Browsing by Author "Corvera, Joel S."

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    A 20-year multicenter analysis of dialysis-dependent patients who had aortic or mitral valve replacement: Implications for valve selection
    (Elsevier, 2019) Manghelli, Joshua L.; Carter, Daniel I.; Khiabani, Ali J.; Gauthier, Jason M.; Moon, Marc R.; Munfakh, Nabil A.; Damiano, Ralph J.; Corvera, Joel S.; Melby, Spencer J.; Surgery, School of Medicine
    Objective Valve selection in dialysis-dependent patients can be difficult because long-term survival is diminished and bleeding risks during anticoagulation treatment are greater in patients with renal failure. In this study we analyzed long-term outcomes of dialysis-dependent patients who underwent valve replacement to help guide optimal prosthetic valve type selection. Methods Dialysis-dependent patients who underwent aortic and/or mitral valve replacement at 3 institutions over 20 years were examined. The primary outcome was long-term survival. A Cox regression model was used to estimate survival according to 5 ages, presence of diabetes, and/or heart failure symptoms. Results Four hundred twenty-three available patients were analyzed; 341 patients had biological and 82 had mechanical valves. Overall complication and 30-day mortality rates were similar between the groups. Thirty-day readmission rates for biological and mechanical groups were 15% (50/341) and 28% (23/82; P = .005). Five-year survival was 23% and 33% for the biological and mechanical groups, respectively. After adjusting for age, New York Heart Association (NYHA) class, and diabetes using a multivariable Cox regression model, survival was similar between groups (hazard ratio, 0.93; 95% confidence interval, 0.66-1.29; P = .8). A Cox regression model on the basis of age, diabetes, and heart failure, estimated that patients only 30 or 40 years old, with NYHA class I-II failure without diabetes had a >50% estimated 5-year survival (P < .001). Conclusions Dialysis-dependent patients who underwent valve replacement surgery had poor long-term survival. Young patients without diabetes or NYHA III or IV symptoms might survive long enough to justify placement of a mechanical valve; however, a biological valve is suitable for most patients.
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    Acute aortic syndrome
    (AME Publishing Company, 2016-05) Corvera, Joel S.; Department of Surgery, IU School of Medicine
    Acute aortic syndrome (AAS) is a term used to describe a constellation of life-threatening aortic diseases that have similar presentation, but appear to have distinct demographic, clinical, pathological and survival characteristics. Many believe that the three major entities that comprise AAS: aortic dissection (AD), intramural hematoma (IMH) and penetrating aortic ulcer (PAU), make up a spectrum of aortic disease in which one entity may evolve into or coexist with another. Much of the confusion in accurately classifying an AAS is that they present with similar symptoms: typically acute onset of severe chest or back pain, and may have similar radiographic features, since the disease entities all involve injury or disruption of the medial layer of the aortic wall. The accurate diagnosis of an AAS is often made at operation. This manuscript will attempt to clarify the similarities and differences between AD, IMH and PAU of the ascending aorta and describe the challenges in distinguishing them from one another.
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    The Addition of Aortic Root Procedures during Elective Arch Surgery Does Not Confer Added Morbidity nor Mortality
    (Elsevier, 2019) Keeling, Brent; Tian, David; Jakob, Heinz; Shrestha, Malakh; Fujikawa, Takuya; Corvera, Joel S.; Di Eusanio, Marco; Leshnower, Bradley; Chen, Edward P.; Medicine, School of Medicine
    Background During elective aortic arch replacement, the addition of an aortic root procedure has an unknown effect on morbidity and mortality. The purpose of this study is to determine the effect of adding an aortic root procedure to elective aortic surgery using the ARCH international database. Methods The ARCH Database was queried for all elective aortic arch replacements with and without aortic root replacement using moderate hypothermic circulatory arrest and antegrade cerebral perfusion from 2000-2015. Propensity score matching analysis was used to balance covariates, and a logistic regression model was created. Results 1169 patients were included for analysis, and 320 (27.4%) underwent an aortic root procedure. Patients undergoing root procedures were younger (69 vs. 61), had less coronary artery disease (20% vs. 32%) and had a higher incidence of Marfan’s syndrome (4.2% vs. 10.0%) (p<0.001 for both). Concomitant CABG (26.6% vs. 19.7%), total aortic arch replacement (41.6% vs. 84.3%), and elephant trunk procedures (46% vs. 17.2%) were performed more frequently in the non-root cohort, (p<0.001 for both). Cardiopulmonary bypass and aortic crossclamp times were significantly longer in the cohort who underwent root procedures while cerebral perfusion times were longer in the non-root cohort (p<0.001 for all). In both the propensity matched and non-matched analyses, postoperative outcomes were not significantly different between patients who underwent root procedures and those who did not (p>0.05 for all outcomes). Multivariable logistic regression analyses showed no difference in mortality rates (Odds ratio 0.62 [0.9-1.34], p=0.22) nor in rates of permanent stroke (Odds ratio 0.89 [0.36-2.24], p=0.81) between root and non-root cohorts. Conclusions The addition of an aortic root procedure during elective aortic arch surgery lengthens cardiopulmonary bypass and aortic crossclamp times but does not increase postoperative morbidity nor mortality.
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    Eleven-Year Experience Treating Blunt Thoracic Aortic Injury at a Tertiary Referral Center
    (Elsevier, 2020) McCurdy, Chelsea M.; Faiza, Zainab; Namburi, Niharika; Hartman, Timothy J.; Corvera, Joel S.; Jenkins, Peter; Timsina, Lava R.; Lee, Lawrence S.; Surgery, School of Medicine
    Background Blunt thoracic aortic injury treatment has evolved over the past decade particularly with respect to endovascular intervention options. We investigated the trends in blunt thoracic aortic injury management and outcomes over an 11-year span at the sole tertiary referral center in our state. Methods We retrospectively reviewed all patients who presented to our institution with blunt traumatic aortic injury between 2007 and 2017. Baseline demographics including aortic injury grade, injury severity score, and abbreviated injury scale were collected. Outcomes were compared by type and timing of treatment, which included either nonoperative management, endovascular repair, or open surgical repair. Bivariate and multivariable analyses were performed to examine treatment group differences and factors associated with 30-day mortality. Results In total, 229 patients were reviewed. The distribution of injury severity was grade 1 (30%), grade 2 (8%), grade 3 (30%), and grade 4 (31%). Overall, 27% of patients underwent endovascular repair, 29% open surgery, and 44% definitive nonoperative management. Over the study period, there was a dramatic decline in open surgery and a corresponding rise in endovascular treatment. Thirty-day mortality for the entire cohort was 22%. Mortality by treatment subgroup was 30% for nonoperative management, 8.2% for endovascular treatment, and 21% for open surgery. Delaying endovascular or open surgical treatment by at least 24 hours after admission was associated with significantly improved 30-day survival. Conclusions Procedural intervention, whether endovascular or surgical, is associated with improved mortality compared with nonoperative treatment. Delayed intervention, particularly in the case of high-grade injuries, may allow for initial patient stabilization and improved outcomes.
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    An Emergent Nexus between Striae and Thoracic Aortic Dissection
    (MDPI, 2021) Landis, Benjamin J.; Vujakovich, Courtney E.; Elmore, Lindsey R.; Pillai, Saila T.; Lee, Lawrence S.; Everett, Jeffrey E.; Markham, Larry W.; Brown, John W.; Hess, Phillip J.; Corvera, Joel S.; Pediatrics, School of Medicine
    Current approaches to stratify the risk for disease progression in thoracic aortic aneurysm (TAA) lack precision, which hinders clinical decision making. Connective tissue phenotyping of children with TAA previously identified the association between skin striae and increased rate of aortic dilation. The objective of this study was to analyze associations between connective tissue abnormalities and clinical endpoints in adults with aortopathy. Participants with TAA or aortic dissection (TAD) and trileaflet aortic valve were enrolled from 2016 to 2019 in the setting of cardiothoracic surgical care. Data were ascertained by structured interviews with participants. The mean age among 241 cases was 61 ± 13 years. Eighty (33%) had history of TAD. While most participants lacked a formal syndromic diagnosis clinically, connective tissue abnormalities were identified in 113 (47%). This included 20% with abdominal hernia and 13% with skin striae in atypical location. In multivariate analysis, striae and hypertension were significantly associated with TAD. Striae were associated with younger age of TAD or prophylactic aortic surgery. Striae were more frequent in TAD cases than age- and sex-matched controls. Thus, systemic features of connective tissue dysfunction were prevalent in adults with aortopathy. The emerging nexus between striae and aortopathy severity creates opportunities for clinical stratification and basic research.
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    Identification of a common polymorphism in COQ8B acting as a modifier of thoracic aortic aneurysm severity
    (Elsevier, 2022-01-13) Landis, Benjamin J.; Lai, Dongbing; Guo, Dong-Chuan; Corvera, Joel S.; Idrees, Muhammad T.; Stadler, Henry W.; Cuevas, Christian; Needler, Gavin U.; Vujakovich, Courtney E.; Milewicz, Dianna M.; Hinton, Robert B.; Ware, Stephanie M.; Pediatrics, School of Medicine
    Thoracic aortic aneurysm (TAA) predisposes to sudden, life-threatening aortic dissection. The factors that regulate interindividual variability in TAA severity are not well understood. Identifying a molecular basis for this variability has the potential to improve clinical risk stratification and advance mechanistic insight. We previously identified COQ8B, a gene important for biosynthesis of coenzyme Q, as a candidate genetic modifier of TAA severity. Here, we investigated the physiological role of COQ8B in human aortic smooth muscle cells (SMCs) and further tested its genetic association with TAA severity. We find COQ8B protein localizes to mitochondria in SMCs, and loss of mitochondrial COQ8B leads to increased oxidative stress, decreased mitochondrial respiration, and altered expression of SMC contractile genes. Oxidative stress and mitochondrial cristae defects were prevalent in the medial layer of human proximal aortic tissues in patients with TAA, and COQ8B expression was decreased in TAA SMCs compared with controls. A common single nucleotide polymorphism (SNP) rs3865452 in COQ8B (c.521A>G, p.H174R) was associated with decreased rate of aortic root dilation in young patients with TAA. In addition, the SNP was less frequent in a second cohort of early-onset thoracic aortic dissection cases compared with controls. COQ8B protein levels in aortic SMCs were increased in TAA patients homozygous for rs3865452 compared with those homozygous for the reference allele. Thus, COQ8B is important for aortic SMC metabolism, which is dysregulated in TAA, and rs3865452 may decrease TAA severity by increasing COQ8B level. Genotyping rs3865452 may be useful for clinical risk stratification and tailored aortopathy management.
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    Outcomes of surgical coronary revascularization performed pre-solid abdominal organ transplant
    (Elsevier, 2020) Matthews, Caleb R.; Millward, James B.; Faiza, Zainab; Namburi, Niharika; Timsina, Lava; Hess, Philip J.; Corvera, Joel S.; Everett, Jeffrey E.; Beckman, Daniel J.; Lee, Lawrence S.; Surgery, School of Medicine
    Background Cardiac risk stratification and coronary angiography are routinely performed as part of kidney and liver transplant candidacy evaluation. There are limited data on the outcomes of surgical coronary revascularization in this patient population. We investigated outcomes in patients with end stage renal or hepatic disease undergoing coronary artery bypass grafting (CABG) to attain kidney or liver transplant candidacy. Methods Retrospective analysis of all patients who underwent isolated CABG at our institution between 2010 and 2016. Patients were divided into two cohorts: Pre-transplant (those undergoing surgery to attain renal or hepatic transplant candidacy) and Non-transplant (all others). Baseline characteristics and postoperative outcomes were compared between groups. Results A total of 1801 patients were included: 28 in Pre-transplant (n=22 kidney, n=7 liver) and 1773 in Non-transplant. Major adverse postoperative outcomes were significantly greater in Pre-transplant compared to Non-transplant: 30-day mortality (14.3% vs. 2.8%, p=0.009), neurologic events (17.9% vs. 4.8%, p=0.011), re-intubation (21.4% vs. 5.8%, p=0.005) and total postoperative ventilation (5.2 vs. 5.0 hours, p=0.0124). One- and five-year mortality in Pre-transplant was 17.9% and 53.6%, respectively. Of the Pre-transplant cohort, three patients (10.7%) underwent organ transplantation (all kidneys) at a mean 436 days after CABG. No patients received liver transplantation. Conclusions Outcomes following CABG in the pre-kidney and pre-liver transplant population are poor. Despite surgical revascularization, the vast majority of patients do not ultimately undergo transplantation. Revascularization strategies and optimal management in this high-risk population warrants further study.
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    The Presence of a Dedicated Cardiac Surgical Intensive Care Service Impacts Clinical Outcomes in Adult Cardiac Surgery Patients
    (Wiley, 2020-04) Lee, Lawrence S.; Clark, Aaron J.; Namburi, Niharika; Naum, Christopher; Timsina, Lava R.; Corvera, Joel S.; Beckman, Daniel J.; Everett, Jeffrey E.; Hess, Philip J.; Medicine, School of Medicine
    Background Postoperative critical care management is an integral part of cardiac surgery that contributes directly to clinical outcomes. In the United States there remains considerable variability in the critical care infrastructure for cardiac surgical programs. There is little published data investigating the impact of a dedicated cardiac surgical intensive care service. Methods A retrospective study examining postoperative outcomes in cardiac surgical patients before and after the implementation of a dedicated cardiac surgical intensive care service at a single academic institution. An institutional Society of Thoracic Surgeons database was queried for study variables. Primary endpoints were the postoperative length of stay, intensive care unit length of stay, and mechanical ventilation time. Secondary endpoints included mortality, readmission rates, and postoperative complications. The effect on outcomes based on procedure type was also analyzed. Results A total of 1703 patients were included in this study—914 in the control group (before dedicated intensive care service) and 789 in the study group (after dedicated intensive care service). Baseline demographics were similar between groups. Length of stay, mechanical ventilation hours, and renal failure rate were significantly reduced in the study group. Coronary artery bypass grafting patients observed the greatest improvement in outcomes. Conclusions Implementation of a dedicated cardiac surgical intensive care service leads to significant improvements in clinical outcomes. The greatest benefit is seen in patients undergoing coronary artery bypass, the most common cardiac surgical operation in the United States. Thus, developing a cardiac surgical intensive care service may be a worthwhile initiative for any cardiac surgical program.
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    Repair of Thoracic and Thoracoabdominal Mycotic Aneurysms and Infected Aortic Grafts Using Allograft
    (Elsevier, 2018) Corvera, Joel S.; Blitzer, David; Copeland, Hannah; Murphy, Daniel; Hess, Philip J.; Pillai, Saila T.; Fehrenbacher, John W.; Surgery, School of Medicine
    Background Mycotic aneurysm of the thoracic or thoracoabdominal aorta and infection of thoracic or thoracoabdominal aortic grafts are challenging problems with high mortality. In-situ reconstruction with cryopreserved allograft(CPA) avoids placement of prosthetic material in an infected field and avoids suppressive antibiotics or autologous tissue coverage. Methods Fifty consecutive patients with infection of a thoracic or thoracoabdominal aortic graft or mycotic aneurysm underwent resection and replacement with CPA from 2006 to 2016. Intravenous antibiotics were continued postoperatively for 6 weeks. Long-term suppressive antibiotics were uncommonly used (8 patients). Follow up imaging occurred at 6, 18 and 42 months postoperatively. Initial follow up was 93% complete. Results Males comprised 64% of the cohort. The mean age was 63±14 years. The procedures performed included reoperations in 37, replacement of the aortic root, ascending aorta or transverse arch in 19, replacement of the descending or thoracoabdominal aorta in 27 and extensive replacement of the ascending, arch and descending or thoracoabdominal aorta in 4. Intraoperative cultures revealed most commonly staphylococcus 24%), enterococcus (12%), candida (6%) and gram negative rods (14%). Operative mortality was 8%, stroke 4%, paralysis 2%, hemodialysis 6%, and respiratory failure requiring tracheostomy 6%. Early reoperation for pseudoaneurysm of the CPA was necessary in 4 patients. One, two and five year survival was 84%, 76% and 64%, respectively. Conclusions Radical resection and in-situ reconstruction with CPA avoids placing prosthetic material in an infected field and provides good early and mid-term outcomes. However, early postoperative imaging is necessary given the risk of pseudoaneurysm formation.