The purpose of this study was to review our experience in the early application of extracorporeal... more The purpose of this study was to review our experience in the early application of extracorporeal membrane oxygenation (ECMO) in patients requiring mechanical assistance after cardiac surgical procedures. The hospital records of all children requiring ECMO after cardiac operation were retrospectively reviewed, and an analysis of variables affecting survival was performed. Fifty pediatric patients between May 1997 and October 2000 required ECMO for cardiopulmonary support after cardiac operation. Patients ranged in age from 1 day to 11 years (median age, 40 days). Forty-eight patients underwent repair of congenital cardiac lesions and 2 were included after receiving a heart transplant. Twenty-two children could not be weaned from cardiopulmonary bypass and were placed on ECMO in the operating room for circulatory support. Of the 28 children who required ECMO in the intensive care unit, 10 had ECMO instituted after cardiopulmonary arrest (mean cardiopulmonary resuscitation time 42 minutes; range, 5 to 110 minutes). In infants with single-ventricle physiology, survival to discharge was 61% (11 of 18 patients) as compared with 43% (14 of 32 patients) in those with biventricular physiology. Thirty of the 50 patients (60%) were successfully weaned from ECMO, of which 25 (83%) were discharged home. Overall survival to discharge in the entire cohort was 50%. Extracorporeal membrane oxygenation support greater than 72 hours was a grave prognostic indicator. Overall survival in this group was 36% (9 of 25 patients) compared with 56% (14 of 25 patients) in those with ECMO support less than 72 hours (p < 0.05). Univariate analysis revealed the presence of renal failure, extended periods of circulatory support, and a prolonged period of cardiopulmonary resuscitation as risk factors for mortality. The presence of shunt-dependent flow, operative procedure, and institution of ECMO in the intensive care unit did not alter survival. Extracorporeal membrane oxygenation provides effective support for postoperative cardiac and pulmonary failure refractory to medical management. Early institution of ECMO may decrease the incidence of cardiac arrest and end-organ damage, thus increasing survival in these critically ill patients.
end-diastolic diameter <I? mm wa> a aigmficant prcdiclor of death ip < 0.01). Correcting this lcf... more end-diastolic diameter <I? mm wa> a aigmficant prcdiclor of death ip < 0.01). Correcting this lcfi ventricular end-diastolic diameter for body ~~~rfw area mow clearly explains the good outcome in the paixnr with ndiameWrof IO.1 mm because lhis patienl's budy SKI'WZ xca was the smallest in the study. This corrcwion. howvcr.
... 7272 Greenville Avenue, Dallas, TX DOI: 10.1161/CIRCULATIONAHA.108.785030 2008;118;e121 Circu... more ... 7272 Greenville Avenue, Dallas, TX DOI: 10.1161/CIRCULATIONAHA.108.785030 2008;118;e121 Circulation Peter Ewert, Lisa K. Jennings and Alan D. Michelson Takahashi, Thomas P. Graham, Jr, Stephen ... Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-...
The number of adults living with congenital heart disease grows annually. The sequelae of congeni... more The number of adults living with congenital heart disease grows annually. The sequelae of congenital heart disease surgery may involve the electrical conduction system, cardiac valves, prosthetic materials, the myocardium, vascular beds, and the nervous system. These sequelae may lead to heart failure. Adults with congenital heart disease develop heart failure as a consequence of: (1) chronic cyanosis, volume overload,
ABSTRACT There are limited data on cardiac function in premature infants. Computer-determined ins... more ABSTRACT There are limited data on cardiac function in premature infants. Computer-determined instantaneous velocities of the left ventricular (LV) minor axis provide estimates of systolic and diastolic function. We determined the LV Maximal Velocity of Shortening(MVS) and Maximal Velocity of Lengthening(MVL) for 32 neonates of various gestational ages(GA) within the first three days of life. Infants with Congenital Heart Disease. Patent Ductus Arteriosus(PDA), asphxia, or sepsis were excluded from the study, x±S.D. were:
Unidirectional block is a fundamental component in the initiation of a reentrant cardiac arrhythm... more Unidirectional block is a fundamental component in the initiation of a reentrant cardiac arrhythmia. The activation seouences of the adult rabbit (n.10) or canine (n=5) left ,~anterior papillary muscle were 'mappkd two-dimensionally using mu1 tiple monopolar extracellular electrodes with computerized data acquisition and analysis. Isochronal maps were then made to determine the activation patterns of the superficial Purkinje (P) layer or the underlying ventricular (V) layer during stimulation of an attached P strand or the apical V surface.
Studies were carried out to find how left-ventricular length and length/diameter ratio relate to ... more Studies were carried out to find how left-ventricular length and length/diameter ratio relate to body size and degree of dilation. By use of M-mode and two-dimensional echocardiography, diastolic cavity long axis (Led), diastolic cavity diameter (Ded), systolic cavity long axis (Les), systolic cavity diameter (Des), fractional L shortening (SFL), and fractional D shortening (SFD) were measured in children, adolescents, and young adults between two and 23 years of age, with body-surface area (BSA) between 0.5 and 2.1 m2 and with a variety of volume loads and SFD values. In normal subjects, Led/Ded was about 1.9. Regardless of age and pathology (in this age range), Led correlated consistently with BSA (Led = 3.9 + 3.2 BSA), indicating that the long axis changes rather little with pathological dilation. A plot of Led/Ded vs BSA/D2ed (in m2/cm2) formed a straight-line relation: Led/Ded = 0.77 + 16.4 BSA/D2ed. Similar relations were found for end-systolic dimensions. End-systolic L/D ratio exceeded end-diastolic L/D ratio to a degree that depended on both end-diastolic L/D ratio and SFD:Les/Des = Led/Ded + (0.22 + 2.67 Led/Ded)(SFD)2. Relations like these may be useful in the interpretation of echocardiographic images. The results suggest that left-ventricular L/D ratio may be influenced by myocardial anisotropy (dominance of hoop over meridional fiber orientation tending to promote prolate shape especially during systole) and external factors that antagonize extension of the long axis.
Original Article from The New England Journal of Medicine — Pharmacokinetics of Indomethacin in t... more Original Article from The New England Journal of Medicine — Pharmacokinetics of Indomethacin in the Neonate.
The Journal of Thoracic and Cardiovascular Surgery, 1998
Objective: This study compares in vivo pulmonary blood flow patterns and shear stresses in patien... more Objective: This study compares in vivo pulmonary blood flow patterns and shear stresses in patients with either the direct atrium-pulmonary artery connection or the bicaval tunnel connection of the Fontan procedure to those in normal volunteers. Comparisons were made with the use of three-dimensional phase contrast magnetic resonance imaging. Methods: Three-dimensional velocities, flows, and pulmonary artery cross-sectional areas were measured in both pulmonary arteries of each subject. Axial, circumferential, and radial shear stresses were calculated with the use of velocities and estimates of viscosity. Results: The axial velocities were not significantly different between subject groups. However, the flows and cross-sectional areas were higher in the normal group than in the two patient groups in both pulmonary arteries. The group with the bicaval connection had circular swirling in the cross section of both pulmonary arteries, causing higher shear stresses than in the controls. The disorder caused by the connection of the atrium to the pulmonary artery caused an increase in some shear stresses over the controls, but not higher than those found in the group having a bicaval tunnel. Conclusions: We found that pulmonary flow was equally reduced compared with normal flow in both patient groups. This reduction in flow can be attributed in part to the reduced size of the pulmonary arteries in both patient groups without change in axial velocity. We also found higher shear stress acting on the wall of the vessels in the patients having a bicaval tunnel, which may alter endothelial function and affect the longevity of the repair. (J Thorac Cardiovasc Surg 1998;116:294-304) Downloaded from Years postop, Years since Fontan operation; BSA, body surface area; NA, not applicable; SV, single ventricle; PS, pulmonic stenosis, S/P, status post; LV, left ventricle; TGA, transposition of the great arteries.
Journal of the American College of Cardiology, 1991
With the current trend to performing surgical valvotomy for infantile aortic stenosis without car... more With the current trend to performing surgical valvotomy for infantile aortic stenosis without cardiac catheterization, there is a need to develop echocardiographic criteria for adequacy of left ventricular size. The echocardiograms and catheterization data of all 25 infants less than 3 months of age undergoing aortic valvotomy for isolated aortic valve stenosis from September 1980 through July 1990 were reviewed. Significant differences (p less than 0.05) between the survivors and nonsurvivors were noted for age at operation (30 +/- 28 vs. 3 +/- 1.5 days), mitral valve diameter (10.1 +/- 1.7 vs. 7.7 +/- 1.5 mm), left ventricular end-diastolic dimension (18.4 +/- 6.4 vs. 11.4 +/- 3 mm), left atrial dimensions (15.3 +/- 3.8 vs. 10 +/- 2.4 mm), left ventricular cross-sectional area on the parasternal long-axis echocardiogram (4 +/- 1.9 vs. 2 +/- 1.9 cm2) and angiographically determined left ventricular end-diastolic volume (43 +/- 23 vs. 11 +/- 5 ml/m2). There was no difference with respect to patient weight, body surface area, aortic root dimension or left ventricular ejection fraction. Left ventricular cross-sectional area less than 2 cm2 as measured on the parasternal long-axis echocardiogram was found in 5 of 7 nonsurvivors and 0 of 12 survivors, making this a risk factor for perioperative death (p less than 0.05). Left ventricular end-diastolic dimension less than 13 mm was found in 5 of 6 nonsurvivors and 2 of 17 survivors, making this another risk factor for early mortality (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Journal of the American College of Cardiology, 1989
Clinical characteristics and angiographic ventricular volume data were obtained in 25 infants age... more Clinical characteristics and angiographic ventricular volume data were obtained in 25 infants aged 1 to 66 days who presented with coarctation of the aorta, ventricular septal defect and congestive heart failure to determine if left ventricular volume loading was present and if there were hemodynamic or volumetric variables that were predictive of operative mortality in this group.
The purpose of this study was to review our experience in the early application of extracorporeal... more The purpose of this study was to review our experience in the early application of extracorporeal membrane oxygenation (ECMO) in patients requiring mechanical assistance after cardiac surgical procedures. The hospital records of all children requiring ECMO after cardiac operation were retrospectively reviewed, and an analysis of variables affecting survival was performed. Fifty pediatric patients between May 1997 and October 2000 required ECMO for cardiopulmonary support after cardiac operation. Patients ranged in age from 1 day to 11 years (median age, 40 days). Forty-eight patients underwent repair of congenital cardiac lesions and 2 were included after receiving a heart transplant. Twenty-two children could not be weaned from cardiopulmonary bypass and were placed on ECMO in the operating room for circulatory support. Of the 28 children who required ECMO in the intensive care unit, 10 had ECMO instituted after cardiopulmonary arrest (mean cardiopulmonary resuscitation time 42 minutes; range, 5 to 110 minutes). In infants with single-ventricle physiology, survival to discharge was 61% (11 of 18 patients) as compared with 43% (14 of 32 patients) in those with biventricular physiology. Thirty of the 50 patients (60%) were successfully weaned from ECMO, of which 25 (83%) were discharged home. Overall survival to discharge in the entire cohort was 50%. Extracorporeal membrane oxygenation support greater than 72 hours was a grave prognostic indicator. Overall survival in this group was 36% (9 of 25 patients) compared with 56% (14 of 25 patients) in those with ECMO support less than 72 hours (p &lt; 0.05). Univariate analysis revealed the presence of renal failure, extended periods of circulatory support, and a prolonged period of cardiopulmonary resuscitation as risk factors for mortality. The presence of shunt-dependent flow, operative procedure, and institution of ECMO in the intensive care unit did not alter survival. Extracorporeal membrane oxygenation provides effective support for postoperative cardiac and pulmonary failure refractory to medical management. Early institution of ECMO may decrease the incidence of cardiac arrest and end-organ damage, thus increasing survival in these critically ill patients.
end-diastolic diameter <I? mm wa> a aigmficant prcdiclor of death ip < 0.01). Correcting this lcf... more end-diastolic diameter <I? mm wa> a aigmficant prcdiclor of death ip < 0.01). Correcting this lcfi ventricular end-diastolic diameter for body ~~~rfw area mow clearly explains the good outcome in the paixnr with ndiameWrof IO.1 mm because lhis patienl's budy SKI'WZ xca was the smallest in the study. This corrcwion. howvcr.
... 7272 Greenville Avenue, Dallas, TX DOI: 10.1161/CIRCULATIONAHA.108.785030 2008;118;e121 Circu... more ... 7272 Greenville Avenue, Dallas, TX DOI: 10.1161/CIRCULATIONAHA.108.785030 2008;118;e121 Circulation Peter Ewert, Lisa K. Jennings and Alan D. Michelson Takahashi, Thomas P. Graham, Jr, Stephen ... Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-...
The number of adults living with congenital heart disease grows annually. The sequelae of congeni... more The number of adults living with congenital heart disease grows annually. The sequelae of congenital heart disease surgery may involve the electrical conduction system, cardiac valves, prosthetic materials, the myocardium, vascular beds, and the nervous system. These sequelae may lead to heart failure. Adults with congenital heart disease develop heart failure as a consequence of: (1) chronic cyanosis, volume overload,
ABSTRACT There are limited data on cardiac function in premature infants. Computer-determined ins... more ABSTRACT There are limited data on cardiac function in premature infants. Computer-determined instantaneous velocities of the left ventricular (LV) minor axis provide estimates of systolic and diastolic function. We determined the LV Maximal Velocity of Shortening(MVS) and Maximal Velocity of Lengthening(MVL) for 32 neonates of various gestational ages(GA) within the first three days of life. Infants with Congenital Heart Disease. Patent Ductus Arteriosus(PDA), asphxia, or sepsis were excluded from the study, x±S.D. were:
Unidirectional block is a fundamental component in the initiation of a reentrant cardiac arrhythm... more Unidirectional block is a fundamental component in the initiation of a reentrant cardiac arrhythmia. The activation seouences of the adult rabbit (n.10) or canine (n=5) left ,~anterior papillary muscle were 'mappkd two-dimensionally using mu1 tiple monopolar extracellular electrodes with computerized data acquisition and analysis. Isochronal maps were then made to determine the activation patterns of the superficial Purkinje (P) layer or the underlying ventricular (V) layer during stimulation of an attached P strand or the apical V surface.
Studies were carried out to find how left-ventricular length and length/diameter ratio relate to ... more Studies were carried out to find how left-ventricular length and length/diameter ratio relate to body size and degree of dilation. By use of M-mode and two-dimensional echocardiography, diastolic cavity long axis (Led), diastolic cavity diameter (Ded), systolic cavity long axis (Les), systolic cavity diameter (Des), fractional L shortening (SFL), and fractional D shortening (SFD) were measured in children, adolescents, and young adults between two and 23 years of age, with body-surface area (BSA) between 0.5 and 2.1 m2 and with a variety of volume loads and SFD values. In normal subjects, Led/Ded was about 1.9. Regardless of age and pathology (in this age range), Led correlated consistently with BSA (Led = 3.9 + 3.2 BSA), indicating that the long axis changes rather little with pathological dilation. A plot of Led/Ded vs BSA/D2ed (in m2/cm2) formed a straight-line relation: Led/Ded = 0.77 + 16.4 BSA/D2ed. Similar relations were found for end-systolic dimensions. End-systolic L/D ratio exceeded end-diastolic L/D ratio to a degree that depended on both end-diastolic L/D ratio and SFD:Les/Des = Led/Ded + (0.22 + 2.67 Led/Ded)(SFD)2. Relations like these may be useful in the interpretation of echocardiographic images. The results suggest that left-ventricular L/D ratio may be influenced by myocardial anisotropy (dominance of hoop over meridional fiber orientation tending to promote prolate shape especially during systole) and external factors that antagonize extension of the long axis.
Original Article from The New England Journal of Medicine — Pharmacokinetics of Indomethacin in t... more Original Article from The New England Journal of Medicine — Pharmacokinetics of Indomethacin in the Neonate.
The Journal of Thoracic and Cardiovascular Surgery, 1998
Objective: This study compares in vivo pulmonary blood flow patterns and shear stresses in patien... more Objective: This study compares in vivo pulmonary blood flow patterns and shear stresses in patients with either the direct atrium-pulmonary artery connection or the bicaval tunnel connection of the Fontan procedure to those in normal volunteers. Comparisons were made with the use of three-dimensional phase contrast magnetic resonance imaging. Methods: Three-dimensional velocities, flows, and pulmonary artery cross-sectional areas were measured in both pulmonary arteries of each subject. Axial, circumferential, and radial shear stresses were calculated with the use of velocities and estimates of viscosity. Results: The axial velocities were not significantly different between subject groups. However, the flows and cross-sectional areas were higher in the normal group than in the two patient groups in both pulmonary arteries. The group with the bicaval connection had circular swirling in the cross section of both pulmonary arteries, causing higher shear stresses than in the controls. The disorder caused by the connection of the atrium to the pulmonary artery caused an increase in some shear stresses over the controls, but not higher than those found in the group having a bicaval tunnel. Conclusions: We found that pulmonary flow was equally reduced compared with normal flow in both patient groups. This reduction in flow can be attributed in part to the reduced size of the pulmonary arteries in both patient groups without change in axial velocity. We also found higher shear stress acting on the wall of the vessels in the patients having a bicaval tunnel, which may alter endothelial function and affect the longevity of the repair. (J Thorac Cardiovasc Surg 1998;116:294-304) Downloaded from Years postop, Years since Fontan operation; BSA, body surface area; NA, not applicable; SV, single ventricle; PS, pulmonic stenosis, S/P, status post; LV, left ventricle; TGA, transposition of the great arteries.
Journal of the American College of Cardiology, 1991
With the current trend to performing surgical valvotomy for infantile aortic stenosis without car... more With the current trend to performing surgical valvotomy for infantile aortic stenosis without cardiac catheterization, there is a need to develop echocardiographic criteria for adequacy of left ventricular size. The echocardiograms and catheterization data of all 25 infants less than 3 months of age undergoing aortic valvotomy for isolated aortic valve stenosis from September 1980 through July 1990 were reviewed. Significant differences (p less than 0.05) between the survivors and nonsurvivors were noted for age at operation (30 +/- 28 vs. 3 +/- 1.5 days), mitral valve diameter (10.1 +/- 1.7 vs. 7.7 +/- 1.5 mm), left ventricular end-diastolic dimension (18.4 +/- 6.4 vs. 11.4 +/- 3 mm), left atrial dimensions (15.3 +/- 3.8 vs. 10 +/- 2.4 mm), left ventricular cross-sectional area on the parasternal long-axis echocardiogram (4 +/- 1.9 vs. 2 +/- 1.9 cm2) and angiographically determined left ventricular end-diastolic volume (43 +/- 23 vs. 11 +/- 5 ml/m2). There was no difference with respect to patient weight, body surface area, aortic root dimension or left ventricular ejection fraction. Left ventricular cross-sectional area less than 2 cm2 as measured on the parasternal long-axis echocardiogram was found in 5 of 7 nonsurvivors and 0 of 12 survivors, making this a risk factor for perioperative death (p less than 0.05). Left ventricular end-diastolic dimension less than 13 mm was found in 5 of 6 nonsurvivors and 2 of 17 survivors, making this another risk factor for early mortality (p less than 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)
Journal of the American College of Cardiology, 1989
Clinical characteristics and angiographic ventricular volume data were obtained in 25 infants age... more Clinical characteristics and angiographic ventricular volume data were obtained in 25 infants aged 1 to 66 days who presented with coarctation of the aorta, ventricular septal defect and congestive heart failure to determine if left ventricular volume loading was present and if there were hemodynamic or volumetric variables that were predictive of operative mortality in this group.
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Papers by Thomas Graham