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Papers by Eugene Blackstone

Research paper thumbnail of Mitral Valve Surgery in the Adult Marfan Syndrome Patient

The Annals of Thoracic Surgery, 2006

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Research paper thumbnail of Surgical management of aortopulmonary window: a 40-year experience

European Journal of Cardio-Thoracic Surgery, 2002

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Research paper thumbnail of analysis using the Duke Activity Status Index Health-related quality of life after coronary artery bypass grafting: A gender

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Research paper thumbnail of Complement and the damaging effects of cardiopulmonary bypass

Thorax, 1983

Postoperative cardiac, pulmonary, renal and coagulation dysfunction, along with C3a levels, were ... more Postoperative cardiac, pulmonary, renal and coagulation dysfunction, along with C3a levels, were studied prospectively in 116 consecutive patients undergoing open cardiac operations and 12 patients undergoing closed operations in the same time period. The level of C3a 3 hours after open operation was high (median value 882 ng X ml-1 plasma) and was related to the C3a level before cardiopulmonary bypass (CPB) (p = 0.03), the level at the end of CPB (p less than 0.0001), elapsed time of CPB (p = 0.07), and older age at operation (p less than 0.0001). It was inversely related to the cardiac output as reflected by the strength of the pedal pulses (p = 0.006). In contrast, C3a levels did not rise in patients undergoing closed operations. The probability of postoperative cardiac dysfunction after open operations (present in 27 of 116 patients) was predicted by C3a levels 3 hours after operation (p = 0.02), the CPB time (p = 0.02), and younger age (p less than 0.0001). The same risk factors pertained for postoperative pulmonary dysfunction (present in 41 of the 116 patients); renal dysfunction (present in 24 of the 116 patients) except that CPB time was not a risk factor here; abnormal bleeding (present in 21 of the 116 patients); and important overall morbidity (present in 26 of 116 patients). As regards important overall morbidity, the C3a level effect became evident at about 1,900 ng X ml-1 (a level reached by 9% of patients); the effect of increasing time of CPB became evident at about 90 minutes of CPB time; and the effect of young age became evident as age decreased from 10 to 4 years. This study demonstrates the damaging effects of CPB, relates them in part to complement activation by the foreign surfaces encountered by the blood, and supports the hypothesis that the mechanisms of the damaging effects include a whole-body inflammatory reaction.

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Research paper thumbnail of Early and late outcome after CABG in patients with evolving myocardial infarction1

Objective: To study the determinants of early and late outcome after coronary artery bypass graft... more Objective: To study the determinants of early and late outcome after coronary artery bypass grafting (CABG) for evolving myocardial infarction. Method: 269 consecutive patients underwent isolated primary or repeat CABG from 1971 to 1992 for evolving myocardial infarction. By institutional policy, these were patients, strictly diagnosed, infarcting either in the cardiac cateterization laboratory, shortly after a previous CABG, or on

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Research paper thumbnail of Propensity scores: Methods, considerations, and applications in the Journal of Thoracic and Cardiovascular Surgery

The Journal of thoracic and cardiovascular surgery, 2015

To review the published literature using propensity scoring, describe shortcomings in the use of ... more To review the published literature using propensity scoring, describe shortcomings in the use of this technique, and provide conceptual background for understanding and correctly implementing studies that use propensity matching. We survey the published statistical literature and make recommendations for a set of standard criteria for studies that use propensity matching. We evaluated adherence to these criteria in recent publications in the Journal of Thoracic and Cardiovascular Surgery and determined how well the standards were applied. We found that studies that use propensity matching are rarely documented well enough to be convincing in their results. When documentation is available, statistical shortcomings are common. Improved statistical practice is needed when using propensity scoring. This article suggests standard criteria for using this method in Journal publications.

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Research paper thumbnail of Coronary artery bypass grafting in diabetics: A growing health care cost crisis

The Journal of thoracic and cardiovascular surgery, 2015

To determine 4-decade temporal trends in the prevalence of diabetes and cardiovascular risk facto... more To determine 4-decade temporal trends in the prevalence of diabetes and cardiovascular risk factors among patients undergoing coronary artery bypass grafting (CABG) and to compare in-hospital outcomes, resource utilization, and long-term survival after CABG in diabetics versus nondiabetics. From January 1972 to January 2011, 10,362 pharmacologically treated diabetics and 45,139 nondiabetics underwent first-time CABG. Median follow-up was 12 years. Direct technical cost data were available from 2003 onward (n = 4679). Propensity matching by diabetes status was used for outcome comparisons. Endpoints were in-hospital adverse events, resource utilization, and long-term survival. Diabetics undergoing CABG increased from 7% in the 1970s to 37% in the 2000s. Their outcomes were worse, with more (P < .05) in-hospital deaths (2.0% vs 1.3%), deep sternal wound infections (2.3% vs 1.2%), strokes (2.2% vs 1.4%), renal failure (4.0% vs 1.3%), and prolonged postoperative hospital stay (9.6% v...

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Research paper thumbnail of Reply

The Annals of thoracic surgery, 2015

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Research paper thumbnail of Surgical management of competing pulmonary blood flow affects survival before Fontan/Kreutzer completion in patients with tricuspid atresia type I

The Journal of thoracic and cardiovascular surgery, Jan 6, 2015

To determine the association between surgical management of pulmonary blood flow (PBF) at initial... more To determine the association between surgical management of pulmonary blood flow (PBF) at initial and staged procedures with survival to Fontan/Kreutzer operation (Fontan) in patients with tricuspid atresia. Infants aged <3 months with tricuspid atresia type I (n = 303) were enrolled from 34 institutions (1999-2013). Among those who underwent surgical intervention (n = 302), initial procedures were: systemic to pulmonary artery shunt (SPS; n = 189; 62%); pulmonary artery banding (PAB; n = 50; 17%); and superior cavopulmonary connection (SCPC; n = 63; 21%). Multiphase parametric-hazard models were used to analyze competing outcomes. Risk-adjusted 6-year survival was lower after SPS (85%; P = .04) versus PAB (93%) or SCPC (93%). Survival after SPS when the main pulmonary artery (MPA) was closed (n = 21) or banded (n = 4) was 60%, versus 93% without MPA intervention (P = .02). After SPS, survival before SCPC was lower with an open ductus arteriosus (n = 7; 76% vs 97%; P = .02). Simi...

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Research paper thumbnail of The fate of pulmonary conduits after the Ross procedure: longitudinal analysis of the German-Dutch Ross registry experience

Heart, 2013

To assess allograft function over time after the Ross procedure. Prospective multicentre registry... more To assess allograft function over time after the Ross procedure. Prospective multicentre registry. 10 cardiac surgery departments in Germany and the Netherlands. Among 1775 consecutive adult patients (mean age 43.7±12.0) who underwent the Ross procedure, 1645 (93%) received an allograft (pulmonary=1612, aortic=12, unknown=21), 120 (6%) a bioprosthesis, and 5 (0.3%) a bovine jugular vein for right ventricular outflow tract reconstruction. Ross procedure. Using non-linear longitudinal models, serial echocardiographic records (N=6950) were studied to assess pulmonary conduit function over time in patients who had undergone the Ross procedure, with a maximum echocardiographic follow-up of 22.4 years (5.5±4.3 years). A slight increase in pulmonary conduit regurgitation grade was observed during follow-up. Freedom from regurgitation grade ≥2+ was 95% after 14 years. Female patient gender, allograft use (compared to bioprosthesis), male donor gender, antibiotic treatment of the allograft, and specific surgical adjustments were associated with a significantly higher regurgitation grade. Mean conduit gradient increased from 4.7 mm Hg at 1 month to 10 mm Hg by 14 years, while peak gradient increased from 8.4 to 18.5 mm Hg. Smaller conduit diameter, male patient gender, younger patient age, younger donor age, and use of a bioprosthesis were associated with a significantly higher mean and peak gradient. During follow-up, 76 reinterventions were required on the pulmonary conduit in 67 patients. Freedom from pulmonary conduit reintervention or dysfunction was 90.6% (95% CI 87.7% to 93.6%) and 79.5% (95% CI 75.2% to 84.0%) at 15 years, respectively. Echocardiographic follow-up of pulmonary conduits shows good conduit durability. Clinically important conduit regurgitation and stenosis are rare in adult patients after the Ross operation.

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Research paper thumbnail of Increasing Disadvantage of "Watchful Waiting" for Repairing Degenerative Mitral Valve Disease

The Annals of thoracic surgery, 2015

Successful durable repair of severe degenerative mitral regurgitation with low operative mortalit... more Successful durable repair of severe degenerative mitral regurgitation with low operative mortality encourages intervention in asymptomatic patients rather than "watchful waiting." Our objectives were to assess trends in patient characteristics, timing of intervention, and evolving surgical techniques at a high-volume center, and determine effects of these changes on outcomes after mitral valve (MV) repair over a 25-year period. From January 1, 1985, to January 1, 2011, 5,902 patients underwent isolated repair (with or without tricuspid repair for functional regurgitation) for degenerative MV disease at Cleveland Clinic. For illustration, the experience is presented in 3 eras: 1985 to 1997 (era 1, n = 1,184), 1997 to 2005 (era 2, n = 2,400), and 2005 to 2011 (era 3, n = 2,318). In era 3, more patients were asymptomatic on presentation (44% in New York Heart Association [NYHA] class I vs 25% in era 1), with less heart failure (11% vs 29%) and atrial fibrillation (9.9% vs 23%...

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Research paper thumbnail of Aortic valve replacement: is valve size important

We sought to determine whether aortic prosthesis size adversely influences survival after aortic ... more We sought to determine whether aortic prosthesis size adversely influences survival after aortic valve replacement. A total of 892 adults receiving a mechanical (n = 346), pericardial (n = 463), or allograft (n = 83) valve for aortic stenosis were observed for up to 20 years (mean, 5.0 +/- 3.9 years) after primary isolated aortic valve replacement. We used multivariable propensity scores to adjust for valve selection factors, multivariable hazard function analyses to identify risk factors for all-cause mortality, and bootstrap resampling to quantify the reliability of the results. Twenty-five percent of patients had indexed internal orifice areas of less than 1.5 cm(2)/m(2) and more than 2 SDs (Z-value) below predicted normal aortic valve size. Mechanical valve orifices were smaller (1.3 +/- 0. 29 cm(2)/m(2), Z = -2.2 +/- 1.16) than pericardial (1.9 +/- 0.36 cm(2)/m(2), Z = -0.40 +/- 1.01) or allograft valves (2.1 +/- 0.50, Z = 0.24 +/- 1.17). The overall survival was 98%, 96%, 86%, 69%, and 49% at 30 days and 1, 5, 10, and 15 years postoperatively. Univariably, survival was weakly and inversely related to manufacturer valve size (P =.16) and internal orifice diameter (P =. 2) but completely unrelated to indexed valve area (P =.6) or Z-value (P =.8). These, and univariable differences among valve types (P =. 004), were accounted for by different prevalences in patient risk factors and not by valve size or type per se. Bootstrap resampling indicated that these findings had a less than 15% chance of being incorrect. Survival after aortic valve replacement is strongly related to patient risk factors but appears not to be adversely affected by moderate patient-prosthesis mismatch (down to about 4 SDs below normal). Aortic root enlargement to accommodate a large prosthesis may be required in few situations.

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Research paper thumbnail of Quantitative electrocardiography for predicting postoperative atrial fibrillation after cardiac surgery

Journal of Electrocardiology, 2000

BackgroundAtrial fibrillation (AF) after cardiac surgery is a common marker of poor outcomes. Qua... more BackgroundAtrial fibrillation (AF) after cardiac surgery is a common marker of poor outcomes. Quantitative electrocardiographic (ECG) measurements may be valuable predictors of postoperative AF.

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Research paper thumbnail of Quantitative electrocardiographic measures and long-term mortality in exercise test patients with clinically normal resting electrocardiograms

American Heart Journal, 2009

Background Currently, the only function of the resting electrocardiogram (ECG) in patients referr... more Background Currently, the only function of the resting electrocardiogram (ECG) in patients referred for exercise testing is to determine whether imaging is mandated. It is unknown if subtle ECG findings in those patients with clinically normal resting ECGs have prognostic significance. Methods We performed a single-center cohort study of 18,964 patients without known cardiovascular disease who had a clinically normal

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Research paper thumbnail of Are All Readmissions Bad Readmissions?

New England Journal of Medicine, 2010

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Research paper thumbnail of Importance of Treadmill Exercise Time as an Initial Prognostic Screening Tool in Patients With Systolic Left Ventricular Dysfunction

Background—We sought to determine whether treadmill exercise time may be of value as an initial p... more Background—We sought to determine whether treadmill exercise time may be of value as an initial prognostic screening tool in ambulatory patients with impaired systolic function who are referred for cardiopulmonary exercise testing. Methods and Results—We studied 2231 adult systolic heart failure patients (27% of whom were women) who underwent cardiopulmonary stress testing using a modified Naughton protocol. We assessed the

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Research paper thumbnail of The return of clinically evident ischemia after coronary artery bypass grafting

Although survival after coronary artery bypass grafting (CABG) is the most serious outcome inform... more Although survival after coronary artery bypass grafting (CABG) is the most serious outcome information, the quality of life in living patients is largely determined by the freedom from ischemic events. The return of angina, acute myocardial infarct and sudden death were studied in a large (n = 5880) population of patients undergoing CABG between 1971 and 1987. The freedom from

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Research paper thumbnail of Injury to a patent left internal thoracic artery graft at coronary reoperation

The purpose of this study was to determine the prevalence, outcome, and operative strategies for ... more The purpose of this study was to determine the prevalence, outcome, and operative strategies for patients having injury to a patent left internal thoracic artery (LITA) graft to the left anterior descending coronary artery (LAD) at coronary reoperation. Of 655 patients with a patent LITA graft to the LAD undergoing coronary reoperation from 1986 to 1997, 35 (5.3%) sustained intraoperative injury to the LITA graft. Strategies to restore flow to the LAD included new saphenous vein graft to the LAD in 15 patients, saphenous vein graft to the LITA stump in 7, saphenous vein graft to the LAD and repair of the LITA graft in 6, and other strategies in 7. All or part of the LITA graft to the LAD was salvaged in 20 patients (57%). Fourteen patients (40%) sustained perioperative myocardial infarction, and 3 patients died (8.6%). The 3 patients who died all had stenosis or thrombosis of the graft to the LAD documented at autopsy. We conclude that (1) the prevalence of injury to a patent LITA graft is 5.3%; (2) a variety of techniques can be used to restore blood flow to the LAD; and (3) ineffective revascularization of the LAD in this situation is associated with operative mortality. At primary coronary artery bypass grafting, the LITA pedicle should be positioned in the left chest away from the posterior sternal table; this strategy may minimize the risk of LITA graft injury at coronary reoperation.

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Research paper thumbnail of Predictors of Mortality and Mortality From Cardiac Causes in the Bypass Angioplasty Revascularization Investigation (BARI) Randomized Trial and Registry

Background—The impact of percutaneous transluminal coronary angioplasty (PTCA) and coronary arter... more Background—The impact of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) on long-term mortality rates in the presence of various demographic, clinical, and angiographic factors is uncertain in the population of patients suitable for both procedures. Methods and Results—In the Bypass Angioplasty Revascularization Investigation (BARI) randomized trial and registry, 3610 patients who were eligible to receive PTCA

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Research paper thumbnail of Aortic Root Replacement With Cryopreserved Allograft for Prosthetic Valve Endocarditis

Background. Our strategy has been to treat aortic pros- thetic valve endocarditis (PVE) with radi... more Background. Our strategy has been to treat aortic pros- thetic valve endocarditis (PVE) with radical debridement of infected tissue and aortic root replacement with a cryopreserved aortic allograft. This study examines the effectiveness of this strategy on hospital mortality and morbidity, recurrent endocarditis, and survival. Methods. From 1988 through 2000, 103 patients with aortic PVE underwent root replacement with a

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Research paper thumbnail of Mitral Valve Surgery in the Adult Marfan Syndrome Patient

The Annals of Thoracic Surgery, 2006

Bookmarks Related papers MentionsView impact

Research paper thumbnail of Surgical management of aortopulmonary window: a 40-year experience

European Journal of Cardio-Thoracic Surgery, 2002

Bookmarks Related papers MentionsView impact

Research paper thumbnail of analysis using the Duke Activity Status Index Health-related quality of life after coronary artery bypass grafting: A gender

Bookmarks Related papers MentionsView impact

Research paper thumbnail of Complement and the damaging effects of cardiopulmonary bypass

Thorax, 1983

Postoperative cardiac, pulmonary, renal and coagulation dysfunction, along with C3a levels, were ... more Postoperative cardiac, pulmonary, renal and coagulation dysfunction, along with C3a levels, were studied prospectively in 116 consecutive patients undergoing open cardiac operations and 12 patients undergoing closed operations in the same time period. The level of C3a 3 hours after open operation was high (median value 882 ng X ml-1 plasma) and was related to the C3a level before cardiopulmonary bypass (CPB) (p = 0.03), the level at the end of CPB (p less than 0.0001), elapsed time of CPB (p = 0.07), and older age at operation (p less than 0.0001). It was inversely related to the cardiac output as reflected by the strength of the pedal pulses (p = 0.006). In contrast, C3a levels did not rise in patients undergoing closed operations. The probability of postoperative cardiac dysfunction after open operations (present in 27 of 116 patients) was predicted by C3a levels 3 hours after operation (p = 0.02), the CPB time (p = 0.02), and younger age (p less than 0.0001). The same risk factors pertained for postoperative pulmonary dysfunction (present in 41 of the 116 patients); renal dysfunction (present in 24 of the 116 patients) except that CPB time was not a risk factor here; abnormal bleeding (present in 21 of the 116 patients); and important overall morbidity (present in 26 of 116 patients). As regards important overall morbidity, the C3a level effect became evident at about 1,900 ng X ml-1 (a level reached by 9% of patients); the effect of increasing time of CPB became evident at about 90 minutes of CPB time; and the effect of young age became evident as age decreased from 10 to 4 years. This study demonstrates the damaging effects of CPB, relates them in part to complement activation by the foreign surfaces encountered by the blood, and supports the hypothesis that the mechanisms of the damaging effects include a whole-body inflammatory reaction.

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Research paper thumbnail of Early and late outcome after CABG in patients with evolving myocardial infarction1

Objective: To study the determinants of early and late outcome after coronary artery bypass graft... more Objective: To study the determinants of early and late outcome after coronary artery bypass grafting (CABG) for evolving myocardial infarction. Method: 269 consecutive patients underwent isolated primary or repeat CABG from 1971 to 1992 for evolving myocardial infarction. By institutional policy, these were patients, strictly diagnosed, infarcting either in the cardiac cateterization laboratory, shortly after a previous CABG, or on

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Research paper thumbnail of Propensity scores: Methods, considerations, and applications in the Journal of Thoracic and Cardiovascular Surgery

The Journal of thoracic and cardiovascular surgery, 2015

To review the published literature using propensity scoring, describe shortcomings in the use of ... more To review the published literature using propensity scoring, describe shortcomings in the use of this technique, and provide conceptual background for understanding and correctly implementing studies that use propensity matching. We survey the published statistical literature and make recommendations for a set of standard criteria for studies that use propensity matching. We evaluated adherence to these criteria in recent publications in the Journal of Thoracic and Cardiovascular Surgery and determined how well the standards were applied. We found that studies that use propensity matching are rarely documented well enough to be convincing in their results. When documentation is available, statistical shortcomings are common. Improved statistical practice is needed when using propensity scoring. This article suggests standard criteria for using this method in Journal publications.

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Research paper thumbnail of Coronary artery bypass grafting in diabetics: A growing health care cost crisis

The Journal of thoracic and cardiovascular surgery, 2015

To determine 4-decade temporal trends in the prevalence of diabetes and cardiovascular risk facto... more To determine 4-decade temporal trends in the prevalence of diabetes and cardiovascular risk factors among patients undergoing coronary artery bypass grafting (CABG) and to compare in-hospital outcomes, resource utilization, and long-term survival after CABG in diabetics versus nondiabetics. From January 1972 to January 2011, 10,362 pharmacologically treated diabetics and 45,139 nondiabetics underwent first-time CABG. Median follow-up was 12 years. Direct technical cost data were available from 2003 onward (n = 4679). Propensity matching by diabetes status was used for outcome comparisons. Endpoints were in-hospital adverse events, resource utilization, and long-term survival. Diabetics undergoing CABG increased from 7% in the 1970s to 37% in the 2000s. Their outcomes were worse, with more (P < .05) in-hospital deaths (2.0% vs 1.3%), deep sternal wound infections (2.3% vs 1.2%), strokes (2.2% vs 1.4%), renal failure (4.0% vs 1.3%), and prolonged postoperative hospital stay (9.6% v...

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Research paper thumbnail of Reply

The Annals of thoracic surgery, 2015

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Research paper thumbnail of Surgical management of competing pulmonary blood flow affects survival before Fontan/Kreutzer completion in patients with tricuspid atresia type I

The Journal of thoracic and cardiovascular surgery, Jan 6, 2015

To determine the association between surgical management of pulmonary blood flow (PBF) at initial... more To determine the association between surgical management of pulmonary blood flow (PBF) at initial and staged procedures with survival to Fontan/Kreutzer operation (Fontan) in patients with tricuspid atresia. Infants aged <3 months with tricuspid atresia type I (n = 303) were enrolled from 34 institutions (1999-2013). Among those who underwent surgical intervention (n = 302), initial procedures were: systemic to pulmonary artery shunt (SPS; n = 189; 62%); pulmonary artery banding (PAB; n = 50; 17%); and superior cavopulmonary connection (SCPC; n = 63; 21%). Multiphase parametric-hazard models were used to analyze competing outcomes. Risk-adjusted 6-year survival was lower after SPS (85%; P = .04) versus PAB (93%) or SCPC (93%). Survival after SPS when the main pulmonary artery (MPA) was closed (n = 21) or banded (n = 4) was 60%, versus 93% without MPA intervention (P = .02). After SPS, survival before SCPC was lower with an open ductus arteriosus (n = 7; 76% vs 97%; P = .02). Simi...

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Research paper thumbnail of The fate of pulmonary conduits after the Ross procedure: longitudinal analysis of the German-Dutch Ross registry experience

Heart, 2013

To assess allograft function over time after the Ross procedure. Prospective multicentre registry... more To assess allograft function over time after the Ross procedure. Prospective multicentre registry. 10 cardiac surgery departments in Germany and the Netherlands. Among 1775 consecutive adult patients (mean age 43.7±12.0) who underwent the Ross procedure, 1645 (93%) received an allograft (pulmonary=1612, aortic=12, unknown=21), 120 (6%) a bioprosthesis, and 5 (0.3%) a bovine jugular vein for right ventricular outflow tract reconstruction. Ross procedure. Using non-linear longitudinal models, serial echocardiographic records (N=6950) were studied to assess pulmonary conduit function over time in patients who had undergone the Ross procedure, with a maximum echocardiographic follow-up of 22.4 years (5.5±4.3 years). A slight increase in pulmonary conduit regurgitation grade was observed during follow-up. Freedom from regurgitation grade ≥2+ was 95% after 14 years. Female patient gender, allograft use (compared to bioprosthesis), male donor gender, antibiotic treatment of the allograft, and specific surgical adjustments were associated with a significantly higher regurgitation grade. Mean conduit gradient increased from 4.7 mm Hg at 1 month to 10 mm Hg by 14 years, while peak gradient increased from 8.4 to 18.5 mm Hg. Smaller conduit diameter, male patient gender, younger patient age, younger donor age, and use of a bioprosthesis were associated with a significantly higher mean and peak gradient. During follow-up, 76 reinterventions were required on the pulmonary conduit in 67 patients. Freedom from pulmonary conduit reintervention or dysfunction was 90.6% (95% CI 87.7% to 93.6%) and 79.5% (95% CI 75.2% to 84.0%) at 15 years, respectively. Echocardiographic follow-up of pulmonary conduits shows good conduit durability. Clinically important conduit regurgitation and stenosis are rare in adult patients after the Ross operation.

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Research paper thumbnail of Increasing Disadvantage of "Watchful Waiting" for Repairing Degenerative Mitral Valve Disease

The Annals of thoracic surgery, 2015

Successful durable repair of severe degenerative mitral regurgitation with low operative mortalit... more Successful durable repair of severe degenerative mitral regurgitation with low operative mortality encourages intervention in asymptomatic patients rather than "watchful waiting." Our objectives were to assess trends in patient characteristics, timing of intervention, and evolving surgical techniques at a high-volume center, and determine effects of these changes on outcomes after mitral valve (MV) repair over a 25-year period. From January 1, 1985, to January 1, 2011, 5,902 patients underwent isolated repair (with or without tricuspid repair for functional regurgitation) for degenerative MV disease at Cleveland Clinic. For illustration, the experience is presented in 3 eras: 1985 to 1997 (era 1, n = 1,184), 1997 to 2005 (era 2, n = 2,400), and 2005 to 2011 (era 3, n = 2,318). In era 3, more patients were asymptomatic on presentation (44% in New York Heart Association [NYHA] class I vs 25% in era 1), with less heart failure (11% vs 29%) and atrial fibrillation (9.9% vs 23%...

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Research paper thumbnail of Aortic valve replacement: is valve size important

We sought to determine whether aortic prosthesis size adversely influences survival after aortic ... more We sought to determine whether aortic prosthesis size adversely influences survival after aortic valve replacement. A total of 892 adults receiving a mechanical (n = 346), pericardial (n = 463), or allograft (n = 83) valve for aortic stenosis were observed for up to 20 years (mean, 5.0 +/- 3.9 years) after primary isolated aortic valve replacement. We used multivariable propensity scores to adjust for valve selection factors, multivariable hazard function analyses to identify risk factors for all-cause mortality, and bootstrap resampling to quantify the reliability of the results. Twenty-five percent of patients had indexed internal orifice areas of less than 1.5 cm(2)/m(2) and more than 2 SDs (Z-value) below predicted normal aortic valve size. Mechanical valve orifices were smaller (1.3 +/- 0. 29 cm(2)/m(2), Z = -2.2 +/- 1.16) than pericardial (1.9 +/- 0.36 cm(2)/m(2), Z = -0.40 +/- 1.01) or allograft valves (2.1 +/- 0.50, Z = 0.24 +/- 1.17). The overall survival was 98%, 96%, 86%, 69%, and 49% at 30 days and 1, 5, 10, and 15 years postoperatively. Univariably, survival was weakly and inversely related to manufacturer valve size (P =.16) and internal orifice diameter (P =. 2) but completely unrelated to indexed valve area (P =.6) or Z-value (P =.8). These, and univariable differences among valve types (P =. 004), were accounted for by different prevalences in patient risk factors and not by valve size or type per se. Bootstrap resampling indicated that these findings had a less than 15% chance of being incorrect. Survival after aortic valve replacement is strongly related to patient risk factors but appears not to be adversely affected by moderate patient-prosthesis mismatch (down to about 4 SDs below normal). Aortic root enlargement to accommodate a large prosthesis may be required in few situations.

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Research paper thumbnail of Quantitative electrocardiography for predicting postoperative atrial fibrillation after cardiac surgery

Journal of Electrocardiology, 2000

BackgroundAtrial fibrillation (AF) after cardiac surgery is a common marker of poor outcomes. Qua... more BackgroundAtrial fibrillation (AF) after cardiac surgery is a common marker of poor outcomes. Quantitative electrocardiographic (ECG) measurements may be valuable predictors of postoperative AF.

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Research paper thumbnail of Quantitative electrocardiographic measures and long-term mortality in exercise test patients with clinically normal resting electrocardiograms

American Heart Journal, 2009

Background Currently, the only function of the resting electrocardiogram (ECG) in patients referr... more Background Currently, the only function of the resting electrocardiogram (ECG) in patients referred for exercise testing is to determine whether imaging is mandated. It is unknown if subtle ECG findings in those patients with clinically normal resting ECGs have prognostic significance. Methods We performed a single-center cohort study of 18,964 patients without known cardiovascular disease who had a clinically normal

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Research paper thumbnail of Are All Readmissions Bad Readmissions?

New England Journal of Medicine, 2010

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Research paper thumbnail of Importance of Treadmill Exercise Time as an Initial Prognostic Screening Tool in Patients With Systolic Left Ventricular Dysfunction

Background—We sought to determine whether treadmill exercise time may be of value as an initial p... more Background—We sought to determine whether treadmill exercise time may be of value as an initial prognostic screening tool in ambulatory patients with impaired systolic function who are referred for cardiopulmonary exercise testing. Methods and Results—We studied 2231 adult systolic heart failure patients (27% of whom were women) who underwent cardiopulmonary stress testing using a modified Naughton protocol. We assessed the

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Research paper thumbnail of The return of clinically evident ischemia after coronary artery bypass grafting

Although survival after coronary artery bypass grafting (CABG) is the most serious outcome inform... more Although survival after coronary artery bypass grafting (CABG) is the most serious outcome information, the quality of life in living patients is largely determined by the freedom from ischemic events. The return of angina, acute myocardial infarct and sudden death were studied in a large (n = 5880) population of patients undergoing CABG between 1971 and 1987. The freedom from

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Research paper thumbnail of Injury to a patent left internal thoracic artery graft at coronary reoperation

The purpose of this study was to determine the prevalence, outcome, and operative strategies for ... more The purpose of this study was to determine the prevalence, outcome, and operative strategies for patients having injury to a patent left internal thoracic artery (LITA) graft to the left anterior descending coronary artery (LAD) at coronary reoperation. Of 655 patients with a patent LITA graft to the LAD undergoing coronary reoperation from 1986 to 1997, 35 (5.3%) sustained intraoperative injury to the LITA graft. Strategies to restore flow to the LAD included new saphenous vein graft to the LAD in 15 patients, saphenous vein graft to the LITA stump in 7, saphenous vein graft to the LAD and repair of the LITA graft in 6, and other strategies in 7. All or part of the LITA graft to the LAD was salvaged in 20 patients (57%). Fourteen patients (40%) sustained perioperative myocardial infarction, and 3 patients died (8.6%). The 3 patients who died all had stenosis or thrombosis of the graft to the LAD documented at autopsy. We conclude that (1) the prevalence of injury to a patent LITA graft is 5.3%; (2) a variety of techniques can be used to restore blood flow to the LAD; and (3) ineffective revascularization of the LAD in this situation is associated with operative mortality. At primary coronary artery bypass grafting, the LITA pedicle should be positioned in the left chest away from the posterior sternal table; this strategy may minimize the risk of LITA graft injury at coronary reoperation.

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Research paper thumbnail of Predictors of Mortality and Mortality From Cardiac Causes in the Bypass Angioplasty Revascularization Investigation (BARI) Randomized Trial and Registry

Background—The impact of percutaneous transluminal coronary angioplasty (PTCA) and coronary arter... more Background—The impact of percutaneous transluminal coronary angioplasty (PTCA) and coronary artery bypass grafting (CABG) on long-term mortality rates in the presence of various demographic, clinical, and angiographic factors is uncertain in the population of patients suitable for both procedures. Methods and Results—In the Bypass Angioplasty Revascularization Investigation (BARI) randomized trial and registry, 3610 patients who were eligible to receive PTCA

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Research paper thumbnail of Aortic Root Replacement With Cryopreserved Allograft for Prosthetic Valve Endocarditis

Background. Our strategy has been to treat aortic pros- thetic valve endocarditis (PVE) with radi... more Background. Our strategy has been to treat aortic pros- thetic valve endocarditis (PVE) with radical debridement of infected tissue and aortic root replacement with a cryopreserved aortic allograft. This study examines the effectiveness of this strategy on hospital mortality and morbidity, recurrent endocarditis, and survival. Methods. From 1988 through 2000, 103 patients with aortic PVE underwent root replacement with a

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