Background The clinical characteristics, management, and outcomes of patients who had intraoperative aortic dissection (IAD) have not been thoroughly investigated. This study compared early and late ...clinical outcomes in patients with IAD vs spontaneous (non-IAD) acute type A aortic dissection. Methods Between January 1, 2000, and July 1, 2008, 251 patients from 4 academic medical centers underwent repair of acute type A aortic dissection; of those, 11 had IAD. The mean age was 72 ± 9 years for patients experiencing IAD and 59 ± 13 years for those with non-IAD ( p = 0.001). Patients with IAD were more likely to have coronary artery disease ( p = 0.003) and a history of arrhythmia ( p = 0.038). Rates for major morbidity, operative mortality, and 5-year actuarial survival were compared between groups. Results Operative mortality was not adversely influenced by IAD (27% IAD vs 17% non-IAD, p = 0.42). There were no differences in the rates of reoperation for bleeding (10% IAD vs 20% non-IAD, p = 0.69), stroke (18% IAD vs 18% non-IAD, p ≥ 0.99), or acute renal failure (9% IAD vs 22% non-IAD, p = 0.47) between the two groups. Actuarial 5-year survival was 64% for IAD patients vs 73% for non-IAD patients ( p = 0.33). Conclusions IAD does not adversely influence early outcomes and actuarial 5-year survival of patients with type A dissection.
Objective The superior hemodynamics and excellent long-term clinical performance of stentless xenografts are well described. However, the early and midterm clinical outcomes of stentless valves in ...patients with acute type A dissection are widely unknown. The current study evaluated the early and midterm clinical outcomes of stentless bioprosthesis for repair of acute type A aortic dissection. Methods Between May 2005 and December 2009, 24 of 80 patients underwent root replacement using the Medtronic Freestyle xenograft (Medtronic Inc, Minneapolis, Minn) at the Meijer Heart Center. Prospective data collection was used for retrospective review. Univariate comparisons of preoperative, intraoperative, and postoperative variables were performed between patients who underwent stentless root bioprosthesis for the correction of acute type A aortic dissection (n = 24). Results The mean age of patients was 57 years, with 15 patients aged less than 65 years. Axillary and femoral artery cannulation were used in 16 patients (67%) and 7 patients (29%), respectively. Median crossclamp and cardiopulmonary bypass times were 198 minutes (92-480 minutes) and 288 minutes (109-588 minutes), respectively. Median circulatory arrest time was 28 minutes (24-50 minutes). Operative mortality rate was 25%. Actuarial 5-year survival was 62.5%. No patients required redo aortic root replacement. Conclusions Stentless valve implantation can be accomplished with satisfactory early and midterm clinical outcomes and is a valuable option in patients with acute aortic dissection who require root replacement.
To assess the incremental value of the left-side-down decubitus view in radiographic evaluation of ileocolic intussusception.
The institutional review board approved this retrospective investigation ...with waiver of informed consent. Between February 24, 2002, and January 25, 2007, 304 studies (300 patients; mean age, 1.3 years; range, 0.1-3.9 years) met the following inclusion criteria: kidney ureter bladder (KUB) and decubitus views obtained, with subsequent proof of diagnosis. Using a consensus approach, two pediatric radiologists evaluated KUB and decubitus views for four variables: (a) discrete mass and (b) small-bowel obstruction (positive criteria); (c) air or stool in ascending colon and (d) cecal air or stool (negative criteria). On the basis of these criteria, each study was graded as negative, positive, or indeterminate for intussusception. Diagnostically determinate studies and the ability to visualize or exclude intussusception were calculated to determine sensitivity and specificity. The difference between proportions was calculated, along with 95% confidence intervals. Agreement between the supine KUB view and supine KUB plus left-side-down decubitus views was tested with the McNemar test.
Intussusception was present in 58 of 304 studies (19%). Adding the decubitus view to the KUB view increased the number of determinate studies from 110 of 304 (36.2%) to 205 of 304 (67.4%) (difference, 31.2 percentage points; P < .001). Intussusception was correctly identified with KUB view alone in 35 of 58 studies (60.3%); this value increased to 43 of 58 (74.1%) with KUB plus decubitus views (P = .0215). Intussusception was correctly excluded with the KUB view alone in 63 of 246 studies (25.6%); this increased to 143 of 246 studies (58.1%) with addition of the decubitus view (P < .0001).
The addition of decubitus views increased the number of diagnostically determinate studies and increased the ability to diagnose or exclude intussusception. The authors believe that a left-side-down decubitus view should be included in the initial evaluation of patients suspected of having intussusception, particularly when the supine view is diagnostically indeterminate.
Abstract Purpose The purposes of the study were to determine the incidence of adrenal insufficiency (AI) using several published techniques, compare the response rates using a low-dose (LD) ...corticotropin (ACTH) stimulation test vs a standard dose (SD), and identify the technique that is most closely related to vasopressor use. Materials and Methods Consecutive adult patients who were undergoing open heart surgery for CAD or valvular disease were prospectively enrolled. Exclusion criteria included history of steroid use, operative steroid, or etomidate administration. Postoperatively, each patient underwent ACTH stimulation with 1 μ g (LD) and 249 μ g (SD), 60 minutes apart. Agreement among the tests was evaluated, and vasopressor use was compared between groups. Results There were 40 patients evaluated. The incidence of AI based on operative change, postoperative values, and LD-ACTH and SD-ACTH tests was 53%, 38%, 60%, and 38%, respectively. Agreement between the LD- and SD-ACTH tests was 73% ( κ = 0.476, P = .001). There was a significant difference in the need for (93% vs 52%, P = .013) and duration (18.9 0-180.6 vs 0.6 0-73.2 hours, P = .003) of vasopressor therapy in patients with and without AI but only using the SD-ACTH definition. Conclusion The incidence of AI will vary greatly based on technique used for diagnosis. The SD-ACTH stimulation test should be used to determine AI in open heart patients postoperatively because of the close association with vasopressor usage.
Paravalvular leak following a mitral valve replacement is a complication seen in approximately 1 of 10 replacements. The corrective method has traditionally been reoperation. Septal occluder devices ...are more commonly being utilized as an alternative percutaneous correction method. We report the use of septal occluder devices in the repair of mitral paravalvular leak in two patients at severely high EuroSCORE II mortality risk. In both patients, the occluder devices became unstable, leading to a recurrence of severe paravalvular leak.
A patient with acute pulmonary embolism suffered cardiac arrest, received manual and mechanical cardiopulmonary resuscitation and tissue plasminogen activator before extracorporeal cardiopulmonary ...resuscitation was initiated. She suffered a type B aortic dissection and retroperitoneal hemorrhage secondary to resuscitation measures. This case report describes high‐risk anticoagulation management for contradicting treatment goals in preparation for pulmonary embolectomy on cardiopulmonary bypass.
Deep sternal infections secondary to bony instability and malunion, can result in mediastinitis. Previous authors have described the use of prophylactic rigid plate fixation in high-risk patients. ...The purpose of our study is to review the use of prophylactic sternal platting with pectoralis advancement flaps in high-risk patients with a history of chest irradiation. Fourteen patients (July 2003-September 2008) with a history of chest irradiation who underwent a median sternotomy followed by prophylactic rigid plate fixation of the sternum were reviewed. Breast cancer was the most common etiology of chest irradiation (n=11, 78%). The average EuroSCORE was 24.06% with 72% of patients having a preoperative New York Heart Association (NYHA) class≥III. There were no episodes of sternal non-union, mediastinitis or death. Follow-up was 100% with a 0% 30-day and a 7.1% one-year mortality rate (non-cardiac). A comparison between mean preoperative left ventricular ejection fraction (LVEF) (49.6%) and postoperative LVEF (59.7%) was statistically significant (P<0.0001). All living patients currently maintain a NYHA class I/II. Prophylactic rigid plate fixation and pectoralis flap coverage decreases the risk of developing sternal dehiscence and postoperative wound complications and should therefore be considered in high-risk patients with a history of chest irradiation.
Objective.—To determine whether volunteers (with or without prior medical training) can correctly apply pressure immobilization (PI) in a simulated snakebite scenario after receiving standard ...instructions describing the technique. Methods.—Twenty emergency medicine physicians (residents and attendings) and 20 lay volunteers without prior formal medical training were given standard printed instructions describing the application of PI for field management of snakebite. They were then supplied with appropriate materials and asked to apply the technique five separate times (twice to another individual one upper and one lower extremity and three times to themselves nondominant upper extremity, dominant upper extremity, and one lower extremity). Successful application was defined a priori by four criteria previously published in the literature: wrap begins at the bite site, entire extremity is wrapped, splint or sling is applied, and pressures under the dressing are between 40 and 70 mm Hg in upper-extremity application and between 55 and 70 mm Hg in lower-extremity use. Pressures were determined using a specially designed skin interface pressure-measuring device placed at the simulated bite site. Results.—The technique was correctly applied as judged by the preset criteria in only 13 out of 100 applications by emergency medicine physicians and in only 5 out of 100 applications by lay people. There was no significant difference in success rates between physicians and lay volunteers. Likewise, there was no significant difference in success based on which extremity was being wrapped. More detailed analysis revealed that the major contributor to failure was inability to achieve recommended target pressures. Conclusions.—Volunteers in a simulated snakebite scenario have difficulty applying PI correctly, as defined in the literature. The major source of failure is an inability to achieve recommended pressure levels under the dressing. New methods of instructing people in the proper use of PI or new technologies to guide or automate application are needed if this technique is to be used consistently in an effective manner for field management of bites by venomous snakes not known to cause significant local wound necrosis.
Summary Reconstruction of sternal nonunion following surgical resection can be difficult. Presented here is a case of sternal salvage with rigid fixation in the face of a massive aortic ...pseudoaneurysm. Plating is a safe and efficient technique that provides bone approximation and results in long term rigid sternal fixation. This case report highlights the history and biomechanical theory and examines the safety and clinical outcomes of sternal reconstruction with plating fixation.
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