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Computational fluid dynamics: a primer for congenital heart disease clinicians. Asian cardiovascular & thoracic annals Gerrah, R., Haller, S. J. 2020: 218492320957163
Abstract

Computational fluid dynamics has become an important tool for studying blood flow dynamics. As an in-silico collection of methods, computational fluid dynamics is noninvasive and provides numerical values for the most important parameters of blood flow, such as velocity and pressure that are crucial in hemodynamic studies. In this primer, we briefly explain the basic theory and workflow of the two most commonly applied computational fluid dynamics techniques used in the congenital heart disease literature: the finite element method and the finite volume method. We define important terminology and include specific examples of how using these methods can answer important clinical questions in congenital cardiac surgery planning and perioperative patient management.

View details for DOI 10.1177/0218492320957163

View details for PubMedID 32878458
Towards virtual surgery planning: the modified Blalock-Taussig Shunt AIMS BIOPHYSICS Haller, S., Gerrah, R., Rugonyi, S. 2020; 7 (3): 169?88
View details for DOI 10.3934/biophy.2020014

View details for Web of Science ID 000545273500004
The Cavoatrial Anastomosis Procedure in Anomalous Connection of Superior Vena Cava to Left Atrium WORLD JOURNAL FOR PEDIATRIC AND CONGENITAL HEART SURGERY Gerrah, R., Escalante, E., Gorenflo, M., Loukanov, T. 2019; 10 (6): 803?5
Abstract

Anomalous connection of the superior vena cava to the morphologic left atrium is a rare congenital systemic venous abnormality. As opposed to pulmonary venous anomalies, the significant right-to-left shunt in these patients warrants a correction early in life. Optimal repair technique for combined pulmonary and systemic venous anomalies is not defined yet. Herein, we describe a neonate with such a diagnosis treated with cavoatrial anastomosis, known as Warden procedure with excellent results.

View details for DOI 10.1177/2150135119878102

View details for Web of Science ID 000495237500025

View details for PubMedID 31701841
Mechanical Concepts Applied in Congenital Heart Disease and Cardiac Surgery. The Annals of thoracic surgery Gerrah, R., Haller, S. J., George, I. 2017; 103 (6): 2005?14
Abstract

All biological processes are governed by principles of physics that dictate the pathophysiology and even the treatment of congenital heart diseases. In this review, basic concepts such as flow, pressure, resistance, and velocity are introduced, followed by more complex laws that describe the relationship between these variables and the disease processes. Finally, physical phenomena such as turbulence, steal and runoff phenomenon, and energy loss are discussed. By application of these principles, one can accurately quantify modifications undertaken to treat diseases, for example, the size of a patch that augments a vessel and the angle of an anastomosis to allow a certain flow.

View details for DOI 10.1016/j.athoracsur.2017.01.068

View details for PubMedID 28457478
Pretreatment of synthetic vascular grafts with heparin before implantation, a simple technique to reduce the risk of thrombosis VASCULAR Gerrah, R., Sunstrom, R., Hohimer, A. R. 2015; 23 (5): 513?18
Abstract

Thrombosis of synthetic grafts commonly used in cardiovascular surgery is a major complication. We examined whether pretreatment of the graft with heparin reduces the risk of early thrombosis. A circuit was assembled to compare two pairs of shunts simultaneously in the same animal. The study shunts were pretreated with heparin. After 2 hours of circulation, clot formation was evaluated by image analysis techniques. The pretreated grafts had fewer blood clots adhered to the surface by direct visual inspection. The image analysis showed 5 vs. 39 clots, 0.01% vs. 1.8% clotted area, and 62 vs. 5630 clot pixel area between the treated and non-treated grafts respectively, p?
View details for DOI 10.1177/1708538114560455

View details for Web of Science ID 000361850400011

View details for PubMedID 25406265
Repair of Tetralogy of Fallot in Children Less Than 4 kg Body Weight PEDIATRIC CARDIOLOGY Gerrah, R., Turner, M. E., Gottlieb, D., Quaegebeur, J. M., Bacha, E. 2015; 36 (7): 1344?49
Abstract

We reviewed our experience of surgical repair of Tetralogy of Fallot (TOF) in children weighing less than or equal to 4 kg to compare outcome of early palliation versus complete repair as the initial surgical approach. Seventy-six patients, weighing ? 4 kg, with TOF surgery between January 2005 and September 2013 were included in this single-center retrospective study. Twenty-five patients who underwent initial shunt procedure followed by later full repair were compared to 51 patients who had primary full repair for differences in baseline characteristics and outcomes. Shunt group patients had lower body weight, 2.76 � 0.69 versus 3.11 � 0.65 (kg), p = 0.03, and lower preoperative oxygen saturations, 82 � 7 versus 90 � 6 (%), p = 0.0001, than full repair group. A higher number of surgical procedures per patient was recorded in shunt patients, 2.29 � 0.59 versus 1.27 � 0.49, p = 0.00002. Thirteen of 51 patients in the full repair group required a repeat surgery. Catheterization procedures were performed in 12 patients in shunt and in 15 patients in full repair group, with interventional angioplasty in three and 11, respectively, p ? 0.05. Two patients, both in the shunt group, died after the surgery. Early full repair had longer hospital stay but significantly less hospitalizations 1.95 � 1.3 versus 2.5 � 1.4, p = 0.03. Initial complete repair of TOF in small children yielded favorable outcome with significantly less surgical procedures and subsequent hospitalizations. Cath laboratory re-interventions for residual defects were similar after both surgical approaches, and type of initial surgery does not predict freedom from re-intervention.

View details for DOI 10.1007/s00246-015-1163-z

View details for Web of Science ID 000361426700004

View details for PubMedID 25835203
A Defined Management Strategy Improves Early Outcomes After the Fontan Procedure: The Portland Protocol ANNALS OF THORACIC SURGERY Sunstrom, R. E., Muralidaran, A., Gerrah, R., Reed, R. D., Good, M. K., Armsby, L. R., Rekito, A. J., Zubair, M., Langley, S. M. 2015; 99 (1): 148?55
Abstract

Patients undergoing the Fontan procedure may have extended hospital stay due to various postoperative factors including prolonged chest tube drainage. Our aim was to determine the efficacy of our Fontan management protocol in reducing chest tube drainage and length of stay.Patients who underwent a Fontan procedure at our institution from June 2008 to September 2013 were analyzed (n = 42). We currently manage our patients according to the PORTLAND protocol: Peripheral vasodilation, Oxygen, Restriction of fluids, Technique of surgery, Low-fat diet, Anticoagulation (including antithrombin III management), No ventilator, and Diuretics. Group A (n = 28) had surgery prior to initiation of this protocol; group B (n = 14) had surgery during the current protocol era.The median number of chest tube days was lower in group B (6 vs 11 days, p < 0.001) as was the total indexed drainage (126 vs 259 mL/kg, p < 0.001). Patients in group B had shorter intensive care unit length of stay (4 vs 7 days, p = 0.004) and hospital length of stay (8 vs 13 days, p = 0.001). Group B had higher preoperative common atrial pressures (7.0 vs 5.8 mm Hg, p = 0.017), end-diastolic pressures (9 vs 7 mm Hg, p = 0.026), and trended toward higher pulmonary artery pressures (11.5 vs 9.5 mm Hg, p = 0.077). There was no statistically significant difference in age, weight, transpulmonary gradient, or pulmonary vascular resistance between groups.The PORTLAND protocol has improved early outcomes after the Fontan procedure. Chest tube drainage and duration, and both intensive care unit and hospital length of stay have been reduced since initiation of this protocol.

View details for DOI 10.1016/j.athoracsur.2014.06.121

View details for Web of Science ID 000347030800040

View details for PubMedID 25442983
The neonatal hypoplastic aortic arch: decisions and more decisions. Seminars in thoracic and cardiovascular surgery. Pediatric cardiac surgery annual Langley, S. M., Sunstrom, R. E., Reed, R. D., Rekito, A. J., Gerrah, R. 2013; 16 (1): 43?51
Abstract

Neonatal patients with hypoplasia of the aortic arch constitute a heterogeneous group with a wide spectrum of severity. The milder end of the spectrum comprises patients with aortic coarctation and isthmus hypoplasia. At the other end of the spectrum are patients with severe transverse arch hypoplasia or hypoplastic left heart syndrome. The aim of this paper is to discuss the various strategies and surgical approaches available for this group of patients, focusing on the surgical decisions that influence individual patient management. Many of the things discussed are applicable to any neonatal arch problem. We also describe and discuss in detail our surgical technique for patients who undergo neonatal repair of a hypoplastic aortic arch via median sternotomy.

View details for DOI 10.1053/j.pcsu.2013.01.008

View details for PubMedID 23561817
Adjustment of the surgical plan in repair of congenital heart disease: the power of cross-sectional imaging and three-dimensional visualization. Congenital heart disease Gerrah, R., Bardo, D. M., Reed, R. D., Sunstrom, R. E., Langley, S. M. 2013; 9 (1): E31?6
Abstract

The purpose of this article is to study the importance of cross-sectional imaging in preoperative evaluation and surgical planning. Echocardiography is the modality of choice to diagnose cardiac diseases. However, in some cases, the data obtained from echocardiogram are insufficient or the image quality is poor. In these cases, additional modalities are being used to provide further information that can aid in guiding medical management of or surgical planning for the patient. Cross-sectional imaging has become widely available in many institutions. These imaging techniques, especially with three-dimensional reconstructions, provide realistic images that have imperative diagnostic values. Moreover, the possibility of sophisticated image-processing techniques provides important hemodynamic characteristics via less invasive methods. In this article, we present three cases in which additional cross-sectional imaging seemed to be a crucial step prior to surgical planning.

View details for DOI 10.1111/chd.12062

View details for PubMedID 23601962
In vivo quantification of clot formation in extracorporeal circuits. Studies in health technology and informatics Gerrah, R., David, O. 2013; 184: 148?50
Abstract

Clot formation is a common complication in extracorporeal circuits. In this paper we describe a novel method for clot formation analysis using image processing. We assembled a closed extracorporeal circuit and circulated blood at varying speeds. Blood filters were placed in downstream of the flow, and clotting agents were added to the circuit. Digital images of the filter were subsequently taken, and image analysis was applied to calculate the density of the clot. Our results show a significant correlation between the cumulative size of the clots, the density measure of the clot based on image analysis, and flow duration in the system.

View details for PubMedID 23400147
Hypoplastic right cervical aortic arch. The Annals of thoracic surgery Gerrah, R., Shah, A., Langley, S. M., Quaegebeur, J. M. 2012; 94 (6): 2127?29
Abstract

We describe a neonate with a rare congenital anomaly of the aorta. The anomaly included a hypoplastic aortic arch that was cervical and right sided. This complex combination was treated by a Norwood type procedure reconstructing a right-sided arch and, in a later stage, a Rastelli procedure. These 2 procedures achieved a 2 ventricular repair. The diagnostic and surgical challenges of this rare anomaly are described in this case report.

View details for DOI 10.1016/j.athoracsur.2012.04.136

View details for PubMedID 23176933
Biventricular pacing improves left ventricular function by 2-D strain in right ventricular failure. The Journal of surgical research Wong, C., Cabreriza, S. E., Nugent, M., Wang, D. Y., Gerrah, R., Rusanov, A., Yalamanchi, V., Wang, A., Cheng, B., Spotnitz, H. M. 2012; 178 (2): 571?77
Abstract

We used speckle-tracking echocardiography to test the hypothesis that regional left ventricular (LV) strain would improve during optimized biventricular pacing (BiVP) in acute right ventricular (RV) pressure overload (PO).Complete heart block and RVPO were induced in five open-chest fully anesthetized pigs. BiVP was optimized by adjusting atrioventricular and interventricular delays to maximize cardiac output derived from an aortic flow probe. LV short axis views were obtained during atrio-RV pacing (RVP), atrio-LV pacing (LVP), and BiVP. Intraventricular synchrony was assessed by comparing speckle-tracking echocardiography-derived time to peak (TTP) strain in the anterior septal (AS) and posterior wall segments. Segmental function was assessed using radial strain.Cardiac output was higher with optimized (RV first) BiVP than with LVP (0.96 � 0.26 L/min versus 0.89 � 0.27 L/min; P = 0.05). AS TTP strain (502 � 19 ms) during LVP was prolonged versus BiVP (392 � 58 ms) and versus RVP (390 � 53 ms) (P = 0.0018). AS TTP strain during LVP was prolonged versus posterior (502 � 19 ms versus 396 � 72 ms, P = 0.0011). No significant difference in TTP strain in these segments was seen with BiVP or RVP. Posterior strain (20% � 5%) increased 66% versus AS strain (12% � 6%) during BiVP (P = 0.0029). A similar increase occurred during RVP (posterior 20% � 3% versus AS 12% � 7%, P = 0.0002). Posterior strain did not increase during LVP.BiVP and RVP restore intraventricular LV synchrony and increase regional function versus LVP during RVPO. RV pre-excitation unloads the RV and reduces the duration of AS contraction, facilitating synchrony of all LV segments and increasing free wall LV contraction.

View details for DOI 10.1016/j.jss.2012.06.001

View details for PubMedID 22748597

View details for PubMedCentralID PMC7020239
Single dose myocardial protection technique utilizing del Nido cardioplegia solution during congenital heart surgery procedures. Perfusion Charette, K., Gerrah, R., Quaegebeur, J., Chen, J., Riley, D., Mongero, L., Corda, R., Bacha, E. 2012; 27 (2): 98?103
Abstract

The single dose cardioplegia technique for myocardial protection during congenital heart surgery is a viable alternative to multidose protocols.Thirty-four pediatric patients with aortic cross clamp times greater than 90 minutes were grouped by modified adult (MA) multidose solution or del Nido (dN) single dose solution. Also, data from eight patients where the cross clamp times were greater than two hours on one dose of dN solution were included.In the 90-minute plus arm of the study, there were no significant differences between the groups when comparing the risk adjustment for congenital heart surgery (RACHS) (p=0.6), cardiopulmonary bypass times (CPB) (p=0.5), aortic cross camp times (p=0.5), weights (p=0.7) and number of intraoperative exogenous blood units (p=0.5). There were significant differences between the groups (p<0.05) in the number of cardioplegia doses and with perioperative glucose levels. In the greater than two hours group, the incidence of complete heart block (CHB) was 0.125% and there were no deaths or mechanical circulatory support (MCS) devices used.del Nido cardioplegia solution is a reasonable tool for myocardial protection during congenital heart surgery that significantly decreased the number of cardioplegic interventions and perioperative glucose values in our study groups.

View details for DOI 10.1177/0267659111424788

View details for PubMedID 22005886
Management of intracranial hemorrhage in a child with a left ventricular assist device. Pediatric transplantation Haque, R., Wojtasiewicz, T., Gerrah, R., Gilmore, L., Saiki, Y., Chen, J. M., Richmond, M., Feldstein, N. A., Anderson, R. C. 2012; 16 (5): E135?9
Abstract

Pediatric patients bridged to heart transplant with LVADs require chronic anticoagulation and are at increased risk of hemorrhagic complications, including intracranial hemorrhage. In this population, intracranial hemorrhage is often fatal. We report a case of successful management of a five-yr-old-boy with DCM on an LVAD who developed a subdural hematoma. We initially chose medical management, weighing the patient's high risk of thromboembolism from anticoagulation reversal against the risk of his chronic subdural hematoma. When head CT showed expansion of the hemorrhage with increasing midline shift, we chose prompt surgical evacuation of the hematoma with partial reversal of anticoagulation, given the increased risk of acute deterioration. The patient ultimately received an orthotopic heart transplant and was discharged with no permanent neurological complications. This represents a case of a pediatric patient on an LVAD who survived a potentially fatal subdural hematoma and was successfully bridged to cardiac transplantation.

View details for DOI 10.1111/j.1399-3046.2012.01650.x

View details for PubMedID 22332723
The first successful use of the Levitronix PediMag ventricular support device as a biventricular bridge to transplant in an infant. The Journal of thoracic and cardiovascular surgery Gerrah, R., Charette, K., Chen, J. M. 2011; 142 (5): 1282?83
View details for DOI 10.1016/j.jtcvs.2011.03.026

View details for PubMedID 21529849
Left ventricular pacing lead insertion via the coronary sinus cardioplegia cannula: a novel method for temporary biventricular pacing during reoperative cardiac surgery. The Journal of thoracic and cardiovascular surgery Wang, D. Y., Gerrah, R., Rusanov, A., Yalamanchi, V., Cabreriza, S. E., Spotnitz, H. M. 2011; 142 (1): 73?76
Abstract

Temporary biventricular pacing to treat low output states after cardiac surgery is an active area of investigation. Reoperative cases are not studied due to adhesions, which preclude left ventricular mobilization to place epicardial pacing wires. In such patients, inserting a temporary left ventricular lead via the coronary sinus cardioplegia cannula may allow for biventricular pacing. We developed a novel technique for intraoperative left ventricular lead placement.Eight domestic pigs underwent median sternotomy and pericardiotomy. Temporary pacing wires were sewn to the right atrium and right ventricle. Complete heart block was induced by ethanol ablation of the atrioventricular node. A 13-French retrograde cardioplegia catheter was introduced via the right atrial free wall into the coronary sinus. A 6-French left ventricular pacing lead was inserted into the cardioplegia catheter and advanced into the coronary sinus during biventricular pacing until left ventricular capture was detected by electrocardiogram and arterial pressure monitoring. Left ventricular capture success rate and electrical performance were recorded during five placement attempts.Left ventricular capture was achieved on 80% of insertion attempts. Left ventricular capture without diaphragmatic pacing was achieved in 7 pigs. Lead tip locations were mostly in lateral and posterior basal coronary vein branches. There were no arrhythmias, bleeding, or perforation associated with lead insertion.Intraoperative biventricular pacing with a left ventricular pacing lead inserted via the coronary sinus cardioplegia cannula is feasible, using standard instrumentation and without requiring cardiac manipulation. This approach merits further study in patients undergoing reoperative cardiac surgery.

View details for DOI 10.1016/j.jtcvs.2010.08.028

View details for PubMedID 20965517

View details for PubMedCentralID PMC3432304
Developing and optimizing a chronic cyanotic swine model. The Journal of surgical research Gerrah, R., Cabreriza, S. E., Rusanov, A., Romanov, A., Khan, A. R., Spotnitz, H. M. 2011; 171 (1): 170?74
Abstract

Pulmonary artery (PA)-left atrial (LA) shunt models in piglets have been described, but technical details critical to limit morbidity/mortality and promote study of chronic cyanosis are lacking. Accordingly, we describe our experience with an optimized technique.In 25 6- to 8-wk-old Yorkshire piglets, a beveled, 8 mm, polytetrafluoroethylene tube graft was anastomosed to the PA and LA. Systemic pressure was maintained at >60 mmHg. Saturation targets were met by adjusting a Teflon band on the graft and distal PA. The target oxygen saturation (SO(2)) was 85% on a 50% fraction of inspired oxygen (FiO(2)). If the SO(2) was <75% on a 50% FiO(2), the graft was constricted to achieve a SO(2) ? 90% on a 100% FiO(2) and 75%-80% on a 21% FiO(2). Complications affecting mortality were neutralized with a stepwise strategy to minimize risk.Thrombosis, blood loss, and arrhythmia were determinants of survival. Protocol optimization over time increased survival while assuring chronic cyanosis. Survival approached 90%, with a SO(2) of 80% to 90%, 3 to 5 wk postoperatively. Complications included bleeding, excessive hypoxemia, uncontrolled shunt flow, arrhythmias, and thrombosis.Refinement of surgical technique, shunt adjustment via graft banding, and thrombotic and arrhythmia prophylaxis are the keys to success with this model.

View details for DOI 10.1016/j.jss.2010.03.004

View details for PubMedID 20605592
Validation of automated monitoring of cardiac output for biventricular pacing optimization. ASAIO J George, E. M., Cabreriza, S. E., Quinn, T. A., Rusanov, A., Gerrah, R., Broyles, J. M., Weinberg, A. D., Spotnitz, H. M. 2010; 56 (3): 265-9
View details for DOI 10.1097/MAT.0b013e3181cf882a
Platelet Function Changes in Different Cardiac Surgery Subgroups as Evaluated With an Innovative Technology INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY Gerrah, R., Brill, A., Varon, D. 2007; 2 (4): 176?83
Abstract

: During cardiac surgery, platelets undergo substantial changes. The purpose of this study was to assess platelet function and compare these changes between different cardiac operations using an innovative technology.: Perioperative platelet function was evaluated by the Impact test [cone and plate(let) analyzer (CPA)]. The Impact test yields 2 parameters for platelet function: average size (AS, the mean size of the platelet aggregates) and surface coverage (SC, the percentage of the surface covered by the platelet aggregates), which correspond to platelet aggregation and adhesion. The study groups were compared for platelet function results in various surgery stages and correlation with bleeding.: A significant decrease in surface coverage was detected on establishment of cardiopulmonary bypass, with an increase up to preoperative values at the end of the surgery in all groups. In contrast to operations performed on bypass, in patients operated without cardiopulmonary bypass, the postoperative AS and SC were higher than the preoperative values, 30.4 � 8.1 ?mol versus 23.3 � 6.9 ?mol, P = 0.02 in AS, and 7.6 � 3.6% versus 5.2 � 1.8%, P = 0.04 in SC. Preoperative AS and SC were the only parameters significantly (P = 0.01) and linearly (r = 0.6) related to postoperative bleeding.: Preoperative platelet function, as evaluated by the CPA, is an independent risk factor determining postoperative bleeding. The off-pump patients presented an increased platelet function at the end of surgery, a finding that can imply a higher risk of thrombosis. The impact test appears to be a useful tool to determine perioperative platelet function and help in prediction of postoperative bleeding.

View details for DOI 10.1097/imi.0b013e318158ccc8

View details for Web of Science ID 000217545200002

View details for PubMedID 22437056
Using cone and plate(let) analyzer to predict bleeding in cardiac surgery. Asian cardiovascular & thoracic annals Gerrah, R., Brill, A., Tshori, S., Lubetsky, A., Merin, G., Varon, D. 2006; 14 (4): 310?15
Abstract

The cone and plate(let) analyzer is an established method for assessing platelet function. It evaluates adherence of platelets on an extracellular matrix, expressed as a percentage of surface coverage and the average size of the aggregates. The purpose of this study was to determine the applicability of the cone and plate(let) analyzer in monitoring platelet function and predicting postoperative bleeding. The relationship between postoperative bleeding, perioperative platelet function, and other parameters was studied. A significant decrease in surface coverage was detected upon establishment of cardiopulmonary bypass (from 6.9% +/- 3.9% to 4.7% +/- 1.7%) with a return to preoperative values at the end of surgery. Preoperative average size and surface coverage were the only parameters that significantly and linearly correlated with postoperative bleeding. Patients with an aggregate average size < 20 microm(2) had a significantly higher incidence of severe bleeding (> 965 mL) than those with a size > 20 microm(2) (44% vs. 0%), and a higher mean blood loss (908 +/- 322 mL vs. 337 +/- 78 mL). Similar results were obtained for surface coverage < 5%, indicating the predictive value of these parameters. Preoperative platelet function as evaluated by the cone and plate(let) analyzer is an independent risk factor determining postoperative bleeding.

View details for DOI 10.1177/021849230601400409

View details for PubMedID 16868105
Stuck bioprosthetic aortic valve - A new entity? A case report HEART SURGERY FORUM Gerrah, R., Pappof, M., Shatz, Pollak, A., Gilon, D. 2005; 8 (6): E447?E448
Abstract

We describe herein a case of bioprosthetic valve malfunction, which closely imitates a stuck valve. Although the term "stuck" was used originally for the immovable mechanical valve leaflets, the echocardiographic manifestation of this malfunction is similar to those of a mechanical one. The clinical presentation of the stuck bioprosthesis is, however, far more benign than a stuck mechanical valve. Familiarity with this entity is important.

View details for DOI 10.1532/HSF98.20051017

View details for Web of Science ID 000234239700013

View details for PubMedID 16283983
Preoperative aspirin administration improves oxygenation in patients undergoing coronary artery bypass grafting CHEST Gerrah, R., Elami, A., Stamler, A., Smirnov, A., Stoeger, Z. 2005; 127 (5): 1622?26
Abstract

Release of thromboxane (Tx) A(2) by platelets may be one of multiple factors that are responsible for lung injury after cardiopulmonary bypass, leading to pulmonary vasoconstriction and impaired oxygenation. In experimental models, the inhibition of Tx receptor or its production improved lung function. The use of aspirin, which is used widely in the treatment of ischemic heart disease because of its antiplatelet activity, is usually discontinued a week before the patient undergoes the operation to restore normal platelet hemostatic function. The purpose of this study was to determine the relationship between the time of cessation of aspirin before coronary artery bypass surgery, and postoperative oxygenation and bleeding.A prospective clinical study comparing the effect of aspirin on postoperative oxygenation in patients who had been treated or had not been treated with aspirin.Tx levels in the pericardial fluid, oxygenation, and bleeding were compared between the two groups.Thirty-two patients with coronary artery disease who were undergoing coronary artery bypass grafting. Fourteen of these patients received aspirin until the day of the operation, whereas 18 patients stopped receiving aspirin at least 1 week before undergoing the operation.Mean (+/- SD) Tx levels in the pericardial fluid were significantly lower in the aspirin group (117 +/- 47 pg/mL) compared to those in the control group (1,306 +/- 2,048 pg/mL; p = 0.02). The duration of ventilation after the operation was significantly longer in the nonaspirin group (9.6 +/- 5.6 h vs 3.8 +/- 1.4 h, respectively; p = 0.0004). Po(2) reached a higher level while patients breathed 100% O(2) in the aspirin group (235 +/- 54 mm Hg vs 176 +/- 27 mm Hg, respectively; p = 0.001). The mean amount of bleeding during the first 24 h after surgery was increased in the aspirin group (710 +/- 202 mL) compared with the nonaspirin group (539 +/- 143 mL; p = 0.01), but these patients did not require more transfusions.The administration of aspirin until the operation may improve oxygenation with only a slight increase in bleeding. This improvement is probably mediated by antiplatelet activity and Tx inhibition by aspirin.

View details for DOI 10.1378/chest.127.5.1622

View details for Web of Science ID 000228987600028

View details for PubMedID 15888837
Beneficial effect of aspirin on renal function in patients with renal insufficiency postcardiac surgery Gerrah, R., Ehrlich, S., Tshori, S., Sahar, G. EDIZIONI MINERVA MEDICA. 2004: 545?50
Abstract

Renal function is one of the most important prognostic factors following cardiac surgery. Whether aspirin affects cardiopulmonary bypass related renal injury is investigated in this study.Ninety-four patients with impaired renal function (creatinine = or >1.5 mg/dl) undergoing coronary artery bypass grafting (CABG) were categorized into 2 groups according to aspirin administration before surgery. Serum creatinine, urinary output and creatinine clearance along with other perioperative factors were compared between the 2 groups prior to surgery, 24 hours and 48 hours following cardiopulmonary bypass.Creatinine levels increased significantly in the second postoperative day only in the non-aspirin (control) group (3.7+/-1.6 vs 2.9+/-1.7 mg/dl, p=0.03). Aspirin (study) group had lower creatinine levels in day 1 (p=0.03) and day 2 (p=0.001). Furthermore, in the study group creatinine clearance was higher in day 1 (34.3+/-14.3 vs 30.9+/-13.1 ml/min, p=0.01) and in day 2 (32.6+/-13.8 vs 26.4+/-9.8 ml, p<0.0001). Creatinine levels at discharge were elevated compared to the preoperative levels in the control group (p=0.01). However, the study group had lower creatinine levels at discharge (2.6+/-1.4 vs 3.8+/-1.6 mg/dl, p<0.0001). Urinary output was higher in the study group in the first postoperative day compared to the control group (p=0.01). Postoperative bleeding was slightly increased in the study group compared to the control group (760+/-230 ml vs 530+/-210 ml, p=0.01).Continuation of aspirin administration until the day of surgery may have a protective effect against renal injury resulting from cardiopulmonary bypass, with only a negligible increase in bleeding. Possible explanations for this effect are antiplatelet activity of aspirin during cardiopulmonary bypass causing inhibition of vasoconstrictive agents like thromboxane, and improvement of renal perfusion by reducing blood viscosity.

View details for Web of Science ID 000228056200003

View details for PubMedID 15746633
Pericardial fluid and serum VEGF in response to different types of heparin treatment INTERNATIONAL JOURNAL OF CARDIOLOGY Gerrah, R., Tshori, S., Gilon, D. 2004; 94 (2-3): 193?96
Abstract

Heparin is an important medication in the treatment of patients with unstable angina pectoris. We designed an observational study to compare the effects of standard heparin (SH) with low molecular weight heparin (LMWH) on vascular endothelial growth factor (VEGF) levels in patients undergoing coronary artery bypass grafting (CABG).Thirty-two patients with unstable angina pectoris undergoing CABG were prospectively categorized into two groups according to the type of heparin administration before surgery. VEGF levels determined by enzyme linked immunosorbent assay (ELISA) were compared between the two groups' blood samples obtained before the surgery and pericardial fluid after pericardial opening.There was no difference in preoperative characteristics between the two groups. Serum VEGF levels were similar (P=0.3) in patients treated by SH (85+/-55 pg/ml) compared to those treated with LMWH (105+/-64 pg/ml). VEGF levels in the pericardial fluid were significantly raised (P<0.0001) in patients of LMWH group (36+/-13 pg/ml) compared to SH group (13+/-6 pg/ml). A good correlation was observed between VEGF in the serum and platelet count in both SH group (r=0.8) and LMWH group (r=0.7).Local response of the ischemic myocardium, as expressed by VEGF levels, differs in patients treated with SH compared to patients treated with LMWH. VEGF levels in pericardial fluid of patients receiving LMWH were 2-3-folds higher than patients in SH group.

View details for DOI 10.1016/j.ijcard.2003.03.022

View details for Web of Science ID 000221168800010

View details for PubMedID 15093980
Aspirin decreases vascular endothelial growth factor release during myocardial ischemia INTERNATIONAL JOURNAL OF CARDIOLOGY Gerrah, R., Fogel, M., Gilon, D. 2004; 94 (1): 25?29
Abstract

Vascular Endothelial Growth Factor (VEGF) is an important angiogenesis factor involved in pathophysiology of cardiovascular diseases. Controlling this factor's level in the serum might have significant prognostic outcomes.Twenty-four patients undergoing coronary artery bypass grafting were prospectively categorized into two groups according to aspirin administration before surgery. Vascular Endothelial Growth Factor levels were compared and correlated and adjusted with platelets count between two groups in the serum, before and after the surgery. Serum creatine kinase (CK) levels were determined before and after the operation in parallel to other clinical data.Vascular Endothelial Growth Factor levels were significantly lower in patients of the aspirin group compared to those of the non-aspirin group; 94+/-61 vs. 241+/-118 pg/ml, p=0.0003, respectively, this-despite an absence of difference in the platelet count between the groups. These titers decreased postoperatively in both groups, 94+/-61 to 10+/-9 pg/ml, p=0.001 in aspirin group and from 241+/-118 to 84+/-54 pg/ml, p=0.001 in control group. Serum creatine kinase levels were higher in the non-aspirin group, 214+/-83 u/l compared to 70+/-32 u/l in the aspirin group. Creatine kinase levels increased significantly postoperatively in both groups; however, the aspirin group had a significantly lower creatine kinase levels compared to non-aspirin group, 107+/-51 vs. 401+/-127 u/l, respectively, p=<0.0001. A significant correlation was seen between VEGF levels and platelets count in both groups, r=0.5.Aspirin treated patients have lower Vascular Endothelial Growth Factor titer levels in the perioperative course. This difference between the aspirin and the non-aspirin group is not accounted for by the platelets count.

View details for DOI 10.1016/j.ijcard.2003.03.007

View details for Web of Science ID 000220258900004

View details for PubMedID 14996470
Platelet function changes as monitored by cone and plate(let) analyzer during beating heart surgery HEART SURGERY FORUM Gerrah, R., Snir, E., Brill, A., Varon, D. 2004; 7 (3): E191?E195
Abstract

Off-pump coronary artery bypass (OPCAB) is believed to reduce cardiopulmonary bypass (CPB)-related complications, including platelet damage. A hypercoagulable state instead of coagulopathy has been reported following OPCAB surgeries due to CPB. Whether platelet function is changed when the injurious effect of CPB is eliminated was investigated.Platelet function was determined with the cone and plate(let) analyzer (CPA) method. The 2 parameters, average size (AS) and surface coverage (SC) of platelet aggregates, were measured with the CPA method to assess platelet aggregation and adhesion. These parameters were evaluated, and their values were compared at several stages of OPCAB surgery. The correlations of postoperative bleeding with platelet function at different stages of the surgery and with other factors, such as platelet count, hematocrit, and transfusions, were studied.Both AS and SC increased during several stages of the operation, and postoperative values (mean +/- SD) were significantly higher than preoperative values (30.4 +/- 8.1 microm 2 versus 23.3 +/- 6.9 microm 2 for AS [ P =.02] and 7.6% +/- 3.6% versus 5.2% +/- 1.8% for SC [ P =.04]). The mean total bleeding volume was 875 micro 415 mL. Preoperative AS and SC were the only parameters significantly ( P =.01) and linearly ( r = 0.7) related to postoperative bleeding.An increased platelet function, as determined by the CPA method, is found following OPCAB surgery. This phenomenon is probably at least partially responsible for the thrombogenic state after OPCAB surgery. Lack of platelet injury attributed to CPB may divert the system toward a more thrombogenic state. Preoperative platelet function, as evaluated by the CPA method, is an independent risk factor determining postoperative bleeding.

View details for DOI 10.1532/HSF98.20041010

View details for Web of Science ID 000223999200003

View details for PubMedID 15262600
Beneficial effect of aspirin on renal function post-cardiopulmonary bypass. Asian cardiovascular & thoracic annals Gerrah, R., Izhar, U. 2003; 11 (4): 304?8
Abstract

Urine thromboxane, plasma creatinine, and creatinine clearance were determined perioperatively in 20 patients undergoing coronary bypass surgery. Ten patients took aspirin until the day of surgery, and 10 discontinued aspirin at least one week before surgery. A significant increase in urine thromboxane following establishment of cardiopulmonary bypass was observed only in the control group. Plasma creatinine increased in the control group on the 1st postoperative day (from 81.9 +/- 13.2 to 97.6 +/- 13.2 micromol.L(-1), p = 0.02) and decreased next day to the preoperative level (82.7 +/- 9 micromol.L(-1), p = 0.03). In the aspirin group, creatinine remained unchanged on the 1st postoperative day (89.4 +/- 14.2 vs. 87.2 +/- 7.7 micromol.L(-1), p = 0.6), and increased significantly on the 2nd day (101.4 +/- 8.5 micromol.L(-1), p = 0.01). The aspirin group had higher creatinine levels (p < 0.0001) and lower creatinine clearance (60.2 +/- 16.5 vs. 82 +/- 25.7 mL.min(-1), p < 0.0001) than the control group on the 2nd postoperative day. A significant positive correlation was seen between urine thromboxane and creatinine on day 2 in both groups (r = 0.6). Aspirin administrated before coronary surgery may have a beneficial effect on renal function, probably mediated by its antiplatelet activity and thromboxane inhibition.

View details for PubMedID 14681089
Cardiac surgery in octogenarians - A better prognosis in coronary artery disease ISRAEL MEDICAL ASSOCIATION JOURNAL Gerrah, R., Izhar, U., Elami, A., Milgalter, E., Rudis, E., Merin, G. 2003; 5 (10): 713?16
Abstract

Cardiac surgery is being performed with increasing frequency in patients aged 80 years and older.To examine the long and short-term results of surgery in this age group.We retrospectively investigated 202 consecutive patients aged 80 years or older who underwent cardiac surgery between 1991 and 1999, Ninety-six operations (48%) were urgent.The study group comprised 140 men (69%) and 62 women (31%) with a mean age of 82.1 years (range 80-89). Preoperatively, 120 patients (59%) had unstable angina, 37 (18%) had left main coronary artery disease, 22 (11%) had renal failure, 17 (8.5%) had a history of stroke and 13 (6.5%) had previous cardiac surgery. Hospital mortality for the whole group was 7.4%. Postoperative complications included: re-exploration for bleeding in 15 (7.4%), stroke in 8 (4%), sternal wound infection in 3 (1.5%), low cardiac output in 17 (8.4%), new Q wave myocardial infarction in 5 (2.5%), renal failure in 17 (8.5%), and atrial fibrillation in 71 (35%). The actuarial survival for patients discharged from the hospital was 66% at 5 years and 46% at 8 years. The type of surgical procedure was significantly associated with increased early mortality (coronary artery bypass grafting only in 2.9%, CABG + valve in 16.1%, valve only in 16.7%; P = 0.01). Significant predictors (P < 0.05) for late mortality included type of surgical procedure, congestive heart failure, and postoperative low cardiac output.When appropriately applied in selected octogenarians, cardiac surgery can be performed with acceptable mortality and good long-term results.

View details for Web of Science ID 000185987000007

View details for PubMedID 14719466
The surgical approach to infective endocarditis: 10 year experience ISRAEL MEDICAL ASSOCIATION JOURNAL Gerrah, R., Rudis, E., Elami, A., Milgalter, E., Izhar, U., Merin, G. 2003; 5 (9): 641?45
Abstract

About 40% of patients with infective endocarditis will require surgical treatment. The guidelines for such treatment were formulated by the American College of Cardiology and American Heart Association in 1998.To examine our experience with surgical treatment of infective endocarditis in light of these guidelines.Surgery was performed in 59 patients with infective endocarditis between 1990 and 1999. The patients' mean age was 48 years (range 13-80). The indications for surgery were hemodynamic instability, uncontrolled infection, and peripheral embolic events. The surgical treatment was based on elimination of infection foci and correction of the hemodynamic derangement. These objectives were met with valve replacement in the majority of patients. Whenever conservative surgery was possible, resection of vegetation and subsequent valve repair were performed and the native valve was preserved.Six patients (10%) died perioperatively from overwhelming sepsis (n = 3), low cardiac output (n = 2) and multiogran failure (n = 1). The mean hospital stay was 15.6 days. Of 59 patients, 47 (80%) underwent valve replacement and in 11 (19%) the surgical treatment was based on valve repair. After 1 year of follow-up there was no re-infection.The new guidelines for surgical treatment of infective endocarditis allow better selection of patients and timing of surgery for this aggressive disease, which consequently decreases the mortality rate. Valve repair is feasible and is preferred whenever possible. According to the new guidelines, patients with neurologic deficit in our series would not have been operated upon, potentially decreasing the operative mortality to 7%.

View details for Web of Science ID 000185317700009

View details for PubMedID 14509154
Impaired oxygenation and increased hemolysis after cardiopulmonary bypass in patients with glucose-6-phosphate dehydrogenase deficiency ANNALS OF THORACIC SURGERY Gerrah, R., Shargal, Y., Elami, A. 2003; 76 (2): 523?27
Abstract

The purpose of this study was to determine whether the damaging effects of cardiopulmonary bypass, ischemia, and reperfusion would be more pronounced in patients with glucose-6-phosphate dehydrogenase deficiency undergoing cardiac surgery.Forty-two patients with glucose-6-phosphate dehydrogenase deficiency underwent open heart procedures using cardiopulmonary bypass. This group was matched with a control group of identical size for comparison of operative course and postoperative outcome. The perioperative variables were compared between the two groups using univariate and multivariate analysis.The duration of ventilation after the operation was significantly longer in the glucose-6-phosphate dehydrogenase-deficient group (13.7 +/- 7.6 hours versus 7.7 +/- 2.8 hours; p < 0.0001). Minimal value of arterial oxygen tension was lower in patients with glucose-6-phosphate dehydrogenase deficiency (66 +/- 12 mm Hg versus 85 +/- 14 mm Hg; p < 0.0001), and more cases of hypoxia (arterial oxygen tension < 60 mm Hg) were found in this group (11 versus 1; p = 0.001). Compared with the control group, patients with glucose-6-phosphate dehydrogenase deficiency had significantly elevated hemolytic indices expressed by bilirubin levels (26 +/- 10 mmol/L versus 17 +/- 6.7 mmol/L; p < 0.0001) and lactic dehydrogenase levels (970 +/- 496 U/L versus 505 +/- 195 U/L; p < 0.0001). They also required significantly more blood transfusion perioperatively (1.9 +/- 1.4 packed cell units/patient versus 0.8 +/- 1.0 packed cell units/patient; p = 0.0001).Patients with glucose-6-phosphate dehydrogenase deficiency who are undergoing cardiac surgery may have a more complicated course with a longer ventilation time, more hypoxia, increased hemolysis, and a need for more blood transfusion. Because this difference may be caused by subnormal free radical deactivation, strategies that minimize bypass in general and free radicals specifically may be beneficial.

View details for DOI 10.1016/S0003-4975(03)00351-5

View details for Web of Science ID 000184616700049

View details for PubMedID 12902098
Traumatic memory: A cause for postoperative delirium - A diagnostic dilemma ISRAEL MEDICAL ASSOCIATION JOURNAL Gerrah, R., Abramovitch, Y., Elami, A. 2001; 3 (11): 858?59
View details for Web of Science ID 000173516100016

View details for PubMedID 11729586

Rabin Gerrah

Clinical Assistant Professor, Cardiothoracic Surgery

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