Gary Lofland - Academia.edu (original) (raw)

Papers by Gary Lofland

Operative Techniques in Thoracic and Cardiovascular Surgery, 2007

P ulmonary atresia (PA) with ventricular septal defect (VSD) and major aortopulmonary collaterals... more P ulmonary atresia (PA) with ventricular septal defect (VSD) and major aortopulmonary collaterals (MAPCAs) is a complex and rare lesion in which considerable morphologic variability exists regarding the sources of pulmonary blood flow. The true central pulmonary arteries range from a size approaching normal to complete absence. Major aortopulmonary collaterals, probably derived embryologically from the splanchnic vascular plexis, 1 are also highly variable in their size, number, course, origin, arborization, and histopathologic makeup. 2-5 A segment of lung may be supplied solely from the true pulmonary arteries, solely from the aortopulmonary collaterals, or from both with connections between the two sources occurring at central or peripheral points and at single or multiple sights. 4 By contrast, the intracardiac component of this defect is usually relatively straightforward, with a large anteriorly malaligned ventricular septal defect, well-developed right and left ventricles with appropriate atrioventricular valves, and concordant atrioventricular and ventriculoarterial connections. More complex intracardiac arrangements may occur but are rare with MAPCAs. More complex intracardiac arrangements occur more frequently with ductal-dependent forms of pulmonary atresia.

Progress in Pediatric Cardiology, 2009

Progress in Pediatric Cardiology, 2013

ABSTRACT The management of patients with interrupted aortic arch and single ventricle can be very... more ABSTRACT The management of patients with interrupted aortic arch and single ventricle can be very frustrating because of the absence of viable tissue with which to reconstruct the arch. This brief paper describes a novel modification of the Norwood procedure using an aortic allograft as valveless conduits to reconstruct the aortic arch.

Progress in Pediatric Cardiology, 2013

ABSTRACT The development of bioengineered heart valves that have prolonged durability and improve... more ABSTRACT The development of bioengineered heart valves that have prolonged durability and improved hydraulic functionality will significantly improve the management of pediatric congenital cardiac patients by limiting multiple reoperations. However, progressing one step further to tissue engineered heart valves that contain viable and phenotypically appropriate cell populations will result in growth capable heart valves that can remodel constructively and synchronously with the patient's somatic growth. Pediatric cardiac surgical and interventional catheter therapeutics now consists of a huge menu of multistage and palliative procedures. Readily available, patient specific or “personal” tissue engineered viable constructs for use as replacements for missing, hypoplastic, or structurally defective cardiac structures will fundamentally alter therapeutic strategies for numerous diagnoses. These transformational developments will result in definitive operations that can be performed early in the patient's life. Altered strategies that will become available are explored for tetralogy of Fallot, pulmonary atresia, congenital aortic stenosis, the single ventricle, and the “failing Fontan”. The barriers and challenges to achieving routinely applicable Tissue Engineered and Regenerative (TERM) Cardiac Surgery Methods are also explored as is a novel concept for the Cardiac Hybrid Operating Room Suite of the 21st Century.

Cardiac Reconstructions with Allograft Tissues, 2005

Journal of Pediatric Surgery, 1987

Although histopathologically benign, cutaneous hemangiomas may be pathophysiologically malignant ... more Although histopathologically benign, cutaneous hemangiomas may be pathophysiologically malignant if they are associated with significant arteriovenous malformation that is hemodynamically compromising. Rapid surgical intervention may be required to prevent clinical deterioration from congestive heart failure as in the case reported here. Angiography may directly influence the surgical approach to the lesion.

Progress in Pediatric Cardiology, 2009

Pulmonary atresia with intact ventricular septum is a rare congenital cardiac anomaly characteriz... more Pulmonary atresia with intact ventricular septum is a rare congenital cardiac anomaly characterized by complete obstruction of outflow from the right ventricle and pulmonary blood flow that is completely ductal dependent. Appropriate therapeutic decision making early in the neonatal period is crucial to immediate survival. Ultimately, definitive palliation or correction is very much dependent upon the adequacy of right-sided cardiac

European Journal of Cardio Thoracic Surgery, 2000

The management of infants and children with pulmonary atresia, ventricular septal defect, and mul... more The management of infants and children with pulmonary atresia, ventricular septal defect, and multiple aorta pulmonary collateral arteries (PA/VSD/MAPCA) has proven to be challenging. Therapeutic approaches have included staged unifocalization, shunting, coiling of collateral vessels, and heart/lung transplantation. Results have been variable and frustrating. Hoping to take advantage of growth potential in pulmonary segments supplied by MAPCA, a more radical approach was adopted in March of 1997. This consists of single stage complete unifocalization with closure of the ventricular septal defect and establishment of right ventricular to pulmonary arterial continuity with a cryopreserved pulmonary allograft (Rastelli type correction) through a midline sternal incision. During an 18-month period, eleven consecutive infants with PA/VSD/MAPCA underwent complete surgical correction. The ages ranged from 5 days to 5 months. Weights ranged from 2.2 to 5.6 kg. Through a standard median sternotomy incision, the pericardium and both pleural spaces were opened. Normothermic cardiopulmonary bypass was instituted. Section of all collaterals was accomplished without hypoxemia, and all collaterals were ligated at their origin from the aorta. They were then brought through posterior mediastinum to construct a pulmonary artery confluence. The ventricular septal defect was closed, and continuity was established between the right ventricle and the newly created pulmonary artery confluence with cryopreserved allografts. Ten of 11 patients survived operation, with postoperative courses that were uncomplicated. Length of stay ranged from 7-16 days, with a median length of stay of 11 days. One perioperative death occurred in a patient with preoperative co-morbidities of necrotizing enterocolitis, with no functioning gastrointestinal tract, intraventricular hemorrhage, and ventilator dependency since birth. At angiography, this patient has no demonstrable central pulmonary arteries and multiple diminutive aorta pulmonary collaterals. Autopsy revealed no demonstrable pulmonary arteries within the pulmonary parenchyma. All patients have been followed closely, and have grown normally. Two patients undergone repeat cardiac catheterization because of the echocardiographic demonstration of right ventricle pressures that had exceeded 50% of systemic. Both patients were treated with balloon angioplasty and one of these patients has had stenting of stenotic pulmonary arterial segments. No other patients have required additional hospitalization. Right ventricular pressures have remained less than fifty percent of systemic by echocardiographic assessment in all other patients. We feel that a single stage correction of pulmonary atresia, ventricular septal defect, and multiple aorta pulmonary collateral arteries can be accomplished in early infancy with acceptable morbidity and mortality. The initiation of normothermic cardio-pulmonary bypass greatly facilitates dissection of collaterals and prevents hypoxemia. Interventional cardiology with balloon angioplasty and stenting of abnormal pulmonary arterial segments is both an important essential adjunct in the management of these patients. We remain optimistic that a single stage approach to this complex lesion coupled with cardiac catheterization, balloon angioplasty, and stenting, will provide long-term results superior to staged approaches.

The Pediatric Infectious Disease Journal, Apr 1, 2002

We describe a case of native valve endocarditis caused by Staphylococcus lugdunensis, a perineal ... more We describe a case of native valve endocarditis caused by Staphylococcus lugdunensis, a perineal skin commensal, and review 28 other cases from the medical literature. Correctly identifying this coagulase-negative organism is critical because endocarditis is usually associated with left sided valvular disruption and life-threatening embolic complications, reminiscent of disease caused by Staphylococcus aureus. Urgent surgical intervention is necessary in most cases.

The Journal of Heart Valve Disease, Jan 4, 2013

: Montage of images displaying the systematic sampling of all decellularized valves biopsied thro... more : Montage of images displaying the systematic sampling of all decellularized valves biopsied through the mid-cusp free edge and leaflet belly to the base, along with the adjacent sinus wall and supravalvular great vessel. These were surveyed with serial sections using four histochemical stains for morphology, and seeking evidence of any microscopic calcium deposits with two calcium mineral-specific stains (Alizarin and von Kossa calcium stains) in addition to the classical H&E and Movat's histology. No micro deposits of calcium mineral were ever seen, as demonstrated in this montage (original magnification, ×100). Normative valve calcium and phosphorus content G. Acharya et al. 7

The Journal of Heart Valve Disease, Jan 4, 2013

: Montage of images displaying the systematic sampling of all decellularized valves biopsied thro... more : Montage of images displaying the systematic sampling of all decellularized valves biopsied through the mid-cusp free edge and leaflet belly to the base, along with the adjacent sinus wall and supravalvular great vessel. These were surveyed with serial sections using four histochemical stains for morphology, and seeking evidence of any microscopic calcium deposits with two calcium mineral-specific stains (Alizarin and von Kossa calcium stains) in addition to the classical H&E and Movat's histology. No micro deposits of calcium mineral were ever seen, as demonstrated in this montage (original magnification, ×100). Normative valve calcium and phosphorus content G. Acharya et al. 7

The Journal of extra-corporeal technology, 2009

There is no reliable clinical indicator showing how long extracorporeal membrane oxygenation (ECM... more There is no reliable clinical indicator showing how long extracorporeal membrane oxygenation (ECMO) implementation can be delayed before the risk of death becomes unacceptably high in neonatal and pediatric respiratory patients. However, the late use of ECMO may be defined by the elevation of specific physiologic markers separate from pulmonary function and hemodynamic assessments that indicate when the optimal time for implementation of ECMO has past, resulting in a higher than normal mortality, possibly due to reperfusion injury. Neonatal patients were reviewed retrospectively to determine if later implementation of ECMO correlated to increased mortality. Neonatal and pediatric respiratory patients placed on ECMO were reviewed retrospectively to determine if the first adjusted anion gap (AGc), the first venoarterial CO2 gradient (p[v-a] CO2), or the first Viability Index (AGc + p[v-a]CO2 = INDEX) on ECMO could be used to identify a cut-point for increased mortality. Expired neonat...

The Journal of extra-corporeal technology

There is no reliable clinical indicator showing how long extracorporeal membrane oxygenation (ECM... more There is no reliable clinical indicator showing how long extracorporeal membrane oxygenation (ECMO) implementation can be delayed before the risk of death becomes unacceptably high in neonatal and pediatric respiratory patients. However, the late use of ECMO may be defined by the elevation of specific physiologic markers separate from pulmonary function and hemodynamic assessments that indicate when the optimal time for implementation of ECMO has past, resulting in a higher than normal mortality, possibly due to reperfusion injury. Neonatal patients were reviewed retrospectively to determine if later implementation of ECMO correlated to increased mortality. Neonatal and pediatric respiratory patients placed on ECMO were reviewed retrospectively to determine if the first adjusted anion gap (AGc), the first venoarterial CO2 gradient (p[v-a] CO2), or the first Viability Index (AGc + p[v-a]CO2 = INDEX) on ECMO could be used to identify a cut-point for increased mortality. Expired neonates (n = 31) were placed on ECMO an average of 2 days later than neonatal survivors (n = 163). The review of 210 respiratory neonatal and pediatric ECMO patients with an overall survival of 82% showed that all three markers were elevated in the expired patients (n = 38, p < .05). Cut-points were an AGc > or = 23 mEq/L, the p[v-a]CO2 > or = 16 mmHg, and the INDEX > or = 28. These values correlated with a significantly higher risk of mortality (p < .05); survival to discharge being 43% or less. Patients under the cut-points had survival rates of 84% or higher. Starting ECMO too late may cause reperfusion injury that reduces survival. This study describes specific physiologic markers taken soon after ECMO initiation that correlate with mortality. These markers, if assessed earlier, may allow for a more timely ECMO implementation and higher survival.

Progress in Pediatric Cardiology, 2009

Coronary artery abnormalities are known to be present in a certain percentage of patients present... more Coronary artery abnormalities are known to be present in a certain percentage of patients presenting with pulmonary atresia and intact ventricular septum. These abnormalities range in severity from small fistulae to complete right ventricular dependence of components in the coronary circulation. These abnormalities are known to complicate therapy preoperatively, during palliation, and during definitive correction. This study will explore the influence of right ventricular morphology and coronary artery dominance and morphology on early mortality in infants with pulmonary atresia and intact ventricular septum, something which has not been previously explored.

The Journal of Thoracic and Cardiovascular Surgery, 2015

Early survival advantages after Norwood with right-ventricle-(RV)-to-pulmonary-artery conduit (NW... more Early survival advantages after Norwood with right-ventricle-(RV)-to-pulmonary-artery conduit (NW-RVPA) over Norwood-operation with a Blalock-Taussig shunt (NW-BT) are offset by concerns regarding delayed RV dysfunction. We compared trends in survival, RV dysfunction, and tricuspid valve regurgitation (TR) between NW-RVPA and NW-BT for propensity-matched neonates with critical left ventricular outflow tract obstruction (LVOTO). In an inception cohort (2005-2014; 21 institutions), 454 neonates with critical LVOTO underwent Norwood stage 1. Propensity-score matching paired 169 NW-RVPA patients with 169 NW-BT patients. End-states were compared between NW-RVPA and NW-BT using competing-risks, multiphase, parametric, hazard analysis. Post-Norwood echocardiogram reports (n = 2993) were used to grade RV dysfunction and TR. Time-related prevalence of ≥moderate RV dysfunction and TR were characterized using nonlinear mixed-model regression, and compared between groups via multiphase, parametric models. Overall 6-year survival was better after NW-RVPA (70%) versus NW-BT (55%; P < .001). Additionally, transplant-free survival during this time was better after NW-RVPA (64%) versus NW-BT (53%; P = .004). Overall prevalence of ≥moderate RV dysfunction reached 11% within 3 months post-Norwood. During this time, RV dysfunction after NW-BT was 16% versus 6% after NW-RVPA (P = .02), and coincided temporally with an increased early hazard for death. For survivors, late RV dysfunction was <5% and was not different between groups (P = .36). Overall prevalence of ≥moderate TR reached 13% at 2 years post-Norwood and was increased after NW-BT (16%) versus NW-RVPA (11%; P = .003). Late TR was similar between groups. Among propensity-score-matched neonates with critical LVOTO, NW-RVPA offers superior 6-year survival with no greater prevalence of RV dysfunction or TR than conventional NW-BT operations.

The Journal of extra-corporeal technology, 2010

A previous review from our institution established clinically measured cut-points that defined th... more A previous review from our institution established clinically measured cut-points that defined the late implementation of extracorporeal membrane oxygenation (ECMO) correlating to increased mortality in neonatal and pediatric respiratory patients. Using the same methods, this review evaluates pediatric and neonatal cardiac and congenital diaphragmatic hernia (CDH) patients to determine if the same cut-points exist in this higher risk patient population. Neonatal and pediatric cardiac and CDH patients placed on ECMO between November 1989 and December 2008 were retrospectively reviewed to determine the first adjusted anion gap (AGc), the first venoarterial carbon dioxide (CO2) gradient (p[v-a]CO2), and the first Viability Index (AGc + p[v-a]CO2 = INDEX) on ECMO. These markers were then analyzed to identify the presence of specific cut-points that marked an increased risk of mortality. The timing of surgery was also reviewed to assess the surgical morbidity on survival. The review of n...

Operative Techniques in Thoracic and Cardiovascular Surgery, 2007

P ulmonary atresia (PA) with ventricular septal defect (VSD) and major aortopulmonary collaterals... more P ulmonary atresia (PA) with ventricular septal defect (VSD) and major aortopulmonary collaterals (MAPCAs) is a complex and rare lesion in which considerable morphologic variability exists regarding the sources of pulmonary blood flow. The true central pulmonary arteries range from a size approaching normal to complete absence. Major aortopulmonary collaterals, probably derived embryologically from the splanchnic vascular plexis, 1 are also highly variable in their size, number, course, origin, arborization, and histopathologic makeup. 2-5 A segment of lung may be supplied solely from the true pulmonary arteries, solely from the aortopulmonary collaterals, or from both with connections between the two sources occurring at central or peripheral points and at single or multiple sights. 4 By contrast, the intracardiac component of this defect is usually relatively straightforward, with a large anteriorly malaligned ventricular septal defect, well-developed right and left ventricles with appropriate atrioventricular valves, and concordant atrioventricular and ventriculoarterial connections. More complex intracardiac arrangements may occur but are rare with MAPCAs. More complex intracardiac arrangements occur more frequently with ductal-dependent forms of pulmonary atresia.

Progress in Pediatric Cardiology, 2009

Progress in Pediatric Cardiology, 2013

ABSTRACT The management of patients with interrupted aortic arch and single ventricle can be very... more ABSTRACT The management of patients with interrupted aortic arch and single ventricle can be very frustrating because of the absence of viable tissue with which to reconstruct the arch. This brief paper describes a novel modification of the Norwood procedure using an aortic allograft as valveless conduits to reconstruct the aortic arch.

Progress in Pediatric Cardiology, 2013

ABSTRACT The development of bioengineered heart valves that have prolonged durability and improve... more ABSTRACT The development of bioengineered heart valves that have prolonged durability and improved hydraulic functionality will significantly improve the management of pediatric congenital cardiac patients by limiting multiple reoperations. However, progressing one step further to tissue engineered heart valves that contain viable and phenotypically appropriate cell populations will result in growth capable heart valves that can remodel constructively and synchronously with the patient's somatic growth. Pediatric cardiac surgical and interventional catheter therapeutics now consists of a huge menu of multistage and palliative procedures. Readily available, patient specific or “personal” tissue engineered viable constructs for use as replacements for missing, hypoplastic, or structurally defective cardiac structures will fundamentally alter therapeutic strategies for numerous diagnoses. These transformational developments will result in definitive operations that can be performed early in the patient's life. Altered strategies that will become available are explored for tetralogy of Fallot, pulmonary atresia, congenital aortic stenosis, the single ventricle, and the “failing Fontan”. The barriers and challenges to achieving routinely applicable Tissue Engineered and Regenerative (TERM) Cardiac Surgery Methods are also explored as is a novel concept for the Cardiac Hybrid Operating Room Suite of the 21st Century.

Cardiac Reconstructions with Allograft Tissues, 2005

Journal of Pediatric Surgery, 1987

Although histopathologically benign, cutaneous hemangiomas may be pathophysiologically malignant ... more Although histopathologically benign, cutaneous hemangiomas may be pathophysiologically malignant if they are associated with significant arteriovenous malformation that is hemodynamically compromising. Rapid surgical intervention may be required to prevent clinical deterioration from congestive heart failure as in the case reported here. Angiography may directly influence the surgical approach to the lesion.

Progress in Pediatric Cardiology, 2009

Pulmonary atresia with intact ventricular septum is a rare congenital cardiac anomaly characteriz... more Pulmonary atresia with intact ventricular septum is a rare congenital cardiac anomaly characterized by complete obstruction of outflow from the right ventricle and pulmonary blood flow that is completely ductal dependent. Appropriate therapeutic decision making early in the neonatal period is crucial to immediate survival. Ultimately, definitive palliation or correction is very much dependent upon the adequacy of right-sided cardiac

European Journal of Cardio Thoracic Surgery, 2000

The management of infants and children with pulmonary atresia, ventricular septal defect, and mul... more The management of infants and children with pulmonary atresia, ventricular septal defect, and multiple aorta pulmonary collateral arteries (PA/VSD/MAPCA) has proven to be challenging. Therapeutic approaches have included staged unifocalization, shunting, coiling of collateral vessels, and heart/lung transplantation. Results have been variable and frustrating. Hoping to take advantage of growth potential in pulmonary segments supplied by MAPCA, a more radical approach was adopted in March of 1997. This consists of single stage complete unifocalization with closure of the ventricular septal defect and establishment of right ventricular to pulmonary arterial continuity with a cryopreserved pulmonary allograft (Rastelli type correction) through a midline sternal incision. During an 18-month period, eleven consecutive infants with PA/VSD/MAPCA underwent complete surgical correction. The ages ranged from 5 days to 5 months. Weights ranged from 2.2 to 5.6 kg. Through a standard median sternotomy incision, the pericardium and both pleural spaces were opened. Normothermic cardiopulmonary bypass was instituted. Section of all collaterals was accomplished without hypoxemia, and all collaterals were ligated at their origin from the aorta. They were then brought through posterior mediastinum to construct a pulmonary artery confluence. The ventricular septal defect was closed, and continuity was established between the right ventricle and the newly created pulmonary artery confluence with cryopreserved allografts. Ten of 11 patients survived operation, with postoperative courses that were uncomplicated. Length of stay ranged from 7-16 days, with a median length of stay of 11 days. One perioperative death occurred in a patient with preoperative co-morbidities of necrotizing enterocolitis, with no functioning gastrointestinal tract, intraventricular hemorrhage, and ventilator dependency since birth. At angiography, this patient has no demonstrable central pulmonary arteries and multiple diminutive aorta pulmonary collaterals. Autopsy revealed no demonstrable pulmonary arteries within the pulmonary parenchyma. All patients have been followed closely, and have grown normally. Two patients undergone repeat cardiac catheterization because of the echocardiographic demonstration of right ventricle pressures that had exceeded 50% of systemic. Both patients were treated with balloon angioplasty and one of these patients has had stenting of stenotic pulmonary arterial segments. No other patients have required additional hospitalization. Right ventricular pressures have remained less than fifty percent of systemic by echocardiographic assessment in all other patients. We feel that a single stage correction of pulmonary atresia, ventricular septal defect, and multiple aorta pulmonary collateral arteries can be accomplished in early infancy with acceptable morbidity and mortality. The initiation of normothermic cardio-pulmonary bypass greatly facilitates dissection of collaterals and prevents hypoxemia. Interventional cardiology with balloon angioplasty and stenting of abnormal pulmonary arterial segments is both an important essential adjunct in the management of these patients. We remain optimistic that a single stage approach to this complex lesion coupled with cardiac catheterization, balloon angioplasty, and stenting, will provide long-term results superior to staged approaches.

The Pediatric Infectious Disease Journal, Apr 1, 2002

We describe a case of native valve endocarditis caused by Staphylococcus lugdunensis, a perineal ... more We describe a case of native valve endocarditis caused by Staphylococcus lugdunensis, a perineal skin commensal, and review 28 other cases from the medical literature. Correctly identifying this coagulase-negative organism is critical because endocarditis is usually associated with left sided valvular disruption and life-threatening embolic complications, reminiscent of disease caused by Staphylococcus aureus. Urgent surgical intervention is necessary in most cases.

The Journal of Heart Valve Disease, Jan 4, 2013

: Montage of images displaying the systematic sampling of all decellularized valves biopsied thro... more : Montage of images displaying the systematic sampling of all decellularized valves biopsied through the mid-cusp free edge and leaflet belly to the base, along with the adjacent sinus wall and supravalvular great vessel. These were surveyed with serial sections using four histochemical stains for morphology, and seeking evidence of any microscopic calcium deposits with two calcium mineral-specific stains (Alizarin and von Kossa calcium stains) in addition to the classical H&E and Movat's histology. No micro deposits of calcium mineral were ever seen, as demonstrated in this montage (original magnification, ×100). Normative valve calcium and phosphorus content G. Acharya et al. 7

The Journal of Heart Valve Disease, Jan 4, 2013

: Montage of images displaying the systematic sampling of all decellularized valves biopsied thro... more : Montage of images displaying the systematic sampling of all decellularized valves biopsied through the mid-cusp free edge and leaflet belly to the base, along with the adjacent sinus wall and supravalvular great vessel. These were surveyed with serial sections using four histochemical stains for morphology, and seeking evidence of any microscopic calcium deposits with two calcium mineral-specific stains (Alizarin and von Kossa calcium stains) in addition to the classical H&E and Movat's histology. No micro deposits of calcium mineral were ever seen, as demonstrated in this montage (original magnification, ×100). Normative valve calcium and phosphorus content G. Acharya et al. 7

The Journal of extra-corporeal technology, 2009

There is no reliable clinical indicator showing how long extracorporeal membrane oxygenation (ECM... more There is no reliable clinical indicator showing how long extracorporeal membrane oxygenation (ECMO) implementation can be delayed before the risk of death becomes unacceptably high in neonatal and pediatric respiratory patients. However, the late use of ECMO may be defined by the elevation of specific physiologic markers separate from pulmonary function and hemodynamic assessments that indicate when the optimal time for implementation of ECMO has past, resulting in a higher than normal mortality, possibly due to reperfusion injury. Neonatal patients were reviewed retrospectively to determine if later implementation of ECMO correlated to increased mortality. Neonatal and pediatric respiratory patients placed on ECMO were reviewed retrospectively to determine if the first adjusted anion gap (AGc), the first venoarterial CO2 gradient (p[v-a] CO2), or the first Viability Index (AGc + p[v-a]CO2 = INDEX) on ECMO could be used to identify a cut-point for increased mortality. Expired neonat...

The Journal of extra-corporeal technology

There is no reliable clinical indicator showing how long extracorporeal membrane oxygenation (ECM... more There is no reliable clinical indicator showing how long extracorporeal membrane oxygenation (ECMO) implementation can be delayed before the risk of death becomes unacceptably high in neonatal and pediatric respiratory patients. However, the late use of ECMO may be defined by the elevation of specific physiologic markers separate from pulmonary function and hemodynamic assessments that indicate when the optimal time for implementation of ECMO has past, resulting in a higher than normal mortality, possibly due to reperfusion injury. Neonatal patients were reviewed retrospectively to determine if later implementation of ECMO correlated to increased mortality. Neonatal and pediatric respiratory patients placed on ECMO were reviewed retrospectively to determine if the first adjusted anion gap (AGc), the first venoarterial CO2 gradient (p[v-a] CO2), or the first Viability Index (AGc + p[v-a]CO2 = INDEX) on ECMO could be used to identify a cut-point for increased mortality. Expired neonates (n = 31) were placed on ECMO an average of 2 days later than neonatal survivors (n = 163). The review of 210 respiratory neonatal and pediatric ECMO patients with an overall survival of 82% showed that all three markers were elevated in the expired patients (n = 38, p < .05). Cut-points were an AGc > or = 23 mEq/L, the p[v-a]CO2 > or = 16 mmHg, and the INDEX > or = 28. These values correlated with a significantly higher risk of mortality (p < .05); survival to discharge being 43% or less. Patients under the cut-points had survival rates of 84% or higher. Starting ECMO too late may cause reperfusion injury that reduces survival. This study describes specific physiologic markers taken soon after ECMO initiation that correlate with mortality. These markers, if assessed earlier, may allow for a more timely ECMO implementation and higher survival.

Progress in Pediatric Cardiology, 2009

Coronary artery abnormalities are known to be present in a certain percentage of patients present... more Coronary artery abnormalities are known to be present in a certain percentage of patients presenting with pulmonary atresia and intact ventricular septum. These abnormalities range in severity from small fistulae to complete right ventricular dependence of components in the coronary circulation. These abnormalities are known to complicate therapy preoperatively, during palliation, and during definitive correction. This study will explore the influence of right ventricular morphology and coronary artery dominance and morphology on early mortality in infants with pulmonary atresia and intact ventricular septum, something which has not been previously explored.

The Journal of Thoracic and Cardiovascular Surgery, 2015

Early survival advantages after Norwood with right-ventricle-(RV)-to-pulmonary-artery conduit (NW... more Early survival advantages after Norwood with right-ventricle-(RV)-to-pulmonary-artery conduit (NW-RVPA) over Norwood-operation with a Blalock-Taussig shunt (NW-BT) are offset by concerns regarding delayed RV dysfunction. We compared trends in survival, RV dysfunction, and tricuspid valve regurgitation (TR) between NW-RVPA and NW-BT for propensity-matched neonates with critical left ventricular outflow tract obstruction (LVOTO). In an inception cohort (2005-2014; 21 institutions), 454 neonates with critical LVOTO underwent Norwood stage 1. Propensity-score matching paired 169 NW-RVPA patients with 169 NW-BT patients. End-states were compared between NW-RVPA and NW-BT using competing-risks, multiphase, parametric, hazard analysis. Post-Norwood echocardiogram reports (n = 2993) were used to grade RV dysfunction and TR. Time-related prevalence of ≥moderate RV dysfunction and TR were characterized using nonlinear mixed-model regression, and compared between groups via multiphase, parametric models. Overall 6-year survival was better after NW-RVPA (70%) versus NW-BT (55%; P < .001). Additionally, transplant-free survival during this time was better after NW-RVPA (64%) versus NW-BT (53%; P = .004). Overall prevalence of ≥moderate RV dysfunction reached 11% within 3 months post-Norwood. During this time, RV dysfunction after NW-BT was 16% versus 6% after NW-RVPA (P = .02), and coincided temporally with an increased early hazard for death. For survivors, late RV dysfunction was <5% and was not different between groups (P = .36). Overall prevalence of ≥moderate TR reached 13% at 2 years post-Norwood and was increased after NW-BT (16%) versus NW-RVPA (11%; P = .003). Late TR was similar between groups. Among propensity-score-matched neonates with critical LVOTO, NW-RVPA offers superior 6-year survival with no greater prevalence of RV dysfunction or TR than conventional NW-BT operations.

The Journal of extra-corporeal technology, 2010

A previous review from our institution established clinically measured cut-points that defined th... more A previous review from our institution established clinically measured cut-points that defined the late implementation of extracorporeal membrane oxygenation (ECMO) correlating to increased mortality in neonatal and pediatric respiratory patients. Using the same methods, this review evaluates pediatric and neonatal cardiac and congenital diaphragmatic hernia (CDH) patients to determine if the same cut-points exist in this higher risk patient population. Neonatal and pediatric cardiac and CDH patients placed on ECMO between November 1989 and December 2008 were retrospectively reviewed to determine the first adjusted anion gap (AGc), the first venoarterial carbon dioxide (CO2) gradient (p[v-a]CO2), and the first Viability Index (AGc + p[v-a]CO2 = INDEX) on ECMO. These markers were then analyzed to identify the presence of specific cut-points that marked an increased risk of mortality. The timing of surgery was also reviewed to assess the surgical morbidity on survival. The review of n...