incidence of report delinquency with MTD data entry vs PC data entry was also significantly reduced [2.1% vs 6.8%, respectively; mean difference 2.2%; 95% CI 0.5 to 9.0; P = 0.02]. Conclusion: Implementation of a MTD system for data entry leads to improved TEE reporting time and reduces TEE reporting delinquency. Further studies are required to determine whether this strategy enhances quality of reporting, optimizes communication between care teams, and improves outcomes without increasing costs.