Lynn C. Huffman

Spontaneous left main coronary artery dissection complicated by pseudoaneurysm formation in pregnancy: role of CT coronary angiography

We report a case of a 26-year-old female, who presented at 34 weeks of an uncomplicated pregnancy with an acute ST elevation anterior wall myocardial infarction. Cardiac catheterization suggested a left main coronary artery dissection with pseudoaneurysm formation. The patients course was complicated by congestive heart failure. She was initially managed conservatively by a multidisciplinary team including heart failure specialists, obstetricians, and cardiovascular surgeons. 4 days after admission, her LMC was imaged by dual-source 64 slice Cardiac computed tomography, coronary dissection was identified extending to the lumen, and the presence of pseudoaneurysm was confirmed. She underwent subsequently a staged procedure, which included placement of an intra-aortic balloon pump, cesarean section, and coronary artery bypass grafting. This case illustrates the utility of coronary artery CT imaging to assess the complexity and stability of coronary artery dissections, thereby helping to determine the need for, and timing of revascularization procedures.

Traumatic diaphragmatic injury: Experience from a level I trauma center

OBJECTIVEnTraumatic diaphragmatic injuries (TDI) are uncommon but associated with substantial morbidity and mortality. We sought to analyze patients with TDI at a large trauma center and associated county coroner to identify characteristics predictive of increased mortality.nnnMETHODSnWe queried a level I university trauma center and associated county coroner databases containing >20,000 patients to identify patients with ICD-9 diagnoses pertaining to TDI from January 1992 through May 2005. Once identified, hospital records, operative details, and autopsy reports were reviewed to determine injury characteristics, treatment provided, and outcome. Statistical analyses were performed using the Student t-test, chi-square analysis, analysis of variance, and multiple logistic regression.nnnRESULTSnTDI were identified in 254 individuals. Two hundred (79%) survived to undergo operation. Of the 81 (32%) deaths, 33 (41%) occurred before arrival at the trauma center. Survivors were younger, had lesser injury severity scores (ISS), were more likely to be female, and had more bilateral injuries (P < or = .002 all) than nonsurvivors. By multiple logistic regression analyses, increased age (odds ratio [OR], 1.044; 95% confidence interval [CI], 1.015-1.074; P = .0029) and greater ISS (OR, 1.145; 95% CI, 1.103-1.188; P < .0001) were predictors of the probability of death in all patients.nnnCONCLUSIONnAlthough TDI may indicate substantive trauma burden in any patient, those with greater ISS and advanced age are at the greatest risk of death.

“Prophylactic” Tricuspid Repair for Functional Tricuspid Regurgitation

BACKGROUNDnThe optimal management of functional tricuspid regurgitation (FTR) in the setting of mitral valve operations remains controversial. The objective of this study is to compare the outcomes of congestive heart failure patients who underwent a prophylactic tricuspid operation for FTR as a component of their initial mitral valve procedure with those who underwent a redo tricuspid operation at a later date for residual FTR.nnnMETHODSnPatients with FTR repaired as a redo operation between 2004 and 2012 were identified. These patients were propensity-matched 1:2 with contemporaneous patients with FTR or tricuspid dilatation who underwent tricuspid repair at the same time as mitral valve repair. Demographic information, postoperative complications, and short-term and long-term mortality rates were compared between groups.nnnRESULTSnThere were 21 patients treated with redo tricuspid valve repair matched with 42 patients treated prophylactically. There were 3 deaths at 30 days in the redo group (14%), compared with zero in the prophylactic group (p=0.03). Overall long-term mortality in the redo group was 29% (6 of 21), with a mean 31 months of follow-up, but was only 14% (6 of 42) in the prophylactic group, with a mean 25 months of follow-up. Kaplan-Meier long-term survival analysis did not reveal a difference between groups (log-rank p=0.37) once the perioperative period was survived.nnnCONCLUSIONSnRedo tricuspid valve repair for residual FTR can be performed with acceptable short-term and long-term mortality. However, treatment of FTR at the time of the initial intervention should be considered, because it is safe and effective. A randomized, controlled trial of prophylactic tricuspid operation for FTR at the time of the mitral operation may be warranted.

Can lung cancer screening by computed tomography be effective in areas with endemic histoplasmosis

OBJECTIVEnLow-dose chest computed tomography (CT) is being evaluated in several national trials as a screening modality for the early detection of lung cancer. The goal of the present study was to determine whether lung cancer screening could be done while minimizing the number of benign biopsy specimens taken in an area endemic for histoplasmosis.nnnMETHODSnThe subjects were recruited by letters mailed to area physicians and local advertisement. The inclusion criteria were age older than 50 years and at least a 20 pack-year smoking history. The exclusion criteria were symptoms suggestive of lung cancer or a history of malignancy in the previous 5 years. The participants completed a questionnaire and underwent a chest CT scan at baseline and annually for 5 years. The management of positive screening results was determined using a defined algorithm: annual follow-up CT scan for nodules less than 5 mm; 6-month follow-up CT scan for nodules 5 to 7 mm; review by our multidisciplinary tumor board for nodules 8 to 12 mm; and biopsy for nodules greater than 12 mm.nnnRESULTSnA total of 132 patients were recruited. Of the 132 patients, 61% had positive baseline CT findings and 22% had positive findings on the annual CT scans. Six cancers were detected. Of these 6 patients, 5 had stage I disease and underwent lobectomy, and 1 had stage IIIA disease and underwent induction chemotherapy and radiotherapy followed by lobectomy. All patients were alive and disease free at a mean follow-up of 41.7 ± 18.6 months. No biopsies were performed for benign lesions. Also, no cancers were missed when the protocol was followed.nnnCONCLUSIONSnScreening with CT can be done effectively in an area endemic for histoplasmosis while minimizing benign biopsies.

Contemporary analysis of early outcomes after lung transplantation in the elderly using a national registry

BACKGROUNDnWith an increasing number of potential recipients and a comparatively static number of donors, lung transplantation (LT) in the elderly has come under significant scrutiny. Previous studies have been limited by single-center experiences with small population sizes and often mixed results. Using a national registry, we sought to evaluate the following: (1) differences in survival outcomes in septuagenarians compared with sexagenarians; and (2) the effect of temporal trends on the development of other comorbidities in this population.nnnMETHODSnWe analyzed the Scientific Registry of Transplant Recipients (SRTR) data files from the United Network for Organ Sharing (UNOS) database to identify recipients who underwent LT between the years 2000 and 2013. The study period was divided into two equal eras. Using Kaplan-Meier analysis, we compared the 30-day, 3-month, 1-year, 3-year and 5-year patient survival between septuagenarians and sexagenarians in both eras. Separate multivariate analyses were performed to estimate the risk of renal failure, risk of rejection and length of hospital stay (LOS) post-LT in each of these time periods.nnnRESULTSnA total of 6,596 patients were identified comprising 1,726 (26.2%) during 2000 to 2005 and 4,870 (73.8%) during 2006 to 2012. In the early era, 32 (1.9%) septuagenarians and 1,694 (98.1%) sexagenarians underwent LT, whereas 543 (11.1%) septuagenarians and 4,327 (88.9%) sexagenarians underwent transplantation in the latter era. A comparison of patient survival between the two groups in the early era revealed no difference at 30 days (95.7% vs 93.8%, p = 0.65). However, 3-month (91.2% vs 75%, p = 0.04) and 1-year patient survival (79.5% vs 62.5%, p = 0.048) were both lower in the septuagenarian group. In the later era, however, there were no differences in 30-day (96.2% vs 96.8, p = 0.5), 3-month (92.7% vs 91.9%, p = 0.56) or 1-year (81.7% vs 78.6%, p = 0.12) patient survival between the two age groups. Survival rates at 3 years (63.7% vs 49.3%, p < 0.001) and 5 years (47.5% vs 28.2%, p < 0.001) were each significantly lower in the septuagenarian group.nnnCONCLUSIONnOverall, LT outcomes for the elderly have improved significantly over time and early outcomes in the modern era rival those found in younger recipients.

Identical tricuspid ring sizing in simultaneous functional tricuspid and mitral valve repair: A simple and effective strategy

OBJECTIVEnMitral valve repair for functional mitral regurgitation is common. Concomitant tricuspid valve repair for associated functional tricuspid regurgitation has gained favor. Controversy exists regarding annuloplasty sizing for tricuspid valve repair.nnnMETHODSnPatients with heart failure having functional mitral regurgitation at the University of Michigan and undergoing mitral valve repair and tricuspid valve repair using identical sized annuloplasty rings between April 2007 and January 2012 were identified. Demographic and clinical records were retrospectively reviewed. Institutional review board approval was obtained for this study.nnnRESULTSnFifty-three patients met inclusion criteria. Mean age was 65 ± 1.7 years. Preoperative New York Heart Association class was III or IV in 81% (43) and mean left ventricular ejection fraction was 33% ± 2.2%. All patients had moderate or greater mitral regurgitation preoperatively and moderate or severe tricuspid regurgitation or a preoperative tricuspid annulus diameter greater than 40 mm. There was no 30-day mortality. Mean immediate postoperative tricuspid valve gradient was 1.75 ± 0.12 mm Hg and was 2.3 ± 0.19 mm Hg at 4 weeks. Four weeks postoperatively 88% (42/48) of patients had tricuspid regurgitation considered to be mild or less. There was no significant decline in right ventricular function by echocardiography over this time period.nnnCONCLUSIONSnFunctional tricuspid regurgitation can be repaired using an undersized rigid annuloplasty ring. Our data suggest that an identical sizing strategy can be used for tricuspid valve repair, as was used for mitral valve repair, without development of tricuspid stenosis or negative effect on right ventricular function. This method seems to prevent recurrence of significant tricuspid regurgitation. The technique we describe provides effective and reproducible results.

Hypertrophic obstructive cardiomyopathy: review of surgical treatment

Hypertrophic cardiomyopathy ranks among the most common congenital cardiac diseases, affecting up to 1 in 200 of the general population. When it causes left ventricular outflow tract obstruction, treatment is guided to reduce symptoms and the risk of sudden cardiac death. Pharmacologic therapy is the first-line treatment, but when it fails, surgical myectomy or percutaneous ablation of the hypertrophic myocardium are the standard therapies to eliminate subaortic obstruction. Both surgical myectomy and percutaneous ablation are proven safe and effective treatments; however, myectomy is the gold standard with a significantly lower complication rate and more complete and lasting reduction of left ventricular outflow tract obstruction.

Transplantation in a patient on extracorporeal membrane oxygenation with infective endocarditis, pericarditis and heparin-induced thrombocytopenia.

Heart failure patients with pacemaker or defibrillator-associated endocarditis in cardiogenic shock have few treatment options. We present a case of an INTERMACS I patient who developed device infection, sepsis, bacterial pericarditis and heparin-induced thrombocytopenia. The patient was stabilized with extracorporeal membrane oxygenation and successfully transplanted.

Ultraportable oxygen concentrator use in U.S. army special operations forward area surgery: A proof of concept in multiple environments

INTRODUCTIONnA limitation to surgical care in an austere environment is the supply of oxygen to support mechanical ventilation and general anesthesia. Portable oxygen concentrators (OCs) offer an alternative to traditional compressed oxygen tanks.nnnOBJECTIVESnWe set out to demonstrate that a low-pressure OC system could supply the mechanical ventilation needs in an austere operating environment.nnnMETHODSnAn ultraportable OC (SAROS Model 3000, SeQual Technologies, Ball Ground, Georgia) was paired with an Impact 754 ventilator (Impact Instrumentation, West Caldwell, New Jersey) to evaluate the delivered fraction of inspired oxygen (FiO2) to a test lung across a range of minute ventilations and at altitudes of 1,200 and 6,500 feet above sea level.nnnRESULTSnThe compressor-driven Impact ventilator was able to deliver FiO2 at close to 0.9 for minute ventilations equal to oxygen flow. Pairing two OCs expanded the range of minute ventilations supported. OCs were less effective at concentrating oxygen at higher altitudes.nnnCONCLUSIONSnThese results demonstrate that low-pressure, ultraportable OCs are capable of delivering high FiO2 during mechanical ventilation in austere locations at both low and high altitudes. Ultraportable OCs could therefore be sufficient to support forward area surgical procedures and positively impact logistics.