Vanatta J.M.,Methodist University
Clinical transplants | Year: 2012
Transplantation at the University of Tennessee Health Science Center in Memphis, which began at the William F. Bowld Hospital and transferred to Methodist University Hospital in 2004, includes pediatric transplantation at LeBonheur Children's Medical Center. The multidisciplinary institute is dedicated to the treatment of patients with end-stage liver and kidney disease and allows those patients access to the integrated expertise of transplant surgeons, hepatologists, and nephrologists. The current, and most successful, era for the program began in 2006, when a change in leadership and clinical vision led to a dramatic increase in clinical activity. These changes have included wider acceptance of potential recipients for liver transplantation and broader use of marginal donor allografts. Streamlined surgical techniques have decreased operative times and have limited blood product usage. Additionally, the program uses an innovative immunosuppression protocol with the world's largest reported series of steroid-free, rabbit anti-thymocyte globulin induction and delayed introduction of tacrolimus in an effort to limit adverse effects of immunosuppression. Such adverse effects may include: infections, post-transplant diabetes mellitus, bone disease, and accelerated fibrosis from recurrent HCV related to steroids and impaired renal function from tacrolimus. These changes have resulted in aggressive donor usage with low complication rates and excellent outcomes.
El-Sherif N.,State University of |
Turitto G.,Methodist University
Cardiology Journal | Year: 2011
Electrolyte disorders can alter cardiac ionic currents kinetics and depending on the changes can promote proarrhythmic or antiarrhythmic effects. The present report reviews the mechanisms, electrophysiolgical (EP), electrocardiographic (ECG), and clinical consequences of electrolyte disorders. Potassium (K+) is the most abundent intracellular cation and hypokalemia is the most commont electrolyte abnormality encountered in clinical practice. The most signifcant ECG manifestation of hypokalemia is a prominent U wave. Several cardiac and non cardiac drugs are known to suppress the HERG K+ channel and hence the IK, and especially in the presence of hypokalemia, can result in prolonged action potential duration and QT interval, QTU alternans, early afterdepolarizations, and torsade de pointes ventricular tachyarrythmia (TdP VT). Hyperkalemia affects up to 8% of hospitalized patients mainlyin the setting of compromised renal function. The ECG manifestation of hyperkalemia depends on serum K+ level. At 5.5-7.0 mmol/L K+, tall peaked, narrow-based T waves are seen. At > 10.0 mmol/L K+, sinus arrest, marked intraventricular conduction delay, ventricular techycardia, and ventricular fibrillation can develop. Isolated abnormalities of extracellular calcium (Ca++) produce clinically significant EP effects only when they are extreme in either direction. Hypocalcemia, frequently seen in the setting of chronic renal insufficiency, results in prolonged ST segment and QT interval while hypercalcemia, usually seen with hyperparathyroidism, results in shortening of both intervals. Although magnesium is the second most abudent intracellular cation, the significance of magnesium disorders are controversial partly because of the frequent association of other electrolyte abnormalities. However, IV magnesium by blocking the L-type Ca++ current can succesfully terminate TdP VT without affecting the prolonged QT interval. Finally, despite the frequency of sodium abnormalities, particularly hyponatremia, its EP effects are rarely clinically significant. © 2011 Via Medica.
Gupta P.K.,Methodist University |
Sundaram A.,Creighton University |
Kent K.C.,University of Wisconsin - Madison
Journal of Vascular Surgery | Year: 2015
Objective Although placement of an open iliac conduit for endovascular aortic aneurysm repair (EVAR) is generally felt to result in higher morbidity and mortality, published literature is scarce. Our objective was to assess 30-day outcomes after elective EVAR with an open iliac conduit using a multi-institutional database. Methods Patients who underwent elective EVAR (n = 14,339) for abdominal aortic aneurysm were identified from the American College of Surgeons National Surgical Quality Improvement Program 2005 to 2011 database. Univariable and multivariable logistic regression analyses were performed. Results An open iliac conduit was used in 231 patients (1.6%), and the remainder had femoral exposure or percutaneous EVAR. Women comprised 32% of patients with iliac conduits in contrast to 17% of those without iliac conduits. Patients with iliac conduits were older and had a lower body mass index. Univariable analysis showed patients with open iliac conduits had a higher incidence of postoperative pneumonia (3.0% vs 1.1%), ventilator dependence (4.8% vs 1.0%), renal failure (3.0% vs 0.7%), cardiac arrest or myocardial infarction (5.2% vs 1.1%), return to the operating room (9.1% vs 3.7%), major morbidity (16.0 vs 6.6%), and death (3.0% vs 0.9%). On multivariable analysis, the use of open iliac conduits was associated with higher risk of 30-day mortality (odds ratio, 2.7; 95% confidence interval, 1.2-6.0) and 30-day major morbidity (odds ratio, 2.3; 95% confidence interval, 1.6-3.3). Conclusions Patients with open iliac conduits for EVAR are more likely to be female and have higher postoperative morbidity and mortality. For patients with complex iliac artery disease, conduits are a viable alternative after EVAR to be performed, albeit at an increased risk. These data do suggest the need for lower-profile grafts and other alternative strategies for navigating complex iliac artery disease. © 2015 Society for Vascular Surgery.
Reddy V.Y.,Mount Sinai School of Medicine |
Exner D.V.,Libin Cardiovascular Institute of Alberta |
Cantillon D.J.,Cleveland Clinic |
Doshi R.,University of Southern California |
And 11 more authors.
New England Journal of Medicine | Year: 2015
BACKGROUND Cardiac pacemakers are limited by device-related complications, notably infection and problems related to pacemaker leads. We studied a miniaturized, fully selfcontained leadless pacemaker that is nonsurgically implanted in the right ventricle with the use of a catheter. METHODS In this multicenter study, we implanted an active-fixation leadless cardiac pacemaker in patients who required permanent single-chamber ventricular pacing. The primary efficacy end point was both an acceptable pacing threshold (.2.0 V at 0.4 msec) and an acceptable sensing amplitude (R wave .5.0 mV, or a value equal to or greater than the value at implantation) through 6 months. The primary safety end point was freedom from device-related serious adverse events through 6 months. In this ongoing study, the prespecified analysis of the primary end points was performed on data from the first 300 patients who completed 6 months of followup (primary cohort). The rates of the efficacy end point and safety end point were compared with performance goals (based on historical data) of 85% and 86%, respectively. Additional outcomes were assessed in all 526 patients who were enrolled as of June 2015 (the total cohort). RESULTS The leadless pacemaker was successfully implanted in 504 of the 526 patients in the total cohort (95.8%). The intention-to-treat primary efficacy end point was met in 270 of the 300 patients in the primary cohort (90.0%; 95% confidence interval [CI], 86.0 to 93.2, P = 0.007), and the primary safety end point was met in 280 of the 300 patients (93.3%; 95% CI, 89.9 to 95.9; P<0.001). At 6 months, device-related serious adverse events were observed in 6.7% of the patients; events included device dislodgement with percutaneous retrieval (in 1.7%), cardiac perforation (in 1.3%), and pacing-threshold elevation requiring percutaneous retrieval and device replacement (in 1.3%). CONCLUSIONS The leadless cardiac pacemaker met prespecified pacing and sensing requirements in the large majority of patients. Device-related serious adverse events occurred in approximately 1 in 15 patients. (Funded by St. Jude Medical; LEADLESS II ClinicalTrials .gov number, NCT02030418.). © 2015 Massachusetts Medical Society. All rights reserved.
Potts M.,Methodist University
The Journal of clinical ethics | Year: 2010
The donation of organs after cardiac death in infants is not morally justified and should not be continued.