Browsing by Author "Turrentine, Mark W."
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Item Outcomes following surgery for primary mediastinal nonseminomatous germ cell tumors in the cisplatin era(Elsevier, 2021-06) Kesler, Kenneth A.; Stram, Amanda R.; Timsina, Lava R.; Turrentine, Mark W.; Brown, John W.; Einhorn, Lawrence H.; Surgery, School of MedicineObjective Treatment of primary mediastinal nonseminomatous germ cell tumors involves cisplatin-based chemotherapy followed by surgery to remove residual disease. We undertook a study to determine short and long-term outcomes. Methods A retrospective analysis of patients with primary mediastinal nonseminomatous germ cell tumors who underwent surgery at our institution from 1982 to 2017 was performed. Results A total of 255 patients (mean age, 29.2 years) were identified. Acute respiratory distress syndrome occurred postoperatively in 27 patients (10.9%), which was responsible for all 11 (4.3%) postoperative deaths. Of patients who developed acute respiratory distress syndrome, more patients received bleomycin-containing chemotherapy (25 out of 169; 14.8%) than non-bleomycin regimens (2 out of 77; 2.6%) (P = .004). With respect to variables independently predictive of long-term survival, evidence of choriocarcinoma before chemotherapy (n = 12) was determined to be an adverse factor (P = .006). In contrast, biopsy-proven elements of seminoma (n = 34) were predictive of improved survival (P = .04). The worst pathology identified in the residual mediastinal mass after chemotherapy was necrosis in 61 patients (25.0%), teratoma in 84 patients (34.4%), and malignant (persistent germ cell or non–germ cell cancer) in 97 patients (39.8%), which influenced overall survival (P < .001). Additionally, teratoma with stromal atypia (n = 18) demonstrated decreased survival compared with teratoma without atypia (n = 66; P = .031). Patients with malignancy involving >50% of the residual mass (n = 47) had a 2.3-fold increased risk of death compared with ≤50% malignancy (n = 45; P = .008). Finally, elevated postoperative serum tumor markers (n = 40) was significantly predictive of adverse survival (P < .001). Conclusions In the treatment of primary mediastinal nonseminomatous germ cell tumors, avoiding bleomycin-containing chemotherapy is important. Pre- and postchemotherapy pathology and postoperative serum tumor markers are independent predictors of long-term survival.Item Outcomes in patients with interrupted aortic arch and associated anomalies: a 20-year experience(Elsevier, 2006-05-01) Brown, John W.; Ruzmetov, Mark; Okada, Yuji; Vijay, Palaniswamy; Rodefeld, Mark D.; Turrentine, Mark W.; Surgery, School of MedicineObjective: The surgical results for the repair of interrupted aortic arch (IAA) have evolved in recent years. We report our results for staged repair of this complex congenital malformation. Methods: Sixty-five patients (mean age, 16.9 ± 41.7 days) were diagnosed with IAA and referred for surgical therapy. The surgical management strategy at our institution between 1982 and 2005 has been one-stage complete repair (n = 13) or staged repair (n = 52) in selected patients. Non-complex patients (group I, n = 51) had a ventricular septal defect (87%), aortopulmonary window (8%), and left ventricular outflow tract obstruction (27%). Group II (n = 14) were patients with Taussig–Bing double outlet right ventricle (n = 6) or truncus arteriosus (n = 8). Method of staged repair of IAA was to transect and turn down the left carotid artery and anastomosis it to the descending aorta (n = 41) or graft interposition (n = 2) combined with a pulmonary artery (PA) banding followed in a few months by delayed ventricular septal defect (VSD) closure and PA de-banding. Results: There were 5 early and 10 late deaths. The actuarial survival including early mortality was 92% at 1 year, 81% at 5 years, and 76% at 10 and 15 years. There was an 81% 15-year survival for children in group I compared with a 54% for children in group II (p ≪ 0.001). Risk factors for increased mortality by univariate analysis were as follows: (1) primary aortic anastomosis (p = 0.03), (2) presence of complex anomalies (p = 0.05), and (3) initial IAA repair performed before 1994 (p = 0.05). Actuarial freedom from any type of aortic reoperation or intervention was 86% at 1 year, 69% at 5 years, and 60% at 10 and 15 years. Univariate and multivariate analyses identified no tested variables as risk factors for reoperation. The majority (86%) was in New York Heart Association (NYHA) class I, and 14% remained in NYHA class II. During the postoperative course there were no neurologic deficits, seizures, and growth disturbances in any patient. Conclusion: Staged repair of IAA using a left carotid artery turn down can be safely applied in IAA patients with and without other intracardiac anomalies with good results. Use of the left carotid artery for arch reconstruction did not result in any detectable neurological events or growth disturbances later in life. Associated anomalies played an important role in outcomes. The long-term probability for reoperation and/or reintervention remains high regardless of operative technique.Item Performance of SynerGraft Decellularized Pulmonary Allografts Compared With Standard Cryopreserved Allografts: Results From Multiinstitutional Data(Elsevier, 2017-03) Bibevski, Steve; Ruzmetov, Mark; Fortuna, Randall S.; Turrentine, Mark W.; Brown, John W.; Ohye, Richard G.; Surgery, School of MedicineBackground Structural deterioration of allografts over time is believed to be at least partly related to an immune response mounted against human leukocyte antigen specific to the transplanted tissue. SynerGraft (SG) processing (CryoLife, Kennesaw, GA) is a technology that decellularizes an allograft leaving only connective tissue, therefore, reducing immunogenicity and potentially increasing durability of the implant. Methods We performed a retrospective review of 163 SG patients and 124 standard allograft controls from 3 medical centers. Patient demographics were tabulated, and conduit stenosis and insufficiency were measured by echocardiography. Results There were 28 deaths (15 of 163 [9%] SG patients vs 13 of 124 [11%] standard patients; p = 0.72), but no deaths were attributed to structural failure of the conduit. The actuarial survival for SG vs standard cohorts was not different at 5 and 10 years. Among the 274 hospital survivors, 17% SG vs 42% standard had evidence for significant conduit dysfunction at the most recent follow-up or before conduit replacement. Freedom from conduit dysfunction was significantly worse at 10 years in the standard group (58%) than in the SG group (83%, p < 0.001). Conclusions This study represents a multiinstitutional retrospective comparison of SG and standard cryopreserved allografts used in right ventricular outflow tract reconstruction in a broad range of patient ages. Our results demonstrate that at an intermediate-term to long-term follow-up, conduit dysfunction and pulmonary insufficiency and stenosis are higher among patients receiving standard allografts. We postulate that the improved durability of SG is related to decreased immunogenicity of the SG technology.Item Post-transplant outcomes in pediatric ventricular assist device patients: A PediMACS–Pediatric Heart Transplant Study linkage analysis(Elsevier, 2017) Sutcliffe, David L.; Pruitt, Elizabeth; Cantor, Ryan S.; Godown, Justin; Lane, John; Turrentine, Mark W.; Law, Sabrina P.; Lantz, Jodie L.; Kirklin, James K.; Bernstein, Daniel; Blume, Elizabeth D.; Surgery, School of MedicineBackground Pediatric ventricular assist device (VAD) support as bridge to transplant has improved waitlist survival, but the effects of pre-implant status and VAD-related events on post-transplant outcomes have not been assessed. This study is a linkage analysis between the PediMACS and Pediatric Heart Transplant Study databases to determine the effects of VAD course on post-transplant outcomes. Methods Database linkage between October 1, 2012 and December 31, 2015 identified 147 transplanted VAD patients, the primary study group. The comparison cohort was composed of 630 PHTS patients without pre-transplant VAD support. The primary outcome was post-transplant survival, with secondary outcomes of post-transplant length of stay, freedom from infection and freedom from rejection. Results At implant, the VAD cohort was INTERMACS Profile 1 in 33 (23%), Profile 2 in 89 (63%) and Profile 3 in 14 (10%) patients. The VAD cohort was older, larger, and less likely to have congenital heart disease (p < 0.0001). However, they had greater requirements for inotrope and ventilator support and increased liver and renal dysfunction (p < 0.0001), both of which normalized at transplant after device support. Importantly, there were no differences in 1-year post-transplant survival (96% vs 93%, p = 0.3), freedom from infection (81% vs 79%, p = 0.9) or freedom from rejection (71% vs 74%, p = 0.87) between cohorts. Conclusions Pediatric VAD patients have post-transplant outcomes equal to that of medically supported patients, despite greater pre-implant illness severity. Post-transplant survival, hospital length of stay, infection and rejection were not affected by patient acuity at VAD implantation or VAD-related complications. Therefore, VAD as bridge to transplant mitigates severity of illness in children.Item Right Ventricular Outflow Tract Reconstruction in Infant Truncus Arteriosus: A 37-year Experience(Elsevier, 2020-01) Herrmann, Jeremy L.; Larson, Emilee E.; Mastropietro, Christopher W.; Rodefeld, Mark D.; Turrentine, Mark W.; Nozaki, Ryoko; Brown, John W.; Surgery, School of MedicineBackground Multiple conduits for right ventricular outflow tract reconstruction exist, although the ideal conduit that maximizes outcomes remains controversial. We evaluated long-term outcomes and compared conduits for right ventricular outflow tract reconstruction in children with truncus arteriosus. Methods Records of patients who underwent truncus arteriosus repair at our institution between 1981 and 2018 were retrospectively reviewed. Primary outcomes included survival and freedom from catheter reintervention or reoperation. Secondary analyses evaluated the effect of comorbidity, operation era, conduit type, and conduit size. Results One hundred patients met inclusion criteria. Median follow-up time was 15.6 years (interquartile range, 5.3-22.2). Actuarial survival at 30 days, 5 years, 10 years, and 15 years was 85%, 72%, 72%, and 68%, respectively. Early mortality was associated with concomitant interrupted aortic arch (hazard ratio, 5.4; 95% confidence interval, 1.7-17.4; P = .005). Median time to surgical reoperation was 4.6 years (interquartile range, 2.9-6.8; n = 58). Right ventricle to pulmonary artery continuity was established with an aortic homograft (n = 14), pulmonary homograft (n = 41), or bovine jugular vein conduit (n = 36) in most cases. Multivariate analysis revealed longer freedom from reoperation with the bovine jugular vein conduit compared with the aortic homograft (hazard ratio, 3.1; 95% confidence interval, 1.3-7.7; P = .02) with no difference compared with the pulmonary homograft. Larger conduit size was associated with longer freedom from reoperation (hazard ratio, 0.7; 95% confidence interval, 0.6-0.9; P < .001). Conclusions The bovine jugular vein conduit is a favorable conduit for right ventricular outflow tract reconstruction in patients with truncus arteriosus. Concomitant interrupted aortic arch is a risk factor for early mortality.Item Tracheostomy Following Surgery for Congenital Heart Disease: 14-year Institutional Experience(Sage, 2016-05) Benneyworth, Brian D.; Shao, Jenny M.; Cristea, A. Ioana; Ackerman, Veda; Rodefeld, Mark D.; Turrentine, Mark W.; Brown, John W.; Department of Pediatrics, IU School of MedicineBackground: Tracheostomy following congenital heart disease (CHD) surgery is a rare event and associated with significant mortality. Hospital survival has been reported from 20% to 40%. Late mortality for these patients is not well characterized. Methods: We performed a retrospective observational study of patients who had a tracheostomy following CHD surgery (excluding isolated patent ductus arteriosus ligation) between January 2000 and December 2013. Patients were categorized into single-ventricle or biventricular physiology groups. Demographics, genetic syndromes, pulmonary disease, and comorbidities were collected. Outcomes including hospital survival, long-term survival, and weaning from positive pressure ventilation are reported. Bivariate and time-to-event models were used. Results: Over a 14-year period, 61 children (0.9% incidence) had a tracheostomy placed following CHD surgery. There were 12 single-ventricle patients and 49 biventricular patients. Prematurity, genetic syndromes, lung/airway disease, and other comorbidities were common in both CHD groups. Gastrostomy tubes were used more frequently in biventricular physiology patients (91.8%) versus single-ventricle patients (66.7%, P = .04). Survival to hospital discharge was 50% in the single-ventricle group compared to 86% in biventricular patients (P = .01). Long-term survival continued to be poor in the single-ventricle group comparatively (three years, 27.8% vs 64.8%, P = .01). Gastrostomy tube placement was independently associated with survival in both groups (P = .002). Conclusion: Tracheostomy is performed following many types of surgery for CHD and is commonly associated with other comorbidities. Both hospital and long-term survival are substantially lower in children with single-ventricle physiology as compared to patients with biventricular physiology.Item Two Decades Using Stentless Porcine Aortic Root in Right Ventricular Outflow Tract Reconstruction(Elsevier, 2020) Kasten, Michael W.; Hermann, Jeremy L.; Cox, Morgan; McCurdy, Chelsea; Tragesser, Cody; Turrentine, Mark W.; Rodefeld, Mark; Brown, John W.; Surgery, School of MedicineBackground The stentless porcine aortic root prosthesis (SPAR) has been described as a suitable valve for right ventricular outflow tract reconstruction (RVOTR). Indiana University Methodist Hospital in Indianapolis, Indiana began using this valve for RVOTR in 1998. This study reports medium-term to late- term outcomes of the valve in the pulmonary position. Methods A retrospective chart review was conducted of patients older than 18 years of age who underwent RVOTR with a SPAR between April 2000 and October 2019. Primary outcomes included survival and freedom from any valvular reintervention. Secondary outcomes included endocarditis and conduit dysfunction detected by routine echocardiography or cardiac magnetic resonance imaging. Results A total of 135 patients underwent RVOTR with a SPAR at a median age of 32.4 years (range, 18 to 71 years). Of these patients, 129 had previous surgery. Indications included pulmonary insufficiency (90.4%), stenosis (34.8%), endocarditis (7.4%), and carcinoid (4.4%). Median follow-up was 2.97 years (interquartile range, 0.6 to 8.0 years). Overall survival was 93.3%, with 3 perioperative death and 6 late deaths. Endocarditis developed in 4 patients (2.9%), 2 of whom required reoperation. Progressive conduit degradation was evident at 10 years, with 22.2% and 7.7% having moderate stenosis and insufficiency, respectively. Eight (5.9%) reinterventions included 2 surgical replacements, 3 percutaneous replacements, and 3 balloon valvuloplasties at means of 8.5, 7.4, and 2.2 years, respectively. Overall freedom from reintervention at 1, 5, and 10 years was 99.1%, 94.7% and 90.7%, respectively. Conclusions In this large, single-institution experience with a long follow-up period, use of the SPAR demonstrated excellent midterm to long-term durability, low rates of endocarditis, and high freedom from reintervention.Item Vasoactive-ventilation-renal score reliably predicts hospital length of stay after surgery for congenital heart disease(Elsevier, 2016-11) Scherer, Bradley; Moser, Elizabeth A. S.; Brown, John W.; Rodefeld, Mark D.; Turrentine, Mark W.; Mastropietro, Christopher W.; Department of Pediatrics, IU School of MedicineObjectives We aimed to further validate the vasoactive-ventilation-renal score as a predictor of outcome in patients recovering from surgery for congenital heart disease. We also sought to determine the optimal time point within the early recovery period at which the vasoactive-ventilation-renal score should be measured. Methods We prospectively reviewed consecutive patients recovering from cardiac surgery within our intensive care unit between January 2015 and June 2015. The vasoactive-ventilation-renal score was calculated at 6, 12, 24, and 48 hours postoperatively as follows: vasoactive-ventilation-renal score = ventilation index + vasoactive-inotrope score + Δ creatinine [change in serum creatinine from baseline*10]. Primary outcome of interest was prolonged hospital length of stay, defined as length of stay in the upper 25%. Receiver operating characteristic curves were generated, and areas under the curve with 95% confidence intervals were calculated for all time points. Multivariable logistic regression modeling also was performed. Results We reviewed 164 patients with a median age of 9.25 months (interquartile range, 2.6-58 months). Median length of stay was 8 days (interquartile range, 5-17.5 days). The area under the curve value for the vasoactive-ventilation-renal score as a predictor of prolonged length of stay (>17.5 days) was greatest at 12 hours postoperatively (area under the curve = 0.93; 95% confidence interval, 0.89-0.97). On multivariable regression analysis, after adjustment for potential confounders, the 12-hour vasoactive-ventilation-renal score remained a strong predictor of prolonged hospital length of stay (odds ratio, 1.15; 95% confidence interval, 1.10-1.20). Conclusions In a heterogeneous population of patients undergoing surgery for congenital heart disease, the novel vasoactive-ventilation-renal score calculated in the early postoperative recovery period can be a strong predictor of prolonged hospital length of stay.