Joseph Rabin

Early Aortic Repair Worsens Concurrent Traumatic Brain Injury

BACKGROUND Blunt thoracic aortic injury (BTAI) and traumatic brain injury (TBI) are the leading causes of death after blunt trauma, and TBI is common among patients with BTAI. Although aspects of aortic management, such as repair timing and procedural anticoagulation therapy, may complicate TBI, the optimal management of these patients is undefined. METHODS Adults with BTAI and moderate to severe TBI admitted to a level I trauma center over 12 years were retrospectively analyzed; patients presenting in extremis were excluded. The primary outcome was neurologic progression within 48 hours of aortic repair. Patients undergoing nonoperative aortic management served as controls for baseline TBI progression. Secondary outcomes were aortic morbidity and mortality and overall inpatient survival. RESULTS Of 309 patients with BTAI, 138 had concurrent TBI, and 75 were included for analysis. Twenty-two (29%) were treated nonoperatively, 29 (39%) had early aortic repair (17 open, 12 endovascular), and 24 (32%) had delayed repair (3 open, 21 endovascular). The severity of TBI was similar between groups. Early aortic repair within 24 hours of admission was independently associated with worsening TBI, regardless of repair modality or anticoagulation use. In contrast, patients undergoing delayed repair had no perioperative neurologic progression despite procedural anticoagulation therapy. Early aortic repair was also associated with increased aortic morbidity and mortality. CONCLUSIONS For patients with BTAI and TBI, early aortic intervention is associated with progressive TBI regardless of repair modality, as well as increased aortic morbidity and mortality. Patients not requiring emergent intervention can undergo delayed repair with full anticoagulation therapy.

Venovenous Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplantation: Successful Transplantation After 155 Days of Support

We present a case of a woman with acute respiratory distress syndrome and irrecoverable lung function that was successfully bridged to lung transplantation after 155 consecutive days of venovenous extracorporeal membrane oxygenation.

Evolution of lesion-specific management of blunt thoracic aortic injury

Developments in diagnosis and treatment have transformed the management of blunt thoracic aortic injuries (BTAIs). For patients in stable condition, treatment practice has shifted from early open repair to nonoperative management for low-grade lesions and routine delayed endovascular repair for more significant injuries. However, effective therapy depends on accurate staging of injury grade and stability to select patients for appropriate management. Recent developments in BTAI risk stratification enable lesion-specific management tailored to the patient and aortic lesion. This review summarizes advances in lesion assessment and treatment and proposes an integrated scheme for the modern management of BTAI.

A Statewide Analysis of the Incidence and Outcomes of Acute Mesenteric Ischemia in Maryland from 2009 to 2013

Introduction Acute mesenteric ischemia is a surgical emergency that entails complex, multi-modal management, but its epidemiology and outcomes remain poorly defined. The aim of this study was to perform a population analysis of the contemporary incidence and outcomes of mesenteric ischemia. Methods This was a retrospective analysis of acute mesenteric ischemia in the state of Maryland during 2009–2013 using a comprehensive statewide hospital admission database. Demographics, illness severity, comorbidities, and outcomes were studied. The primary outcome was inpatient mortality. Survivors and non-survivors were compared using univariate analyses, and multivariable logistic regression analysis was performed to evaluate risk factors for mortality. Results During the 5-year study period, there were 3,157,499 adult hospital admissions in Maryland. A total of 2,255 patients (0.07%) had acute mesenteric ischemia, yielding an annual admission rate of 10/100,000. Increasing age, hypercoagulability, cardiac dysrhythmia, renal insufficiency, increasing illness severity, and tertiary hospital admission were associated with development of mesenteric ischemia. Inpatient mortality was high (24%). After multivariate analysis, independent risk factors for death were age >65 years, critical illness severity, mechanical ventilation, tertiary hospital admission, hypercoagulability, renal insufficiency, and dysrhythmia. Conclusion Acute mesenteric ischemia occurs in approximately 1/1,000 admissions in Maryland. Patients with mesenteric ischemia have significant illness severity, substantial rates of organ dysfunction, and high mortality. Patients with chronic comorbidities and acute organ dysfunction are at increased risk of death, and recognition of these risk factors may enable prevention or earlier control of mesenteric ischemia in high-risk patients.

Restricted Albumin Utilization Is Safe and Cost Effective in a Cardiac Surgery Intensive Care Unit

BACKGROUND Volume expansion is often necessary after cardiac surgery, and albumin is often administered. Albumins high cost motivated an attempt to reduce its utilization. This study analyzes the impact limiting albumin infusion in a cardiac surgery intensive care unit. METHODS This retrospective study analyzed albumin use between April 2014 and April 2015 in patients admitted to a cardiac surgery intensive care unit. During the first 9 months, there were no restrictions. In January 2015, institutional guidelines limited albumin use to patients requiring more than 3 L crystalloid in the early postoperative period, hypoalbuminemic patients, and to patients considered fluid overloaded. Albumin utilization was obtained from pharmacy records and compared with outcome quality metrics. RESULTS In all, 1,401 patients were admitted over 13 months. Albumin use, mortality, ventilator days, patients receiving transfusions, and length of stay were compared for 961 patients before and 440 patients after guidelines were initiated. After restrictive guidelines were instituted, albumin utilization was reduced from a mean of 280 monthly doses to a mean of 101 monthly doses (p < 0.001). There was also a trend toward reduced ventilator days. Mortality, length of stay, and transfusion requirements demonstrated no significant change. Based on an average wholesale price and an average monthly reduction of 180 albumin doses, the cardiac surgery intensive care unit demonstrated more than

The Evolution of Management Strategies for Blunt Aortic Injury

45,000 of wholesale savings per month after restrictions were implemented. CONCLUSIONS Albumin restriction in the cardiac surgery intensive care unit was feasible and safe. Significant reductions in utilization and cost with no changes in morbidity or mortality were demonstrated. These findings may provide a strategy for reducing cost while maintaining quality of care.

Blunt Aortic Injury in a Patient With Prior Coronary Artery Bypass Surgery

Blunt traumatic aortic injury is a leading cause of death after blunt trauma. Changes in the treatment of this potentially lethal condition include advances in diagnostic capabilities, with improved CT scanners and the development of improved surgical techniques. A wide spectrum of aortic injury can now be appreciated and such injury stratification identifies patients suitable for medical management alone, delayed surgical repair, or emergent surgical intervention. Finally, the development of endovascular technology has fundamentally changed the surgical repairs that can be successfully utilized in this challenging patient population.

Perioperative Management of the Cardiac Transplant Recipient

Traumatic aortic rupture is a significant challenge, further complicated by prior coronary artery bypass graft surgery with a left internal mammary artery anastomosis. We present a patient with prior coronary artery bypass graft and valve replacement who sustained multiple injuries, including an aortic rupture, after a motor vehicle crash. This report describes successful treatment of a patient with a thoracic endograft and carotid subclavian bypass to preserve the left internal mammary artery inflow.

Comparison of aneurysmal and non-pathologic human ascending aortic tissue in shear

Management of the cardiac transplant recipient includes careful titration of inotropes and vasopressors. Recipient pulmonary hypertension and ventilatory status must be optimized to prevent allograft right ventricular failure. Vasoplegia, coagulopathy, arrhythmias, and renal dysfunction also require careful management to achieve an optimal outcome. Primary graft dysfunction (PGD) can be an ominous problem after cardiac transplantation. Although mild degrees of PGD may be managed medically, mechanical circulatory support with extracorporeal membrane oxygenation or temporary ventricular assist devices may be required. Retransplantation may be necessary in some cases.

Incidence and outcomes of thoracic aortic injuries with regionalized care in a mature trauma system

Background: The mechanical properties of the aorta may provide some guidance to cardiovascular surgeons treating aortic disease. While tensile tests are traditional, recent work suggests that shear is important in aortic dissection. Characterizing the differences or similarities in the mechanical shear stress response of non‐pathologic human ascending aortic tissue and of tissue that has remodeled to become aneurysmal contributes to understanding the differences in behavior of the two tissues. Methods: Fresh non‐pathological and aneurysmal tissue acquired from the operating room is deformed in translational shear at approximately physiological rates to 67% deformation followed by stress relaxation to allow comparison of their mechanical behavior. Aneurysmal tissue is tested at 1 mm/s or 12 mm/s and normal tissue at 12 mm/s. The deformation is either in the circumferential or longitudinal direction for a total of 48 specimens. Findings: The shear response at 12 mm/s in non‐pathological and aneurysmal tissue is similar in the circumferential direction but different in the longitudinal direction. Tissue type accounts for up to 30% of the variation in the longitudinal direction. The aneurysmal tissue response is rate‐dependent. Both tissues exhibit significant shear stress relaxation. Interpretation: Remodeling to create the aneurysm modifies the bond strength between collagen fibers and the extracellular matrix. The time‐dependent response is probably due to interstitial fluid behavior. Thoracic surgeons must use caution in applying aortic stress values in the literature because they depend on the deformation rate. HighlightsAneurysmal longitudinal shear stress exceeds that in non‐diseased tissue at 12 mm/s.Aneurysmal tissue is shear deformation rate‐dependent near physiological rates.Shear stress relaxation is similar in aneurysmal and non‐diseased tissues.Stress relaxation in aneurysmal tissue is faster after the higher shear rate.Shear stress relaxation is most likely due to interstitial fluid redistribution.