Robert M Applebaum, M.D.

Impact of moderate functional mitral insufficiency in patients undergoing surgical revascularization
Grossi, Eugene A; Crooke, Gregory A; DiGiorgi, Paul L; Schwartz, Charles F; Jorde, Ulrich; Applebaum, Robert M; Ribakove, Greg H; Galloway, Aubrey C; Grau, Juan B; Colvin, Stephen B
2006 Jul 4;114(1 Suppl):I573-I576, Circulation
BACKGROUND: Mild and moderate functional ischemic mitral insufficiency present at the time of surgical revascularization present clinical uncertainty. It is unclear whether the relatively poor outcomes in this cohort are dependent on valvular function or related to left ventricular dysfunction. The purpose of this study was to examine the early and late outcomes in patients with less-than-severe functional ischemic mitral insufficiency at the time of isolated coronary artery bypass grafting (CABG). METHODS AND RESULTS: From 1996 through 2004, 2242 consecutive patients undergoing isolated CABG were identified as having none to moderate mitral regurgitation (MR) and no valve leaflet pathology. All of the patients at this single institution routinely had an intraoperative transesophageal echocardiography, prospectively quantified MR, and ejection fraction (EF). The New York State Cardiac Surgery Reporting System infrastructure was used to prospectively collect in-hospital patient variables and outcomes. Social Security Death Benefit Index was used to determine long-term survival. Odds ratio and significance (P value) are presented for each determined risk factor. There were 841 patients (37.5%) with no MR, 1137 (50.7%) with mild MR, and 264 (11.8%) with moderate MR. The patients with moderate MR were more likely to be older, female, and have more renal disease, previous MI, congestive heart failure, previous cardiac surgery, and lower EFs. Hospital mortality was independently and significantly associated with renal disease, decreasing EF, increasing age, previous cardiac operation, and cerebral vascular disease. Multivariable analysis revealed decreased survival with increasing age, previous operation, congestive heart failure, diabetes, nonelective operation, decreasing EF, and the presence of moderate MR (expbeta = 1.49; P=0.007) and mild MR (expbeta = 1.34; P=0.033). CONCLUSIONS: Independent of ventricular function, mild and moderate functional mitral insufficiency are associated with significantly decreased survival in patients undergoing CABG. Whether correction of moderate functional MR at the time of CABG improves outcome still needs to be determined
— id: 67535, year: 2006, vol: 114, page: I573, stat: Journal Article,

Impact of moderate functional mitral insufficiency in patients undergoing surgical revascularization
Grossi, EA; DiGiorgi, PL; Schwartz, CF; Ulrich, J; Applebaum, RM; Ribakove, GH; Galloway, AC; Grau, JB; Colvin, SB
2005 OCT 25 ;112(17):U556-U556, Circulation
— id: 60207, year: 2005, vol: 112, page: U556, stat: Journal Article,

Comparison of image quality between a narrow caliber transesophageal echocardiographic probe and the standard size probe during intraoperative evaluation
Reynolds, Harmony R; Spevack, Daniel M; Shah, Alan; Applebaum, Robert M; Kanchuger, Mark; Tunick, Paul A; Kronzon, Itzhak
2004 Oct;17(10):1050-1052, Journal of the American Society of Echocardiography
BACKGROUND: Transesophageal echocardiography (TEE) has become an integral part of the evaluation and monitoring of patients during cardiac operation. Until recently, the smallest TEE probe with multiplane imaging measured 13 mm in diameter. This size is now standard for adult TEE probes. Recently, a new TEE probe has become available (MiniMulti TEE probe, Philips Medical Systems, Andover, Mass), which has a diameter of 8 mm. Although using a smaller probe is attractive, the quality of images it generates when used in adults has not yet been examined. OBJECTIVE: The purpose of this study was to compare TEE studies done with both probes. METHODS: After informed consent was obtained, full intraoperative TEE studies were performed in 20 patients with a small pediatric probe. The study was then repeated using a standard adult probe. The studies were read in random order by two experienced echocardiographers blinded to probe used. For each study, 18 anatomic cardiac structures and 5 Doppler patterns were subjectively graded as excellent (1), good (2), fair (3), or poor (4) in quality. The average score for each structure or Doppler profile was computed for each probe. RESULTS: The average score for all findings was lower (better) for the adult TEE probe (1.4 +/- 0.4 vs 1.7 +/- 0.4; P =.003). When each finding was compared separately, several cardiac structures (left ventricle [LV], pericardium, right ventricle [RV], interatrial septum, left atrium, left atrial appendage, mitral valve, aortic valve) had better scores with the adult probe, and the differences for the LV and RV were larger than those for the other findings (LV scores differed by 0.7, P =.0004; RV scores differed by 0.5, P =.01). There was no significant difference between probes when evaluating venous structures (coronary sinus, superior vena cava, pulmonary vein), the thoracic aorta, or the right atrium or tricuspid valve. In addition, Doppler patterns were not significantly different with the two probes. There were two findings that were missed with the small probe and seen with the adult probe (one aortic plaque and one left atrial appendage thrombus). CONCLUSIONS: In the adult, the larger probe provides better images, particularly of the RV and LV. In addition, important findings may be missed with the smaller probe. However, if the adult probe cannot be passed, the pediatric probe is a reasonable alternative
— id: 45390, year: 2004, vol: 17, page: 1050, stat: Journal Article,

Comparison of a small (pediatric) transesophageal echocardiography probe with a standard (adult) probe
Reynolds, HR; Spevack, DM; Shah, A; Applebaum, RM; Kanchuger, M; Tunick, PA; Kronzon, I
2004 MAR 3 ;43(5):350A-350A, Journal of the American College of Cardiology
— id: 42452, year: 2004, vol: 43, page: 350A, stat: Journal Article,

Anterior leaflet resection of the mitral valve
Saunders, Paul C; Grossi, Eugene A; Schwartz, Charles F; Grau, Juan B; Ribakove, Greg H; Culliford, Alfred T; Applebaum, Robert M; Galloway, Aubrey C; Colvin, Steven B
2004 Summer;16(2):188-193, Seminars in thoracic & cardiovascular surgery
Triangular resection is a reconstructive option for treatment of anterior leaflet mitral disease with segmental prolapse. In our experience, it is a safe and reproducible technique, associated with low rates of recurrent MR or need for reoperation, as well as decreased likelihood for systolic anterior motion after mitral repair. We review our experience with this technique over a 25-year experience with mitral valve reconstruction
— id: 45685, year: 2004, vol: 16, page: 188, stat: Journal Article,

Revascularization alone for functional mitral regurgitation: A propensity case-match analysis of the off pump coronary artery bypass approach
Saunders, PC; Grossi, EA; Schwartz, CF; Applebaum, RM; Ribakove, GH; Culliford, AT; Galloway, AC; Colvin, SB
2004 MAR 3 ;43(5):274A-274A, Journal of the American College of Cardiology
— id: 42552, year: 2004, vol: 43, page: 274A, stat: Journal Article,

Propensity case-matched analysis of off-pump coronary artery bypass grafting in patients with atheromatous aortic disease
Sharony, Ram; Grossi, Eugene A; Saunders, Paul C; Galloway, Aubrey C; Applebaum, Robert; Ribakove, Greg H; Culliford, Alfred T; Kanchuger, Marc; Kronzon, Itzhak; Colvin, Stephen B
2004 Feb;127(2):406-413, Journal of thoracic & cardiovascular surgery
OBJECTIVE: Atheromatous aortic disease is a risk factor for excessive mortality and stroke in patients undergoing coronary artery bypass grafting. Outcomes of off-pump coronary artery bypass grafting and coronary artery bypass grafting with cardiopulmonary bypass in patients with severe atheromatous aortic disease were compared by propensity case-match methods. METHODS: Routine intraoperative transesophageal echocardiography identified 985 patients undergoing isolated coronary artery bypass grafting with severe atheromatous disease in the aortic arch or ascending aorta. Off-pump coronary artery bypass grafting was performed in 281 patients (28.5%). Propensity matched-pairs analysis was used to match patients undergoing off-pump coronary artery bypass grafting (n = 245) with patients undergoing coronary artery bypass grafting with cardiopulmonary bypass. RESULTS: Univariate analysis revealed decreased hospital mortality (16/245, 6.5% vs 28/245, 11.4%; P =.058) and stroke prevalence (4/245, 1.6% vs 14/245, 5.7%; P =.03) in off-pump coronary artery bypass grafting compared with coronary artery bypass grafting with cardiopulmonary bypass. Freedom from any postoperative complication was higher in off-pump coronary artery bypass grafting compared with coronary artery bypass grafting with cardiopulmonary bypass (226/245, 92.2% vs 196/245, 80.0%; P <.001). Multivariable analysis of preoperative risk factors showed that increased hospital mortality was associated with coronary artery bypass grafting with cardiopulmonary bypass (odds ratio = 2.7; P =.01), fewer grafts (P =.05), acute myocardial infarction (odds ratio = 11.5; P <.001), chronic obstructive pulmonary disease (odds ratio = 2.4; P =.03), previous cardiac surgery (odds ratio = 10.2, P =.05), and peripheral vascular disease (odds ratio = 2.1; P =.05). Cardiopulmonary bypass was the only independent risk factor for stroke (odds ratio = 3.6, P =.03). At 36 months' follow-up, comparable survival was observed in the off-pump coronary artery bypass grafting and coronary artery bypass grafting with cardiopulmonary bypass groups (74% vs 72%). Multivariable analysis revealed that renal disease (P <.001), advanced age (P <.001), previous myocardial infarction (P =.03), and lower number of grafts (P =.02) were independent risks for late mortality. CONCLUSIONS: Patients with severe atherosclerotic aortic disease who undergo off-pump coronary artery bypass grafting have a significantly lower prevalence of hospital mortality, perioperative stroke, and overall complications than matched patients who underwent coronary artery bypass grafting with cardiopulmonary bypass. Routine intraoperative transesophageal echocardiography identifies severe atheromatous aortic disease and directs the choice of surgical technique
— id: 42050, year: 2004, vol: 127, page: 406, stat: Journal Article,

Semirigid partial annuloplasty band allows dynamic mitral annular motion and minimizes valvular gradients: an echocardiographic study
Sharony, Ram; Saunders, Paul C; Nayar, Ambika; McAleer, Eileen; Galloway, Aubrey C; Delianides, Julie; Schwartz, Charles F; Applebaum, Robert M; Kronzon, Itzhak; Colvin, Stephen B; Grossi, Eugene A
2004 Feb;77(2):518-522, Annals of thoracic surgery
BACKGROUND: Traditional mitral annuloplasty devices include both rigid rings, which restrict annular motion, and soft rings and bands, which can locally deform. Conflicting data exist regarding their impact on annular dynamics. We studied mitral annuloplasty with a semirigid partial band and with a nearly complete rigid ring. METHODS: Intraoperative three-dimensional transesophageal echocardiograms (n = 14) and predischarge transthoracic echocardiograms were retrospectively analyzed in patients undergoing mitral valve repair for degenerative disease with either a rigid ring (n = 77) or a semirigid partial band (n = 38). Each transesophageal echocardiogram was analyzed with TomTec three-dimensional software to produce cardiac cycle frame planimetry and to measure device geometry. Actual device sizes provided reference dimensions. Blinded analysis of Doppler data from transthoracic echocardiograms was performed. RESULTS: Validation of the quantitative transesophageal echocardiogram methodology revealed a 1.3% +/- 0.3% (mean +/- standard error of the mean) underestimation of actual linear dimension. With the semirigid partial band, systolic valve orifice area and intertrigonal distance decreased from 6.14 +/- 0.37 to 5.55 +/- 0.24 cm(2) (-9.6%; p = 0.01) and from 2.69 +/- 0.08 to 2.55 +/- 0.13 cm (-5.2%; p = 0.03), respectively. Systolic anterior-posterior distance decreased from 2.1 +/- 0.10 to 1.95 +/- 0.06 cm (-7.1%; p = 0.01) compared with diastole. In contrast, rigid ring orifice area was unchanged (4.12 +/- 0.15 to 4.10 +/- 0.16 cm(2); -0.5%; p = 0.48) during the cardiac cycle. Transthoracic echocardiography revealed significantly lower mitral inflow gradients with semirigid partial band (mean gradients compared with rigid ring, 4.0 +/- 0.3 versus 5.0 +/- 0.3 mm Hg; p = 0.02; peak gradients, 8.9 +/- 0.5 versus 11.1 +/- 0.5 mm Hg; p = 0.01). CONCLUSIONS: Three-dimensional transesophageal echocardiographic measurements of annular dynamics are valid and reliable when discrete annuloplasty devices are present. In contrast to the rigid ring, the semirigid partial band permits more physiologic geometric changes and is associated with lower postoperative mitral valve gradients
— id: 42597, year: 2004, vol: 77, page: 518, stat: Journal Article,

Routine intraoperative transesophageal echocardiography identifies patients with atheromatous aortas: Impact on "off-pump" coronary artery bypass and perioperative stroke
Grossi, Eugene A; Bizekis, Costas S; Sharony, Ram; Saunders, Paul C; Galloway, Aubrey C; Lapietra, Angelo; Applebaum, Robert M; Esposito, Rick A; Ribakove, Greg H; Culliford, Alfred T; Kanchuger, Marc; Kronzon, Itzhak; Colvin, Stephen B
2003 Jul;16(7):751-755, Journal of the American Society of Echocardiography
BACKGROUND: Patients with severe atheromatous aortic disease (AAD) undergoing coronary artery bypass grafting (CABG) have increased operative risks. The 'off-pump' CABG (OPCAB) technique was evaluated in patients given the diagnosis of severe AAD by routine transesophageal echocardiography. METHODS: A total of 5737 patients underwent CABG, with 913 having transesophageal echocardiography findings of severe AAD. Of the patients with severe AAD, 678 (74.3%) had conventional CABG and 235 (25.7%) had OPCAB. RESULTS: Hospital mortality was 8.7% for conventional CABG and 5.1% for OPCAB (P =.08). Multivariate analysis revealed that increased mortality was significantly associated with acute myocardial infarction, conventional CABG, age, renal disease, history of stroke, and ejection fraction < 30%. Neurologic complications occurred in 6.3% of patients undergoing CABG and in 2.1% undergoing OPCAB (P =.01). Freedom from any complication was significantly greater with OPCAB. CONCLUSION: Routine intraoperative transesophageal echocardiography identifies patients with severe AAD. In these patients, OPCAB technique is associated with a lower risk of death, stroke, and all complications
— id: 36724, year: 2003, vol: 16, page: 751, stat: Journal Article,

Substernal epicardial echocardiography: review of a new technique
Reynolds, Harmony R; Nayar, Ambika C; McAleer, Eileen P; Schwartz, Jesse D; Tunick, Paul A; Applebaum, Robert M; Colvin, Stephen B; Culliford, Alfred T; Galloway, Aubrey C; Grossi, Eugene A; Ribakove, Gregory H; Kronzon, Itzhak
2003 Nov;16(11):1204-1210, Journal of the American Society of Echocardiography
BACKGROUND: Patients after cardiac operation pose a challenge to the treating physician-these patients may become critically ill and are among the most difficult to image using transthoracic echocardiography. Several factors contribute to this, including difficulties in positioning the patient, inability of the patient to cooperate with instructions, surgical dressings, and hyperinflated lungs. Transesophageal echocardiography may be performed when transthoracic echocardiography is not diagnostic; however, transesophageal echocardiography is semi-invasive and does not lend itself to prolonged or repeated monitoring. METHODS: Recently, a new approach to echocardiography for use in the patient after operation has been introduced with the modification of the standard mediastinal drainage tube to allow for substernal epicardial echocardiography (SEE). The SEE tube has 2 lumens. The first allows for routine mediastinal drainage and the second has a blind end that permits the insertion of a standard transesophageal echocardiographic probe for high-resolution imaging as often as is desired over the period during which the mediastinal tube is in place. CONCLUSION: This article reviews the technique of SEE including a description of the method of performance of SEE (with representative images), a review of the published literature on this new modality, examples of clinical use, and a discussion of the advantages, indications, and limitations of SEE with an eye toward future directions for research
— id: 42051, year: 2003, vol: 16, page: 1204, stat: Journal Article,

Substernal epicardial echocardiography may be a critical diagnostic tool in the postoperative cardiac surgery patient
Reynolds, HR; Applebaum, RM; Spevack, DM; Shah, A; Mcaleer, EP; Nayar, AC; Tunick, PA; Lapietra, A; Patel, S; Bizekis, CS; Wood, MG; Grossi, EA; Ribakove, GH; Colvin, SB; Kronzon, I
2003 MAR 19 ;41(6):449A-449A, Journal of the American College of Cardiology
— id: 37102, year: 2003, vol: 41, page: 449A, stat: Journal Article,

Off-pump coronary artery bypass grafting reduces mortality and stroke in patients with atheromatous aortas: a case control study
Sharony, Ram; Bizekis, Costas S; Kanchuger, Marc; Galloway, Aubrey C; Saunders, Paul C; Applebaum, Robert; Schwartz, Charles F; Ribakove, Greg H; Culliford, Alfred T; Baumann, F Gregory; Kronzon, Itzhak; Colvin, Stephen B; Grossi, Eugene A
2003 Sep 9;108 Suppl 1(19):II15-II20, Circulation
BACKGROUND: Patients with severe atheromatous aortic disease (AAD) who undergo coronary artery bypass (CABG) have an increased risk of death and stroke. We hypothesized that in these high risk patients, off-pump coronary artery bypass (OPCAB) technique is associated with lower morbidity and mortality. METHODS AND RESULTS: Between June 1993 and January 2002, 5737 patients undergoing CABG had routine intra-operative TEE with 913 (15.9%) found to have severe AAD in the aortic arch or ascending aorta. Of these, 211 patients who underwent OPCAB were matched with 211 on-pump CABG patients by age, ejection fraction, history of stroke, cerebrovascular disease, diabetes, renal disease, nonelective operation, and previous cardiac surgery. Hospital mortality was 11.4% (24/211) for on-pump CABG and 3.8% (8/211) for OPCAB (P=0.003). Multivariate analysis revealed that increased mortality was associated with on-pump CABG (P=0.001), acute MI (P=0.03), number of grafts (P=0.01), age (P=0.01), history of stroke or cerebrovascular disease (P=0.04), CHF (P=0.02), and peripheral vascular disease (P=0.03). Multivariate analysis showed that OPCAB technique was associated with decreased stroke (P=0.05). Freedom from any complication was 78.7% for on-pump CABG and 91.9% for OPCAB (P<0.001). At 36 month follow-up multivariate analysis revealed that increased mortality was associated with age (P=0.001), previous MI (P=0.03), and renal disease (P=0.04), whereas increased survival was associated with increased number of grafts (P=0.001) and OPCAB (P=0.01). CONCLUSIONS: OPCAB surgery in patients with severe AAD is associated with lower risk of death, stroke and complications and improved mid-term survival. Routine intra-operative TEE allows identification of these patients and directs choice of appropriate surgical technique
— id: 39076, year: 2003, vol: 108 Suppl 1, page: II15, stat: Journal Article,

Aortic valve replacement in patients with impaired ventricular function
Sharony, Ram; Grossi, Eugene A; Saunders, Paul C; Schwartz, Charles F; Ciuffo, Giovanni B; Baumann, F Gregory; Delianides, Julie; Applebaum, Robert M; Ribakove, Greg H; Culliford, Alfred T; Galloway, Aubrey C; Colvin, Stephen B
2003 Jun;75(6):1808-1814, Annals of thoracic surgery
BACKGROUND: Patients with reduced ventricular function undergoing aortic valve replacement have increased operative risks, but the impact of valvular pathophysiology and other risk factors has not been clearly defined. METHODS: From June 1992 through June 2002, 1,402 consecutive patients underwent isolated aortic valve surgery with or without coronary artery bypass grafting; of these patients, 416 had an ejection fraction less than 40% and are the subject of this report. These patients (mean age, 68.6) had severe stenosis (62.5%), severe regurgitation (30.3%), or mixed disease (7.2%). Aortic valve replacement plus coronary artery bypass grafting was performed in 48.4% of patients, and 27% had previous cardiac surgery. Follow-up included echocardiography and survival analysis. RESULTS: Hospital mortality was 10.1% (42 of 416), with no difference between aortic stenosis (9.6%) and regurgitation (11.1%). Multivariate analysis revealed that age (p = 0.002) and renal disease (odds ratio = 4.2; 95% confidence interval, 1.9 to 9.3; p = 0.001) were independently associated predictors of mortality. Valvular pathophysiology had no impact on mortality. Peripheral vascular disease, multivessel coronary disease, and renal disease were associated risks for any postoperative complication. Peripheral vascular disease (odds ratio = 12.3, p = 0.02), history of cerebrovascular disease (odds ratio = 4.8, p = 0.038), and diabetes (odds ratio = 2.7, p = 0.04) were associated risks for stroke. The ejection fraction was more than 40% in 52% of the patients who had postoperative echocardiography (mean follow-up, 6 months). Actuarial survival revealed no difference between pathophysiologic groups. CONCLUSIONS: Aortic valve surgery in patients with impaired ventricular function carries an acceptable operative risk that can be stratified by age and comorbidities. The type of valvular pathophysiology does not significantly affect mortality
— id: 36725, year: 2003, vol: 75, page: 1808, stat: Journal Article,

Off pump CABG reduces mortality and neurologic complications in patients with atheromatous aortas: A case control study
Bizekis, CS; Grossi, EA; Sharony, R; Galloway, AC; Applebaum, R; Esposito, RA; Ribakove, GH; Culliford, AT; Kanchuger, M; Kronzon, I; Colvin, SB
2002 NOV 5 ;106(19):638-638, Circulation
— id: 37208, year: 2002, vol: 106, page: 638, stat: Journal Article,

The risk of the development of aortic stenosis in patients with "benign" aortic valve thickening
Cosmi, John E; Kort, Smadar; Tunick, Paul A; Rosenzweig, Barry P; Freedberg, Robin S; Katz, Edward S; Applebaum, Robert M; Kronzon, Itzhak
2002 Nov 11;162(20):2345-2347, Archives of internal medicine
BACKGROUND: Aortic valve thickening (AVT) without aortic stenosis (AS) is common and was often considered benign. However, it has recently been found to be associated with increased morbidity and mortality. It is unknown whether patients with AVT are at risk for the development of AS. METHODS: Our echocardiography database from 1987 to 1993 was searched for cases of AVT with at least 1 year of echocardiographic follow-up. The risk of the development of AS was compared in patients with and without AVT. RESULTS: There were 2131 patients with AVT and at least 1 year of echocardiographic follow-up. Aortic stenosis developed in 338 patients (15.9%) (mild, 10.5%; moderate, 2.9%; and severe, 2.5%). Multivariate analysis, including age, left ventricular hypertrophy, and mitral annular calcification, revealed that only mitral annular calcification was independently and significantly associated with progression to AS. CONCLUSIONS: Aortic valve thickening without stenosis is common, and it may progress to significant AS. It is possible that this development of AS may be responsible for some of the increased morbidity and mortality in patients with AVT
— id: 39568, year: 2002, vol: 162, page: 2345, stat: Journal Article,

Pulmonary vein isolation during minimally invasive mitral valve surgery: One-year follow-up
Mirchandani, S; Holmes, DS; Chinitz, LA; Bernstein, NE; Applebaum, RM; Colvin, SB; Galloway, AC; Grossi, EA
2002 Mar 6;39(5):120A-120A, Journal of the American College of Cardiology
— id: 27516, year: 2002, vol: 39, page: 120A, stat: Journal Article,

Benign metastasizing leiomyomatosis diagnosed by echocardiography
Nayar, Ambika C; McAleer, Eileen P; Tunick, Paul A; Applebaum, Robert M; Colvin, Stephen B; Kronzon, Itzhak
2002 Oct;19(7 Pt 1):571-572, Echocardiography
— id: 36727, year: 2002, vol: 19, page: 571, stat: Journal Article,

Effect of treatment on the incidence of stroke and other emboli in 519 patients with severe thoracic aortic plaque
Tunick, Paul A; Nayar, Ambika C; Goodkin, Gregory M; Mirchandani, Sunil; Francescone, Steven; Rosenzweig, Barry P; Freedberg, Robin S; Katz, Edward S; Applebaum, Robert M; Kronzon, Itzhak
2002 Dec 15;90(12):1320-1325, American journal of cardiology
Severe aortic plaques seen on transesophageal echocardiography (TEE) are a high-risk cause of stroke and peripheral embolization. Evidence to guide therapy is lacking. Retrospective information was obtained regarding the occurrence of embolic events (stroke, transient ischemic attacks, or peripheral emboli) in 519 patients with severe thoracic aortic plaque seen on TEE since 1988. Treatment with statins, warfarin, or antiplatelet medications was noted. Treatment was not randomized. In a matched-paired analysis, each patient taking each class of therapy was matched for age, gender, previous embolic event, hypertension, diabetes, congestive failure, and atrial fibrillation to someone not taking that medication. Multivariate analysis was also performed. An embolic event occurred in 111 patients (21%). Multivariate analysis showed that statin use was independently protective against recurrent events (p = 0.0001). Matched analysis also showed a protective effect of statins (p = 0.0004; absolute risk reduction 17%, relative risk reduction 59%, number needed to treat [n = 6]). No protective effect was found for warfarin or antiplatelet drugs. The odds ratio for embolic events was 0.3 (95% confidence interval [CI] 0.2 to 0.6) for statin therapy, 0.7 (95% CI 0.4 to 1.2) for warfarin, and 1.4 (95% CI 0.8 to 2.4) for antiplatelet agents. Thus, there is a protective effect of statin therapy, and no significant benefit of warfarin or antiplatelet drugs on the incidence of stroke and other embolic events in patients with severe thoracic aortic plaque on TEE
— id: 36577, year: 2002, vol: 90, page: 1320, stat: Journal Article,

Minimally invasive versus sternotomy approaches for mitral reconstruction: comparison of intermediate-term results
Grossi EA; LaPietra A; Ribakove GH; Delianides J; Esposito R; Culliford AT; Derivaux CC; Applebaum RM; Kronzon I; Steinberg BM; Baumann FG; Galloway AC; Colvin SB
2001 Apr;121(4):708-713, Journal of thoracic & cardiovascular surgery
BACKGROUND: This study compares intermediate-term outcomes of mitral valve reconstruction after either the standard sternotomy approach or the new minimally invasive approach. Although minimally invasive mitral valve operations appear to offer certain advantages, such as reduced postoperative discomfort and decreased postoperative recovery time, the intermediate-term functional and echocardiographic efficacy has not yet been documented. METHODS: From May 1996 to February 1999, 100 consecutive patients underwent primary mitral reconstruction through a minimally invasive right anterior thoracotomy and peripheral cardiopulmonary bypass and Port-Access technology (Heartport, Inc, Redwood City, Calif). Outcomes were compared with those for our previous 100 patients undergoing primary mitral repair who were operated on with the standard sternotomy approach. RESULTS: Although patients were similar in age, the patients undergoing the minimally invasive approach had a lower preoperative New York Heart Association classification (2.1 +/- 0.5 vs 2.6 +/- 0.6, P <.001). There was one (1.0%) hospital mortality with the sternotomy approach and no such case with the minimally invasive approach. Follow-up revealed that residual mitral insufficiency was similar between the minimally invasive and sternotomy approaches (0.79 +/- 0.06 vs 0.77 +/- 0.06, P =.89, 0- to 3-point scale); likewise, the cumulative freedom from reoperation was not significantly different (94.4% vs 96.8%, P =.38). Follow-up New York Heart Association functional class was significantly better in the patients undergoing the minimally invasive approach (1.5 +/- 0.05 vs 1.2 +/- 0.05, P <.01). CONCLUSIONS: These findings demonstrate comparable 1-year follow-up results after minimally invasive mitral valve reconstruction. Both echocardiographic results and New York Heart Association functional improvements were compatible with results achieved with the standard sternotomy approach. The minimally invasive approach for mitral valve reconstruction provides equally durable results with marked advantages for the patient and should be more widely adopted
— id: 21220, year: 2001, vol: 121, page: 708, stat: Journal Article,

Aortic valve surgery in patients with impaired ventricular function
Grossi, EA; Esposito, RA; Lapietra, A; Baumann, FG; Bizekis, CS; Delianides, J; Applebaum, RM; Ribakove, GH; Culliford, AT; Galloway, AC; Colvin, SB
2001 OCT 23 abstract #2613;104(17):553-553, Circulation
— id: 33420, year: 2001, vol: 104, page: 553, stat: Journal Article,

Decreased stroke with routine intraoperative transesophogeal echocardiography in coronary artery bypass grafting
Grossi, EA; Galloway, AC; Lapietra, A; Applebaum, RM; Esposito, RA; Bizekis, CS; Ribakove, GH; Culliford, AT; Kanchugar, M; Kronzon, I; Colvin, SB
2001 OCT 23 abstract #2091;104(17):441-441, Circulation
— id: 33419, year: 2001, vol: 104, page: 441, stat: Journal Article,

Minimally invasive aortic valve replacement: echocardiographic and clinical results
Kort S; Applebaum RM; Grossi EA; Baumann FG; Colvin SB; Galloway AC; Ribakove GH; Steinberg BM; Piedad B; Tunick PA; Kronzon I
2001 Sep;142(3):476-481, American heart journal
BACKGROUND: Port access has been described for mitral and bypass surgery. The purpose of this study was to review the clinical and echocardiographic outcomes of aortic valve replacement by use of port access. METHODS: Between 1996 and 1999, 153 port-access aortic valve replacements were performed at our institution. The mean age was 63 years (range 16-91 years); 58% were male. The New York Heart Association mean class was III; 18% were in class IV. Thirteen percent had diabetes, 42% hypertension, 7% prior transient ischemic episode or stroke, 7% lung disease, 3% renal failure, and 13% previous surgery. Echocardiograms were obtained after valve replacement in 125 patients (96 intraoperative transesophageal and 97 transthoracic echoes). RESULTS: Median length of stay was 8 days. There were no intraoperative deaths; 10 patients (6.5%) died in the postoperative period. Stroke occurred in 4 (2.6%), sepsis in 5 (3.3%), renal failure in 5 (3.3%), pneumonia in 3 (2%), and wound infection in 1 (0.7%). Tissue prosthesis was present in 83 and a mechanical prosthesis in 42. No or trace regurgitation was seen on 94 of 96 (98%) postbypass intraoperative echocardiograms and mild on 2. On follow-up echocardiograms, moderate regurgitation was seen in 4 of 97 (4.1%), mild-to-moderate in 2 (2.1%), mild in 18 (18.6%), and no or trace in 71 (73.2%). Of those who had aortic regurgitation on intraoperative or follow-up echocardiograms, it was paravalvular in 8. CONCLUSIONS: Minimally invasive aortic valve replacement with a port-access approach is feasible, even in high-risk patients. Small incisions, a low infection rate, and a short length of stay are attainable. However, the complications associated with traditional aortic valve replacement still occur. Echocardiography is valuable both for intraoperative monitoring and follow-up of this new procedure
— id: 26678, year: 2001, vol: 142, page: 476, stat: Journal Article,

Acquired aorta-pulmonary artery fistula: diagnosis by multiple imaging modalities
Kort S; Tunick PA; Applebaum RM; Hayes R; Krinsky GA; Sadler W; Culliford A; Grossi E; Ostrowski J; Kronzon I
2001 Aug;14(8):842-845, Journal of the American Society of Echocardiography
Acquired communication between the aorta and the pulmonary artery is a rare phenomenon. We describe two patients with a thoracic aortic aneurysm in whom the diagnosis of a communication with the pulmonary artery was first made on transthoracic echocardiography and then more completely elucidated by means of multiple imaging modalities: transesophageal echocardiography, epiaortic ultrasound, computed tomography, and magnetic resonance imaging. Representative images from these complementary studies are presented. A successful repair of the fistula was subsequently accomplished in both patients
— id: 26710, year: 2001, vol: 14, page: 842, stat: Journal Article,

Port-Access aortic valve replacement: Echocardiographic and clinical results
Kort, S; Applebaum, RM; Grossi, EA; Colvin, SB; Galloway, AC; Ribakove, GH; Baumann, FG; Piedad, B; Tunick, PA; Kronzon, I
2001 FEB ;37(2):422A-422A, Journal of the American College of Cardiology
— id: 33422, year: 2001, vol: 37, page: 422A, stat: Journal Article,

Abdominal aortic aneurysms and thoracic aortic atheromas
Reynolds HR; Tunick PA; Kort S; Rosenzweig BP; Freedberg RS; Katz ES; Applebaum RM; Portnay EL; Adelman MA; Attubato MJ; Kronzon I
2001 Nov;14(11):1127-1131, Journal of the American Society of Echocardiography
BACKGROUND: Abdominal aortic aneurysm (AAA) is associated with atherosclerosis elsewhere. Thoracic aortic atheromas (ATHs) seen on transesophageal echocardiography (TEE) are an important cause of stroke and peripheral embolization. The purposes of this study were to determine whether an association exists between AAA and ATHs and to assess the importance of screening patients with ATHs for AAA. METHODS: For the retrospective analysis, 109 patients with AAA and 109 matched controls were compared for the prevalence of ATHs on TEE and for historical variables. For the prospective analysis, screening for AAA on ultrasonography was performed in 364 patients at the time of TEE. RESULTS: Results of the retrospective analysis showed that ATHs were present in 52% of patients with AAA and in 25% of controls (odds ratio [OR] = 3.3; P =.00003). There was a significantly higher prevalence of hypertension, myocardial infarction, heart failure, smoking, and carotid or peripheral arterial disease in patients with AAA. However, only ATHs were independently associated with AAA on multivariate analysis (P =.001). Results of the prospective analysis showed that screening at the time of TEE in 364 patients revealed AAA in 13.9% of those with ATHs and in 1.4% of those without ATHs (P <.0001; OR = 11.4). CONCLUSIONS: (1) There is a strong, highly significant association between abdominal aneurysm and thoracic atheromas. (2) Patients with AAA may be at high risk for stroke because of the concomitance of thoracic aortic atheromas. (3) The high prevalence of abdominal aneurysm in patients with thoracic atheromas suggests that screening for abdominal aneurysm should be carried out in all patients with thoracic atheromas identified by TEE
— id: 26574, year: 2001, vol: 14, page: 1127, stat: Journal Article,

Pulmonary venous flow in large, uncomplicated atrial septal defect
Saric M; Applebaum RM; Phoon CK; Katz ES; Goldstein SA; Tunick PA; Kronzon I
2001 May;14(5):386-390, Journal of the American Society of Echocardiography
BACKGROUND: The pulmonary venous flow velocity pattern (PVFVP) in atrial septal defect (ASD) has not been previously studied in detail. Normally, PVFVP is primarily determined by the left heart performance. We hypothesized that the impact of left-sided heart dynamics on PVFVP is diminished in patients with ASD because of the presence of a left-to-right shunt into the low-resistance right side of the heart. METHODS AND RESULTS: Transesophageal echocardiography was performed in 19 adults and 3 children with a large, uncomplicated secundum ASD (maximum diameter 0.6 to 3.0 cm). All patients were in normal sinus rhythm with an average heart rate of 78 bpm in adults and 116 bpm in children. In 21 subjects the antegrade PVFVP lacked distinct systolic (S) and diastolic (D) waves. Instead, we observed a single continuous antegrade wave extending from the beginning of systole to the onset of atrial contraction. Furthermore, the amplitude of the atrial reversal (AR) wave was smaller than in historical controls. In 3 patients in whom ASD was surgically repaired, we observed an immediate return of distinct S and D waves postoperatively. This confirmed that PVFVP abnormality was indeed the result of the ASD. Also a large increase in the AR wave amplitude (46 + 15 cm/s) was noted postoperatively. CONCLUSIONS: This previously unrecognized PVFVP comprising a single continuous antegrade wave and a diminished AR wave sheds new light on the hemodynamics of ASDs. Its presence may also alert the echocardiographer to the possibility of an ASD when the septal defect cannot be visualized directly
— id: 20687, year: 2001, vol: 14, page: 386, stat: Journal Article,

Case report of robotic instrument-enhanced mitral valve surgery
Grossi EA; Lapietra A; Applebaum RM; Ribakove GH; Galloway AC; Baumann FG; Ursomanno P; Steinberg BM; Colvin SB
2000 Dec;120(6):1169-1171, Journal of thoracic & cardiovascular surgery
— id: 33339, year: 2000, vol: 120, page: 1169, stat: Journal Article,

Rapid pulmonary vein isolation for atrial fibrillation during minimally invasive mitral valve surgery
Holmes, DS; Chinitz, LA; Pierce, WJ; Bernstein, NE; Applebaum, RM; Colvin, SB; Galloway, AC; Grossi, EA
2000 OCT 31 abstract #2351;102(18):484-484, Circulation
— id: 33424, year: 2000, vol: 102, page: 484, stat: Journal Article,

Surgical left atrial appendage ligation is frequently incomplete: A transesophageal echocardiographic study
Katz ES; Tsiamtsiouris T; Applebaum RM; Schwartzbard A; Kronzon I
2000 Aug;36(2):468-471, Journal of the American College of Cardiology
OBJECTIVES: This study sought to determine the incidence of incomplete ligation of the left atrial appendage (LAA) during mitral valve surgery. BACKGROUND: Ligation of the LAA to prevent future thromboembolic events is commonly performed during mitral surgery. However, success in completely exduding the appendage from the circulation has never been systematically assessed. METHODS: Using transesophageal Doppler echocardiography, we studied 50 patients who underwent mitral valve surgery and ligation of the LAA. Thirty patients were studied immediately postoperative, and 20 patients were studied 6 days to 13 years after surgery. Incomplete ligation was detected by demonstrating a color jet traversing the separation between the left atrial body and appendage. RESULTS: Transesophageal echocardiography detected incomplete LAA ligation in 18 of 50 (36%) patients. The incidence of incomplete ligation was not significantly different between patients studied immediately postoperative and patients studied at various times after surgery. Type of mitral surgery (repair vs. replacement), operative approach (sternotomy vs. port access), left atrial size or degree of mitral regurgias unrelated to type of surgery, surgical approach, left atrial size or degree of mitral regurgitation. Residual communication between the incompletely ligated appendage and the left atrial body may produce a milieu of stagnant blood flow within the appendage and be a potential mechanism for embolic events
— id: 8152, year: 2000, vol: 36, page: 468, stat: Journal Article,

Robotic-assisted instruments enhance minimally invasive mitral valve surgery
LaPietra A; Grossi EA; Derivaux CC; Applebaum RM; Hanjis CD; Ribakove GH; Galloway AC; Buttenheim PM; Steinberg BM; Culliford AT; Colvin SB
2000 Sep;70(3):835-838, Annals of thoracic surgery
BACKGROUND: The potential for totally endoscopic mitral valve surgery has been advanced by the development of minimally invasive techniques. Recently surgical robots have offered instrument access through small ports, obviating the need for a significant thoracotomy. This study tested the hypothesis that a microsurgical robot with 5 degrees of freedom is capable of performing an endoscopic mitral valve replacement (MVR). METHODS: Dogs (n = 6) were placed on peripheral cardiopulmonary bypass; aortic occlusion was achieved with endoaortic clamping and transesophageal echocardiographic control. A small left seventh interspace 'service entrance' incision was used to insert sutures, retractor blade, and valve prosthesis. Robotically controlled instruments included a thoracoscope and 5-mm needle holders. MVR was performed using an interrupted suture technique. RESULTS: Excellent visualization was achieved with the thoracoscope. Instrument setup required 25.8 minutes (range 12 to 37); valve replacement required 69.3+/-5.39 minutes (range 48 to 78). MVR was accomplished with normal prosthetic valve function and without misplaced sutures or inadvertent injuries. CONCLUSIONS: This study demonstrates the feasibility of adjunctive use of robotic instrumentation for minimally invasive MVR. Clinical trials are indicated
— id: 28921, year: 2000, vol: 70, page: 835, stat: Journal Article,

Aortic valve replacement in patients with aortic stenosis and severe left ventricular dysfunction
Powell DE; Tunick PA; Rosenzweig BP; Freedberg RS; Katz ES; Applebaum RM; Perez JL; Kronzon I
2000 May 8;160(9):1337-1341, Archives of internal medicine
BACKGROUND: The outcome of aortic valve replacement for severe aortic stenosis is worse in patients with impaired left ventricular function. Such dysfunction in aortic stenosis may be reversible if caused by afterload mismatch, but not if it is caused by superimposed myocardial infarction. METHODS: From our echocardiography database, 55 patients with severe aortic stenosis (valve area < or =0.75 cm2) and ejection fractions of 30% or lower who subsequently underwent aortic valve replacement were included. The operative mortality and clinical follow-up were detailed. RESULTS: There were 10 perioperative deaths (operative mortality, 18%). Twenty (36%) of the 55 patients had a prior myocardial infarction. In the 35 patients without prior myocardial infarction, there was only 1 death (3%). In contrast, 9 of 20 patients with prior myocardial infarction died (mortality rate, 45%; P< or =.001). The factors significantly associated with perioperative death on univariate analysis (functional class, mean aortic gradient, and prior myocardial infarction) were entered into a model for stepwise logistic regression. This multivariate analysis showed that only prior myocardial infarction was independently associated with perioperative death (odds ratio, 14.9; 95% confidence interval, 2.4-92.1; P = .004). CONCLUSIONS: The risk of aortic valve replacement in patients with severe aortic stenosis and severely reduced left ventricular systolic function is extremely high if the patients have had a prior myocardial infarction. This information should be factored into the risk-benefit analysis that is done preoperatively for these patients, and it may preclude operation for some
— id: 11701, year: 2000, vol: 160, page: 1337, stat: Journal Article,

The Role of Transesophageal Echocardiography During Port-Access Minimally Invasive Cardiac Surgery: A New Challenge for the Echocardiographer
Applebaum RM; Colvin SB; Galloway AC; Ribakove GH; Grossi EA; Tunick PA; Kronzon I I
1999 Aug;16(6):595-602, Echocardiography
The recent development of endovascular catheters that are placed via the femoral artery and vein has enabled patients to be placed on cardiopulmonary bypass without the need for direct visualization of the heart or great vessels via sternotomy. This has allowed cardiac surgery to be performed through smaller, thoracotomy incisions. Placement of these catheters initially was performed under fluoroscopic guidance, which has major imaging limitations. Now, transesophageal echocardiography (TEE) has replaced fluoroscopy as the primary imaging technique to assist in the placement of endovascular catheters during minimally invasive, port-access cardiac surgery. In our institution, 449 port-access procedures have been performed from May 1996 through July 1998. We found that TEE is able to adequately visualize the cardiac structures and assist in the placement of the endovascular catheters in all patients. Fluoroscopy is helpful only as an aid to the use of TEE for placement of the coronary sinus catheter
— id: 33337, year: 1999, vol: 16, page: 595, stat: Journal Article,

Massive Atrial Septal Lipomatous Hypertrophy
Saric M; Applebaum RM; Culliford AT; Huang J; Scholes JV; Kronzon I I
1999 Nov;16(8):833-834, Echocardiography
— id: 28919, year: 1999, vol: 16, page: 833, stat: Journal Article,

Pulmonary venous flow in large uncomplicated atrial septal defects
Saric, M; Applebaum, RM; Phoon, CK; Goldstein, SA; Tunick, PA; Kronzon, I
1999 NOV 2 ;100(18):213-213, Circulation
— id: 53789, year: 1999, vol: 100, page: 213, stat: Journal Article,

Utility of transesophageal echocardiography during port-access minimally invasive cardiac surgery
Applebaum RM; Cutler WM; Bhardwaj N; Colvin SB; Galloway AC; Ribakove GH; Grossi EA; Schwartz DS; Anderson RV; Tunick PA; Kronzon I
1998 Jul 15;82(2):183-188, American journal of cardiology
In this study, we sought to determine the use of transesophageal echocardiography (TEE) as the primary imaging technique to assist in the placement of endovascular catheters during minimally invasive, port-access cardiac surgery. The recent development of endovascular catheters that are placed via the femoral artery and vein has enabled patients to be placed on cardiopulmonary bypass without the need for direct visualization of the heart or great vessels via sternotomy. This has allowed cardiac surgery to be performed through smaller thoracotomy incisions. Placement of these catheters has previously been performed with fluoroscopic guidance, which has major imaging limitations. Thirty-six patients underwent port-access cardiac surgery at our institution during the study period. All patients underwent intraoperative TEE. We used TEE to visualize the coronary sinus os, right atrium and superior vena cava, and thoracic aorta to assist with placement of the coronary sinus catheter, venous cannula, and endoaortic clamp. Twenty patients underwent mitral valve surgery, 14 patients coronary artery bypass grafting, 1 patient aortic valve replacement, and 1 patient repair of an atrial septal defect by the port-access approach. TEE was able to adequately visualize the cardiac structures and assist in the placement of the endovascular catheters in all patients. Fluoroscopy was only helpful as an aid to TEE for placement of the coronary sinus catheter. TEE is an excellent imaging modality for the proper placement of these new endovascular catheters, obviating the need for fluoroscopy, except to be on standby and for placement of the coronary sinus catheter
— id: 12089, year: 1998, vol: 82, page: 183, stat: Journal Article,

Utility of three-dimensional echocardiography during balloon mitral valvuloplasty
Applebaum RM; Kasliwal RR; Kanojia A; Seth A; Bhandari S; Trehan N; Winer HE; Tunick PA; Kronzon I
1998 Nov;32(5):1405-1409, Journal of the American College of Cardiology
OBJECTIVES: We investigated the role of three-dimensional echocardiography in assessing mitral valve anatomy in greater detail in patients immediately before and after balloon mitral valvuloplasty (BMV). BACKGROUND: Three-dimensional echocardiography is a recently developed, evolving imaging technique that allows visualization of intracardiac structures from any perspective. METHODS: We studied 19 patients undergoing BMV using transesophageal echocardiography (TEE) (Chicago, Illinois) to image the mitral valve. The TEE was interfaced to a TomTec three-dimensional workstation that allows electrocardiographic and respiratory cycle gated image acquisition. The acquired images are digitized, and after postprocessing a three-dimensional image is reconstructed. The mitral valve was viewed 'en-face' as if looking up from the left ventricle. RESULTS: The mean mitral valve area (by pressure half-time from the Doppler of the two-dimensional echocardiogram) increased after BMV from 0.86+/-0.06 cm2 to 2.07+/-0.10 cm2, p < 0.0001. This was similar to the mitral valve areas obtained by planimetry from the three-dimensional images. The three-dimensional reconstructions showed a complete commissural split in 10 patients and partial splitting in 9 patients. In three of the eight patients who had an increase in the amount of mitral regurgitation secondary to BMV, the three-dimensional reconstructions were able to detect tears within the valve leaflet. One leaflet tear actually extended up to the mitral valve annulus and was associated with the only case of severe mitral regurgitation. CONCLUSIONS: The three-dimensional echocardiographic reconstruction enabled visualization of the mitral valve so that commissural splitting and leaflet tears not seen on the two-dimensional echocardiogram became visible
— id: 7487, year: 1998, vol: 32, page: 1405, stat: Journal Article,

Effects of intraaortic balloon counterpulsation on carotid artery blood flow
Applebaum RM; Wun HH; Katz ES; Tunick PA; Kronzon I
1998 May;135(5 Pt 1):850-854, American heart journal
BACKGROUND: The intraaortic balloon pump has been shown to improve cardiac output and diastolic coronary flow. Animal studies with balloon counterpulsation have shown variable effects on carotid and cerebral blood flow. We investigated the effects of counterpulsation with the intraaortic balloon pump on blood flow in the common carotid artery in human beings. METHODS AND RESULTS: We studied 14 patients who had an intraaortic balloon pump placed for clinical indications; 9 were hypotensive (4 in the setting of an acute myocardial infarction and 5 immediately after cardiac surgery). Five patients required counterpulsation after undergoing complicated coronary angioplasty. Common carotid artery blood flow was assessed with carotid Duplex scanning both with and without 1:1 balloon augmentation. We found no net increase in the total blood flow in the common carotid artery with intraaortic balloon counterpulsation. This result occurred despite a significant mean increase in both the peak flow velocity and flow velocity integral of the augmented diastolic flows by 160% and 78%, respectively. Total flow did not change because an early systolic reversal of blood flow was seen only with balloon augmentation, which negated the augmented diastolic flow. CONCLUSION: Despite a significant augmentation in diastolic blood flow with balloon counterpulsation, no increase occurred in total carotid artery blood flow. This appeared to be caused by improper timing of balloon deflation. This could result in no improvement in cerebral blood flow with intraaortic balloon pump counterpulsation in critically ill patients
— id: 7485, year: 1998, vol: 135, page: 850, stat: Journal Article,

Transesophageal echocardiography as the guiding imaging technique during port access minimally invasive cardiac surgery
Applebaum, RM; Cutler, WM; Bhardwaj, N; Colvin, SB; Galloway, AC; Ribakove, GH; Grossi, EA; Schwartz, DS; Anderson, RV; Tunick, PA; Kronzon, I
1998 FEB ;31(2):87A-87A, Journal of the American College of Cardiology
— id: 33432, year: 1998, vol: 31, page: 87A, stat: Journal Article,

Initial echocardiogram after mitral valve reconstruction predicts durability of repair
Grossi, EA; Applebaum, RM; Galloway, AC; Spencer, FC; Kronzon, I; Colvin, SB
1998 FEB ;31(2):399A-399A, Journal of the American College of Cardiology
— id: 33434, year: 1998, vol: 31, page: 399A, stat: Journal Article,

Surgical left atrial appendage ligation is frequently incomplete: A transesophageal echocardiographic study
Katz, ES; Tsiamtsiouris, T; Applebaum, RM; Schwartzbard, A; Kronzon, I
1998 OCT 27 ;98(17):501-501, Circulation
— id: 53667, year: 1998, vol: 98, page: 501, stat: Journal Article,

Minimally invasive port-access coronary artery bypass grafting with early angiographic follow-up: initial clinical experience
Ribakove GH; Miller JS; Anderson RV; Grossi EA; Applebaum RM; Cutler WM; Buttenheim PM; Baumann FG; Galloway AC; Colvin SB
1998 May;115(5):1101-1110, Journal of thoracic & cardiovascular surgery
OBJECTIVE: New techniques for minimally invasive coronary artery bypass grafting have recently emerged. The purpose of this study was to determine the safety and efficacy of Port-Access (Heartport, Inc., Redwood City, Calif.) coronary revascularization and to evaluate with angiography the early graft patency rate with this new approach. METHODS: From October 1996 to May 1997, 31 patients underwent Port-Access coronary artery bypass grafting with an anterior minithoracotomy and endovascular-occlusion cardiopulmonary bypass. There were 26 men and 5 women with a mean age of 62 years (range 42 to 82 years). Fifteen patients underwent single bypass; 12 patients underwent double bypass, and 4 patients underwent triple bypass. Bypass conduits included the left internal thoracic artery (n = 30), right internal thoracic artery (n = 2), radial artery (n = 10), and saphenous vein (n = 6). Three sequential grafts were used. Angiographic studies of the bypass grafts were performed in 27 of 31 patients (87%). RESULTS: There were no deaths, neurologic deficits, myocardial infarctions, or aortic dissections. Conversion to sternotomy was not required in any case. There were two reoperations for bleeding, one reoperation for tamponade, and one reoperation for pulmonary embolus. Postoperative angiography revealed anastomotic patency of the left internal thoracic artery to left anterior descending artery in 26 of 26 grafts (100%) with overall anastomotic patency in 43 of 44 grafts (97.7%). CONCLUSION: These results demonstrate that Port-Access coronary artery bypass can be performed accurately and safely with acceptable morbidity. This approach allows for multivessel revascularization on an arrested, protected heart with excellent anastomotic precision and reproducible early graft patency
— id: 7756, year: 1998, vol: 115, page: 1101, stat: Journal Article,

Transesophageal echocardiographic identification of a retrograde dissection of the ascending aorta caused by inadvertent cannulation of the common carotid artery
Applebaum RM; Adelman MA; Kanschuger MS; Jacobowitz G; Kronzon I
1997 Sep;10(7):749-751, Journal of the American Society of Echocardiography
Retrograde aortic dissections can be a complication of vascular procedures. We describe a case of an inadvertent cannulation of the right common carotid artery during an attempt at inserting a pulmonary artery catheter. This resulted in dissection of the right common carotid, subclavian, and innominate arteries. Transesophageal echocardiography was able to visualize a retrograde dissection extending back into the ascending aorta
— id: 12268, year: 1997, vol: 10, page: 749, stat: Journal Article,

Sequential external counterpulsation increases cerebral and renal blood flow
Applebaum RM; Kasliwal R; Tunick PA; Konecky N; Katz ES; Trehan N; Kronzon I
1997 Jun;133(6):611-615, American heart journal
The purpose of this study was to evaluate the effect of sequential external counterpulsation (SECP) on cerebral and renal blood flow. The effect of SECP on carotid and renal artery blood flow was studied in 35 and 18 patients, respectively. With a portable unit, cuffs were applied to the calves and thighs, sequentially inflated with air at the onset of diastole, and deflated at the onset of systole. Carotid and renal artery Duplex studies were performed during intermittent SECP. Flow velocity and flow velocity integral were measured at baseline and during SECP. Diastolic augmentation of carotid and renal artery flow velocity was observed in all patients. The mean carotid flow velocity integral increased by 22% from 27.7 +/- 1.8 cm to 33.1 +/- 2.3 cm (P = 0.001). The mean renal artery flow velocity integral increased by 19% from 21 +/- 1 cm to 25 +/- 1 cm (P = 0.0001). With SECP, a new diastolic Doppler flow velocity wave was observed, with an average peak carotid diastolic flow velocity of 56 +/- 4 cm/sec and an average peak renal artery diastolic flow velocity of 40 +/- 2.5 cm/sec. This diastolic wave was 75% (carotid) and 68% (renal) as high as the systolic wave during SECP. In addition, with SECP the systolic wave increased by 6% and 8% in the carotid and renal artery, respectively (P = 0.02 and 0.006, respectively). In conclusion, SECP significantly increases carotid and renal blood flow. This noninvasive, harmless treatment may be useful to support patients with decreased cerebral and renal perfusion
— id: 7103, year: 1997, vol: 133, page: 611, stat: Journal Article,

Three dimensional ultrasonic imaging of femoral arterial pseudoaneurysms
Applebaum, RM; Kronzon, I; Attubato, MJ; Feit, F
1997 FEB ;29(2):9450-9450, Journal of the American College of Cardiology
— id: 53294, year: 1997, vol: 29, page: 9450, stat: Journal Article,

Intra-aortic balloon pumping does not improve carotid artery blood flow
Applebaum, RM; Wun, HH; Katz, ES; Tunick, PA; Kronzon, I
1997 FEB ;29(2):8043-8043, Journal of the American College of Cardiology
— id: 53291, year: 1997, vol: 29, page: 8043, stat: Journal Article,

Increase in renal blood flow with external counterpulsation
Kasliwal, R; Trehan, N; Tunick, PA; Konecky, N; Applebaum, RM; Katz, ES; Kronzon, I
1997 FEB ;29(2):14157-14157, Journal of the American College of Cardiology
— id: 53290, year: 1997, vol: 29, page: 14157, stat: Journal Article,

Tortuosity of the descending thoracic aorta simulating dissection on transesophageal echocardiography
Katz ES; Applebaum RM; Earls JP; Krinsky G; Weinreb J; Kronzon I
1997 Jan-Feb;10(1):83-87, Journal of the American Society of Echocardiography
In an 80-year-old patient with syncope, a markedly tortuous descending thoracic aorta produced images on transesophageal echocardiography which were suggestive of an intimal flap caused by dissection. A magnetic resonance aortogram clearly showed that the trans-esophageal echocardiogram was a false positive. In addition, multiplanar reconstructed images of the magnetic resonance aortogram through the tortuous descending thoracic aorta could reproduce images similar to that seen by transesophageal echocardiography. Because transesophageal echocardiography has become a popular imaging modality for the detection of aortic dissection, it is essential for echocardiographers to be aware of possible pitfalls which may create false positive findings
— id: 12417, year: 1997, vol: 10, page: 83, stat: Journal Article,

Minimally invasive mitral valve replacement: port-access technique, feasibility, and myocardial functional preservation
Schwartz DS; Ribakove GH; Grossi EA; Buttenheim PM; Schwartz JD; Applebaum RM; Kronzon I; Baumann FG; Colvin SB; Galloway AC
1997 Jun;113(6):1022-1030, Journal of thoracic & cardiovascular surgery
OBJECTIVE: This experiment examined the feasibility of minimally invasive port-access mitral valve replacement via a 2.5 cm incision. METHODS: The study evaluated valvular performance and myocardial functional recovery in six mongrel dogs after port-access mitral valve replacement with a St. Jude Medical prosthesis (St. Jude Medical, Inc., St. Paul, Minn.). Femoro-femoral cardiopulmonary bypass and a balloon catheter system for myocardial protection with cardioplegic arrest (Heartport, Inc., Redwood City, Calif.) were used. The mitral valve was replaced through a 2.5 cm port in the left side of the chest, and the animals were weaned from bypass. Cardiac function was measured before and at 30 and 60 minutes after bypass. Left ventricular pressure and electrical conductance volume were used to calculate changes in load-independent indexes of ventricular function. RESULTS: Each procedure was successfully completed. Recovery of left ventricular function was excellent at 30 and 60 minutes after bypass compared with the prebypass values for elastance (30 minutes = 4.04 +/- 0.97 and 60 minutes = 4.27 +/- 0.57 vs prebypass = 4.45 +/- 0.96; p = 0.51) and for preload recruitable stroke work (30 minutes = 76.23 +/- 4.80 and 60 minutes = 71.21 +/- 2.99 vs prebypass = 71.23 +/- 3.75; p = 0.45). Preload recruitable work area remained at 96% and 85% of baseline at 30 and 60 minutes (p = not significant). In addition, transesophageal echocardiography demonstrated normal prosthetic valve function, as well as normal regional and global ventricular wall motion. Autopsy revealed secure annular-sewing apposition and normal leaflet motion. CONCLUSIONS: These results suggest that minimally invasive mitral valve replacement using percutaneous cardiopulmonary bypass with cardioplegic arrest is technically reproducible, achieves normal valve placement, and results in complete cardiac functional recovery. Minimally invasive mitral valve replacement is now feasible, and clinical trials are indicated
— id: 7256, year: 1997, vol: 113, page: 1022, stat: Journal Article,

Evaluation and management of cholesterol embolization and the blue toe syndrome
Applebaum RM; Kronzon I
1996 Sep;11(5):533-542, Current opinion in cardiology
The blue toe syndrome is characterized by tissue ischemia secondary to cholesterol crystal or atherothrombotic embolization leading to occlusion of small vessels. Embolization occurs typically from an ulcerated atherosclerotic plaque located in the aorto-iliac-femoral arterial system. Clinical presentation can range from a cyanotic toe to a diffuse multiorgan systemic disease that can mimic other systemic illness. Mortality can be higher than 70% depending on the scope of the illness. Embolization can occur spontaneously or from a variety of insults such as invasive vascular procedures, anticoagulation, or thrombolytic therapy. Angiography, duplex ultrasonography, computerized tomographic scanning, and magnetic resonance imaging have been used to image the offending lesions, with angiography considered the 'gold standard' despite its inherent risks. Recently, transesophageal echocardiography has been shown to be a helpful tool in imaging the thoracic aorta and delineating in great detail the anatomy of the aortic atheroma. At present, surgery remains the most viable treatment option. However, we look to the future for large randomized trials to help predict embolization and thus the proper medical therapy
— id: 12549, year: 1996, vol: 11, page: 533, stat: Journal Article,

Utility of three dimensional echocardiography during balloon mitral valvuloplasty
Kasliwal, RR; Kanojia, A; Applebaum, RM; Seth, A; Bhandari, S; Trehan, N; Winer, HE; Kronzon, I
1996 OCT 15 ;94(8):419-419, Circulation
— id: 52741, year: 1996, vol: 94, page: 419, stat: Journal Article,

Incomplete occlusion of left ventricular aneurysms after endoventricular aneurysmorrhaphy: diagnosis by echocardiography and ventriculography
Katz ES; Applebaum RM; Pierson C; Chinitz L; Colvin SB; Kronzon I
1996 May;38(1):96-99, Catheterization & cardiovascular diagnosis
Surgical treatment of left ventricular aneurysms have recently focused on maintaining normal left ventricular geometry by using a circular patch repair to exclude the aneurysmal cavity (endoaneurysmorrhaphy). We describe two patients who underwent this procedure and were subsequently found by echocardiography and angiography to have a residual communication between the left ventricular cavity and the aneurysm which contained thrombus. This finding may have implications regarding the optimal hemodynamic result of the surgery and the risk of thromboembolism
— id: 12616, year: 1996, vol: 38, page: 96, stat: Journal Article,

A systematic comparison of community care demonstrations
Kemper, Peter; Applebaum, Robert; Harrigan, Margaret
[Rockville, Md.] : National Center for Health Services Research and Health Care Technology Assessment, 1987,
— id: 67, year: 1987, vol: , page: , stat: ,