Publications

2011
Matyal R, Warraich HJ, Panzica P, Khabbaz KR, Mahmood F. Echo rounds: bifid atrial septal aneurysm: visualization with three-dimensional transesophageal echocardiography. Anesth Analg. 2011;112 (6) :1300-2.
Warraich H, Matyal R, Shahul S, Mitchell J, Panzica P, Khabbaz K, Mahmood F. Giant saphenous vein graft pseudoaneurysm causing tricuspid valve stenosis. J Card Surg. 2011;26 (2) :177-80.Abstract
We present the case of a 72-year-old male who was diagnosed with a saphenous vein graft pseudoaneurysm, detected on routine chest echocardiogram 13 years after undergoing coronary artery bypass graft surgery. Intraoperative transesophageal echocardiography revealed the pseudoaneurysm to be causing functional tricuspid stenosis, which was relieved after surgical excision of the mass.
Sundar S, Novack V, Jervis K, Bender PS, Lerner A, Panzica P, Mahmood F, Malhotra A, Talmor D. Influence of low tidal volume ventilation on time to extubation in cardiac surgical patients. Anesthesiology. 2011;114 (5) :1102-10.Abstract
BACKGROUND: Low tidal volumes have been associated with improved outcomes in patients with established acute lung injury. The role of low tidal volume ventilation in patients without lung injury is still unresolved. We hypothesized that such a strategy in patients undergoing elective surgery would reduce ventilator-associated lung injury and that this improvement would lead to a shortened time to extubation METHODS: A single-center randomized controlled trial was undertaken in 149 patients undergoing elective cardiac surgery. Ventilation with 6 versus 10 ml/kg tidal volume was compared. Ventilator settings were applied immediately after anesthesia induction and continued throughout surgery and the subsequent intensive care unit stay. The primary endpoint of the study was time to extubation. Secondary endpoints included the proportion of patients extubated at 6 h and indices of lung mechanics and gas exchange as well as patient clinical outcomes. RESULTS: Median ventilation time was not significantly different in the low tidal volume group; a median (interquartile range) of 450 (264-1,044) min was achieved compared with 643 (417-1,032) min in the control group (P = 0.10). However, a higher proportion of patients in the low tidal volume group was free of any ventilation at 6 h: 37.3% compared with 20.3% in the control group (P = 0.02). In addition, fewer patients in the low tidal volume group required reintubation (1.3 vs. 9.5%; P = 0.03). CONCLUSIONS: Although reduction of tidal volume in mechanically ventilated patients undergoing elective cardiac surgery did not significantly shorten time to extubation, several improvements were observed in secondary outcomes. When these data are combined with a lack of observed complications, a strategy of reduced tidal volume could still be beneficial in this patient population.
Maslow A, Gemignani A, Singh A, Mahmood F, Poppas A. Intraoperative assessment of mitral valve area after mitral valve repair: comparison of different methods. J Cardiothorac Vasc Anesth. 2011;25 (2) :221-8.Abstract
OBJECTIVE: In the present study, 3 different methods to measure the mitral valve area (MVA) after mitral valve repair (MVRep) were studied. Data obtained immediately after repair were compared with postoperative data. The objective was to determine the feasibility and correlation between intraoperative and postoperative MVA data. DESIGN: A prospective study. SETTING: A tertiary care medical center. PARTICIPANTS: Twenty-five elective adult surgical patients scheduled for MVRep. METHODS: Echocardiographic data included MVAs obtained using the pressure half-time (PHT), 2-dimensional planimetry (2D-PLAN), and the continuity equation (CE). These data were obtained immediately after cardiopulmonary bypass and were compared with data obtained before hospital discharge (transthoracic echocardiogram 1) and 6 to 12 months after surgery (transthoracic echocardiogram 2). Intraoperative care was guided by hemodynamic goals designed to optimize cardiac function. RESULTS: The data show good agreement and correlation between MVA obtained with PHT and 2D-PLAN within and between each time period. MVA data obtained with the CE in the postoperative period were lower than and did not correlate or agree as well with other MVA data. CONCLUSION: The MVA recorded immediately after valve repair, using PHT, correlated and agreed with MVA data obtained in the postoperative period. These results contrast with previously published data and could highlight the impact of hemodynamic function during the assessment of MVA.
Swaminathan M, Mahmood F. Thinking beyond the aortic valve: implications of a diseased aorta. J Cardiothorac Vasc Anesth. 2011;25 (2) :370.
Bose RR, Matyal R, Warraich HJ, Summers J, Subramaniam B, Mitchell J, Panzica PJ, Shahul S, Mahmood F. Utility of a transesophageal echocardiographic simulator as a teaching tool. J Cardiothorac Vasc Anesth. 2011;25 (2) :212-5.Abstract
OBJECTIVE: This study was designed to test the hypothesis that simulator-based transesophageal echocardiographic training was a more effective method of training anesthesia residents with no prior experience in echocardiography as compared with conventional methods of training (books, articles, and web-based resources). STUDY DESIGN: A prospective randomized study. SETTING: An academic medical center (teaching hospital). PARTICIPANTS: The participants consisted of first-year anesthesia residents. INTERVENTION: The study design was composed of 2 groups: a control group (group 1, conventional group) and a study group (group 2, simulator group). The residents belonging to group 2 (simulator group) received a 90-minute simulator-based teaching session moderated by a faculty experienced in transesophageal echocardiography. Residents belonging to group 1 (conventional group) were asked to review the guidelines of the comprehensive intraoperative transesophageal echocardiographic examination published by the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists. They also were encouraged to use other learning resources (eg, textbooks, electronic media, and web-based resources) to understand the underlying concepts of echocardiography. Written pre- and post-test was administered to both groups. MEASUREMENTS AND MAIN RESULTS: The groups were compared for the pretest scores by the nonparametric Mann-Whitney U test. Pre- and post-test scores were compared with a Wilcoxon paired test in the individual groups. The results showed a statistically significant difference between the scores of the 2 groups with better scores in the simulation group in the post-training test. CONCLUSION: The simulator-based teaching model for transesophageal echocardiography is a better method of teaching the basic concepts of transesophageal echocardiography like anatomic correlation, structure identification, and image acquisition.
Mahmood F, Swaminathan M. Aortic stenosis and mitral regurgitation: not as simple as it looks. J Cardiothorac Vasc Anesth. 2011;25 (5) :887-8.
Warraich HJ, Shahul S, Matyal R, Mahmood F. Bench to bedside: dynamic mitral valve assessment. J Cardiothorac Vasc Anesth. 2011;25 (5) :863-6.Abstract
PURPOSE: The authors analyze a commercially available software package capable of geometrically reconstructing the mitral valve (MV) dynamically throughout systole. DESCRIPTION: Three-dimensional echocardiography has revolutionized the understanding of MV geometry. Advanced quantification software can be used to assess geometric changes in the MV, which have been shown to have important implications for MV surgery. EVALUATION: The authors performed geometric analysis on 24 patients, with both anatomically normal and abnormal MVs to assess the feasibility of this new software. The application of this new software is briefly reviewed. CONCLUSION: This new software, despite its limitations, allows an improved perspective on MV geometry with implications for MV repair and surgical decision making.
Warraich HJ, Hayward G, Matyal R, Shahul S, Subramaniam B. Fate of mitral regurgitation after aortic valve replacement for aortic stenosis. J Cardiothorac Vasc Anesth. 2011;25 (5) :885-6.
Matyal R, Skubas NJ, Shernan SK, Mahmood F. Perioperative assessment of diastolic dysfunction. Anesth Analg. 2011;113 (3) :449-72.Abstract
Assessment of diastolic function should be a component of a comprehensive perioperative transesophageal echocardiographic examination. Abnormal diastolic function exists in >50% of patients presenting for cardiac and high-risk noncardiac surgery, and has been shown to be an independent predictor of adverse postoperative outcome. Normalcy of systolic function in 50% of patients with congestive heart failure implicates diastolic dysfunction as the probable etiology. Comprehensive evaluation of diastolic function requires the use of various, load-dependent Doppler techniques This is further complicated by the additional effects of dehydration and anesthetic drugs on myocardial relaxation and compliance as assessed by these Doppler measures. The availability of more sophisticated Doppler techniques, e.g., Doppler tissue imaging and flow propagation velocity, makes it possible to interrogate left ventricular diastolic function with greater precision, analyze specific stages of diastole, and to differentiate abnormalities of relaxation from compliance. Additionally, various Doppler-derived ratios can be used to estimate left ventricular filling pressures. The varying hemodynamic environment of the operating room mandates modification of the diagnostic algorithms used for ambulatory cardiac patients when left ventricular diastolic function is evaluated with transesophageal echocardiography in anesthetized surgical patients.
Mahmood F, Swaminathan M. Postinfarction ventricular septal defects: surgical or percutaneous closure-between a rock and a hard place. J Cardiothorac Vasc Anesth. 2011;25 (6) :1217-8.
Warraich HJ, Bhatti UA, Shahul S, Pinto D, Liu D, Matyal R, Mahmood F. Unilateral pulmonary edema secondary to mitral valve perforation. Circulation. 2011;124 (18) :1994-5.
2010
Cummisford K, Sundar S, Hagberg R, Mahmood F. Real-time three-dimensional transesophageal echocardiography and a congenital bilobar left atrial appendage. J Cardiothorac Vasc Anesth. 2010;24 (3) :475-7.
Gerstle J, Shahul S, Mahmood F. Echocardiographically derived parameters of fluid responsiveness. Int Anesthesiol Clin. 2010;48 (1) :37-44.
Matyal R, Mahmood F, Chaudhry H, Cummisford K, Hagberg R, Mahmood F. Left atrial appendage thrombus and real-time 3-dimensional transesophageal echocardiography. J Cardiothorac Vasc Anesth. 2010;24 (6) :977-9.
Stamou SC, Khabbaz KR, Mahmood F, Zimetbaum P, Hagberg RC. A multidisciplinary approach to the minimally invasive pulmonary vein isolation for treatment of atrial fibrillation. Ann Thorac Surg. 2010;89 (2) :648-50.Abstract
Bilateral pulmonary vein isolation along with amputation of the left atrial appendage has become a well-recognized technique for the management of atrial fibrillation. We describe our multidisciplinary approach to minimally invasive bilateral pulmonary vein isolation, left atrial appendage resection, and ablation of autonomic ganglia.
Mahmood F, Swaminathan M. Ordinary images--extraordinary stories: echo challenges and clinical decisions. J Cardiothorac Vasc Anesth. 2010;24 (1) :5-6.
Darke M, Pawloski J, Khabbaz KR, Mahmood F. Rheumatic mitral and aortic stenosis: to replace or not to replace--that is the question--part 2. J Cardiothorac Vasc Anesth. 2010;24 (2) :364-5.
Darke M, Pawloski J, Khabbaz KR, Mahmood F. Rheumatic mitral and aortic stenosis: to replace or not to replace--that is the question--part 1. J Cardiothorac Vasc Anesth. 2010;24 (1) :191-2.
Cummisford KM, Manning W, Karthik S, Mahmood FU. 3D TEE and systolic anterior motion in hypertrophic cardiomyopathy. JACC Cardiovasc Imaging. 2010;3 (10) :1083-4.

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