Andrei Churyla

Factors Associated With Survival Following Blunt Chest Trauma in Older Patients: Results From a Large Regional Trauma Cooperative

HYPOTHESIS We hypothesized that patient factors, injury patterns, and therapeutic interventions influence outcomes among older patients incurring traumatic chest injuries. DESIGN Patients older than 50 years with at least 1 rib fracture (RF) were retrospectively studied, including institutional data, patient data, clinical interventions, and complications. Univariable and multivariable analyses were performed. SETTING Eight trauma centers. PATIENTS A total of 1621 patients. MAIN OUTCOME MEASURE Survival. RESULTS Patient data collected include the following: age (mean, 70.1 years), number of RFs (mean, 3.7), Abbreviated Injury Scale chest score (mean, 2.7), Injury Severity Score (mean, 11.7), and mortality (overall, 4.6%). On univariable analysis, increased mortality was associated with admission to high-volume trauma centers and level I centers, preexisting coronary artery disease or congestive heart failure, intubation or development of pneumonia, and increasing age, Injury Severity Score, and number of RFs. On multivariable analysis, strongest predictors of mortality were admission to high-volume trauma centers, preexisting congestive heart failure, intubation, and increasing age and Injury Severity Score. Using this predictive model, tracheostomy and patient-controlled analgesia had protective effects on survival. CONCLUSIONS In a large regional trauma cooperative, increasing age and Injury Severity Score were independent predictors of survival among older patients incurring traumatic RFs. Admission to high-volume trauma centers, preexisting congestive heart failure, and intubation added to mortality. Therapies associated with improved survival were patient-controlled analgesia and tracheostomy. Further regional cooperation should allow development of standard care practices for these challenging patients.

Transcatheter Aortic Valve Implantation

Severe aortic stenosis (AS) is a life-threatening condition when left untreated. Aortic valve replacement (AVR) is the gold standard treatment for the majority of patients; however, transcatheter aortic valve implantation/replacement (TAVI/TAVR) has emerged as the preferred treatment for high-risk or inoperable patients. The concept of transcatheter heart valves originated in the 1960s and has evolved into the current Edwards Sapien and Medtronic CoreValve platforms available for clinical use. Complications following TAVI, including cerebrovascular events, perivalvular regurgitation, vascular injury, and heart block have decreased with experience and evolving technology, such that ongoing trials studying TAVI in lower risk patients have become tenable. The multidisciplinary team involving the cardiac surgeon and cardiologist plays an essential role in patient selection, procedural conduct, and perioperative care.

De novo atrial fibrillation after mitral valve surgery.

Objectives We sought to determine the incidence and risk factors for de novo atrial fibrillation (>90 days after surgery) in patients without preoperative atrial fibrillation. Methods From 2004 to 2014, 2261 patients underwent mitral valve surgery; 1288 patients (57%) did not have a history of atrial fibrillation, and 930 patients had rhythm information more than 90 days after surgery. De novo atrial fibrillation and death probabilities were estimated using a semi‐competing risks, multi‐state model. Univariable and multivariable risk factors for developing atrial fibrillation were identified using the Fine–Gray model. Results The 5‐ and 10‐year incidences of de novo atrial fibrillation were 14% and 23%, respectively. Univariable risk factors were older age, more complex operations, more tricuspid regurgitation, and congestive heart failure (all P < .05). Patients with degenerative mitral regurgitation were less likely to develop atrial fibrillation (hazard ratio [HR], 0.4; 95% confidence interval [CI], 0.24‐0.65; P < .001). Multivariable risk factors for de novo atrial fibrillation were tricuspid valve surgery (HR, 1.80; 95% CI, 1.22, 2.65; P = .003), aortic valve surgery (HR, 1.49; 95% CI, 1.03‐2.17; P = .035), and older age (HR, 1.03; 95% CI, 1.02‐1.05; P < .001). De novo atrial fibrillation did not affect overall survival (P = .41). Among patients who developed de novo atrial fibrillation, we observed increased use of warfarin (P < .001) and a strong trend toward an increased risk of stroke (P = .055). Conclusions De novo atrial fibrillation develops progressively after mitral surgery and is associated with a strong trend toward stroke. Patients at high risk could be studied in a trial to reduce atrial fibrillation.

When is a Maze Procedure a Maze Procedure

The initial surgical attempts to treat atrial fibrillation (AF) were isolation procedures designed to confine the arrhythmia to a specific area of the heart for relief of symptoms. The first surgical attempt to ablate AF was unsuccessful but was quickly followed by the Maze-I procedure on September 25, 1987. Because of several adverse sequelae of the Maze-I procedure, it was sequentially modified to the Maze-II and then Maze-III procedures. The Maze-IV procedure was introduced some 10 years later; these are the only 4 procedures that adhere to the concept of a maze pattern of lesions to ablate AF and leave both atria capable of being activated during normal sinus rhythm. The term maze procedure has become generic for virtually any operation designed to treat AF, but procedures that do not adhere to the concept of creating lesions of conduction block in the pattern of a maze are not maze procedures. These include, among others, the Wolf Mini-Maze, the Left-Sided Maze, and the 5-Box Maze, none of which are truly based on the maze-pattern concept. The cardinal feature of maze procedures that is necessary for both effectiveness and comparability to classical maze procedures includes lines of conduction block that preclude macro-reentry anywhere in either atrium while leaving both atria capable of activation by a sinus-generated impulse. Components essential to achieving this include appropriate lesions in both atria, the absence of gaps that allow electrical activity to bypass an intended line of block, and the absence of alternate pathways by which impulses can reach the intended maze exit.

The Maze Procedure and Postoperative Pacemakers

BACKGROUND There is concern that the right atrial lesions of the maze procedure lead to more permanent pacemakers postoperatively and that they provide little therapeutic advantage over left atrial lesions alone. METHODS A discussion of the pertinent anatomy related to atrial fibrillation and the performance of the maze procedure, the potential ways that the specialized conduction system could theoretically be damaged by the procedure, non-procedure-related causes for increased postoperative pacemaker requirements, and the basis for the efficacy of the right atrial lesions of the maze procedure are presented. Several factors that can lead to a dysfunctional sinoatrial node preoperatively in patients with atrial fibrillation are also discussed. RESULTS The reasons new permanent pacemakers are required after a maze procedure include the high success rates of the surgery with subsequent unmasking of preoperative sick sinus syndrome, excessive extracardiac dissection that damages the autonomic nerve input to the heart, premature pacemaker implantation for a temporary junctional rhythm immediately postoperatively, surgical error, and patient selection. CONCLUSIONS There are numerous reasons why patients need new pacemakers after a maze procedure, but the right atrial lesions of the procedure rarely, if ever, are the cause.

A Hybrid Maze Procedure for Long-Standing Persistent Atrial Fibrillation

BACKGROUND Catheter ablation (CA) for long-standing persistent atrial fibrillation (LSPAF) is suboptimal, and open surgical ablation, although more successful, is too invasive to be a first-line therapy. Less invasive hybrid procedures that combine thoracoscopic surgery (TS) with CA have been only marginally more successful for LSPAF than CA alone. METHODS Joint hybrid procedures for LSPAF are based on the assumption that AF surgery and CA procedures can be guided by intraoperative mapping. However, intraoperative mapping is not always dependable because of the transient nature of the sustaining reentrant drivers. The best results in patients with LSPAF have been attained with the non-guided, anatomy-based surgical Maze-III and Maze-IV procedures. Likewise, a staged TS/CA hybrid procedure that creates a combination of lesions that adhere to the concept of a Maze pattern, that is, a Hybrid Maze-IV procedure, should be more effective for LSPAF. RESULTS Initial TS includes all lesions of the Maze-IV procedure except the mitral line, coronary sinus lesion, and one right atrial lesion. Follow-up CA at 3 months includes touching up any incomplete TS lesions, a cavotricuspid isthmus lesion, and a mitral line/coronary sinus lesion in the 10% to 15% of patients with post-TS perimitral flutter. This combination of TS and CA lesions creates a complete Maze-IV procedure. CONCLUSIONS It is possible to create the complete lesion pattern of a Maze-IV procedure with a staged TS/CA hybrid procedure. The success of this Hybrid Maze procedure in patients with LSPAF should be the same as that attained with an open surgical Maze-IV procedure.

Transcatheter aortic valve replacement using the transaortic approach

This is a frail 73-year-old male with symptomatic critical aortic stenosis (AS). He has suffered a significant functional decline with associated shortness of breath and chest discomfort. His past medical history is significant for coronary artery disease with prior bypass grafting, porcelain aorta, chronic kidney disease-stage III, diabetes mellitus, hypertension, hyperlipidemia, and peripheral arterial disease. Echocardiography demonstrates tri-leaflet, calcific AS with an aortic valve area of 0.7 cm, a jet velocity of 5.0 m/s, and a mean gradient of 60 mmHg. Cardiac catheterization reveals a widely patent LIMA-to-LAD with patent vein grafts and limited native coronary flow.

Chronic Mesh Infections

Chronic mesh infection can occur after acute infection or may present with an indolent course. The risk of infection and the associated immune response can vary with each mesh bioprosthesis. Treatment usually requires mesh excision, although mesh salvage has been reported.