Ming-Shian Lu

Blunt traumatic cardiac rupture: therapeutic options and outcomes.

INTRODUCTIONnCardiac rupture following blunt thoracic trauma is rarely encountered by clinicians, since it commonly causes death at the scene. With advances in traumatology, blunt cardiac rupture had been increasingly disclosed in various ways. This study reviews our experience of patients with suspected blunt traumatic cardiac rupture and proposes treatment protocols for the same.nnnMETHODSnThis is a 5-year retrospective study of trauma patients confirmed with blunt traumatic cardiac rupture admitted to a university-affiliated tertiary trauma referral centre. The following information was collected from the patients: age, sex, mechanism of injury, initial effective diagnostic tool used for diagnosing blunt cardiac rupture, location and size of the cardiac injury, associated injury and injury severity score (ISS), reversed trauma score (RTS), survival probability of trauma and injury severity scoring (TRISS), vital signs and biochemical lab data on arrival at the trauma centre, time elapsed from injury to diagnosis and surgery, surgical details, hospital course and final outcome.nnnRESULTSnThe study comprised 8 men and 3 women with a median age of 39 years (range: 24-73 years) and the median follow-up was 5.5 months (range: 1-35 months). The ISS, RTS, and TRISS scores of the patients were 32.18+/-5.7 (range: 25-43), 6.267+/-1.684 (range: 2.628-7.841), and 72.4+/-25.6% (range: 28.6-95.5%), respectively. Cardiac injuries were first detected using focused assessment with sonography for trauma (FAST) in 4 (36.3%) patients, using transthoracic echocardiography in 3 (27.3%) patients, chest CT in 1 (9%) patient, and intra-operatively in 3 (27.3%) patients. The sites of cardiac injury comprised the superior vena cava/right atrium junction (n=4), right atrial auricle (n=1), right ventricle (n=4), left ventricular contusion (n=1), and diffuse endomyocardial dissection over the right and left ventricles (n=1). Notably, 2 had pericardial lacerations presenting as a massive haemothorax, which initially masked the cardiac rupture. The in-hospital mortality was 27.3% (3/11) with 1 intra-operative death, 1 multiple organ failure, and 1 death while waiting for cardiac transplantation. Another patient with morbid neurological defects died on the thirty-third postoperative day; the overall survival was 63.6% (7/11). Compared with the surviving patients, the fatalities had higher RTS and TRISS scores, serum creatinine levels, had received greater blood transfusions, and had a worse preoperative conscious state.nnnCONCLUSIONSnWe proposed a protocol combining various diagnostic tools, including FAST, CT, transthoracic echocardiography, and TEE, to manage suspected blunt traumatic cardiac rupture. Pericardial defects can mask the cardiac lesion and complicate definite cardiac repair. Comorbid trauma, particularly neurological injury, may have an impact on the survival of such patients, despite timely repair of the cardiac lesions.

Extracorporeal life support in post-traumatic respiratory distress patients

BACKGROUNDnExtracorporeal life support (ECLS) has been applied successfully to patients with acute cardiopulmonary failure. However, ECLS remains controversial for traumatized patients who are prone to bleeding.nnnPATIENTS AND METHODSnFrom March 2004 to October 2007, nine patients with post-traumatic respiratory distress refractory to ventilator support were treated with ECLS. Mean patient age was 35.1+/-9.7 (range, 18-47) years, average injury severity score (ISS) was 44.56+/-4.93 (range, 35-50), and Sequential Organ Failure Assessment score (SOFA) score was 12.1+/-3.67 (range, 7-16). Before ECLS, all patients had received thoracic interventions, including four lung resections, with a mean PaO(2) of 49.04+/-9.82 (range, 31-64) mmHg and PaCO(2) of 66.4+/-15.72 (range, 45-86) mmHg. Seven patients were supported in standard veno-venous mode, and the other two were initially supported in veno-arterial mode due to hemodynamic instability.nnnRESULTSnMedian interval from trauma to ECLS was 33 (range, 4-384) h, and median duration of ECLS was 145 (range, 69-456) h. Six (66.7%) patients received additional surgeries during ECLS. One died of sepsis from occult colon rupture and the other of acute liver failure, 6 and 13 days respectively after trauma. Seven (77.8%) patients were weaned and discharged.nnnCONCLUSIONSnUsing ECLS to resuscitate traumatic respiratory distress proved to be safe and effective when conventional therapies had been exhausted. Early deployment of ECLS to preserve systemic organ perfusion, aggressive treatment of coexisting injuries and tailored anticoagulation protocols are crucial to a successful outcome.

Traumatic pericardial effusion: Impact of diagnostic and surgical approaches

INTRODUCTIONnIn trauma patients with chest injuries, traumatic pericardial effusion is an important scenario to consider because of its close linkage to cardiac injury. Even with advances in imaging, diagnosis remains a challenge and use of which surgical approach is controversial. This study reviews the treatment algorithm, surgical outcomes, and predictors of mortality for traumatic pericardial effusion.nnnPATIENTS AND METHODSnInformation on demographics, mechanisms of trauma, injury scores, diagnostic tools, surgical procedures, associated injuries, and hospital events were collected retrospectively from a tertiary trauma center.nnnRESULTSnBetween June 2003 and December 2009, 31 patients (23 males and 8 females) with a median age of 31 (range 16-77), who had undergone surgical drainage of pericardial effusion were enrolled in the study. Blunt trauma accounted for 27 (87.1%) insults, and penetrating injury accounted for 4 (12.9%). Patients were diagnosed by Focused Assessment with Sonography for Trauma (FAST) (8 patients), computerized tomography (7 patients), echocardiography (9 patients), and incidentally during surgery (7 patients). Notably, sixteen (51.7%) patients required surgical repair for traumatic cardiac ruptures, including 6 (19.6%) with pericardial defects who presented initially with hemothorax. The surgical approaches were subxiphoid in 8 patients (25.8%), thoracotomy in 7 (22.6%), and sternotomy in 19 (61.2%), including 3 conversions from thoracotomy. The survival to discharge rate was 77.4% (24/31). Concomitant cardiac repair, associated pericardial defects, and initial surgical approach did not affect survival, but the need for massive transfusion, cardiopulmonary cerebral resuscitation (CPCR), trauma score, and incidental discovery at surgery all had a significant impact on the outcome.nnnCONCLUSIONSnPrecise diagnoses of traumatic pericardial effusions are still challenging and easily omitted even with FAST, repeat cardiac echo and CT. The number of patients with traumatic pericardial effusion requiring surgical repair is high. Standardized therapeutic protocol, different surgical approaches have not impact on survival. Correct identification, prompt drainage, and preparedness for concomitant cardiac repair seem to be the key to better outcomes.

COR TRIATRIATUM SINISTRUM: SURGICAL EXPERIENCE IN TAIWAN

PurposeCor triatriatum sinister, more commonly referred to as cor triatriatum (CT), is characterized by a common pulmonary venous chamber (proximal chamber) separated from the left atrium (distal chamber) by a fibromuscular septum. This report of our experience updates the surgical results of this anomaly in the Asian population.MethodsBetween January 1992 and May 2005, nine patients with cor triatriatum underwent surgical correction at Chang Gung Memorial Hospital. We retrospectively analyzed their cardiac anatomy, clinical data, surgical procedures and follow-up data.ResultsThe mean age at surgery was 260 ± 215 days (range, 20–790 days), with the exception of one patient who underwent surgery at 31 years of age. Three patients had a partial anomalous pulmonary venous connection, one had a complete atrioventricular canal defect, and one had another major complex cardiac anomaly. Eight corrective operations and one palliative operation were performed. There was no surgical mortality. The mean follow-up time was 52.1 ± 43.6 months (range, 17–139 months).ConclusionOur findings show that surgical correction is efficient and safe for this rare cardiac anomaly.

Angiosarcoma in the aortic arch presented as repeat strokes

DISCUSSION We have successfully followed up the first case of multiple pulmonary meningioma by CT scan for more than 10 years after the first operation. During this period, the possibility of metastasis from an intracranial or intraspinal primary tumor was excluded by imaging modalities including CT scan and MRI. Another lesion developed in the right lung and was histologically confirmed to be meningioma, but increase in size was very slow and the lesion has remained solitary. Immunohistochemically, the findings supported a meningothelial origin for the lesion, in line with other reports.

Innominate artery aneurysm as presentation of angiosarcoma

SIX WEEKS PRIOR TO ADMISSION, A 66-YEAR-OLD MAN presented at a local clinic with a 4-month history of dysphagia and paresthesia in his right arm. No body weight loss, hoarseness, or hemopytsis was noted. Diagnostic bronchoscopy, panendoscopy, and chest computed tomography (CT) without contrast was performed to determine the existence of a possible mediastinal lesion. No esophageal, endobroncheal, or lung lesion was found. However, chest CT revealed the presence of an anterior mediastinal mass. The mass was oval and measured 5 cm in diameter. CT angiography was performed 2 days later. It revealed the presence of a mediastinal mass bulging from the aortic arch. The mass was eventually identified as an innominate artery aneurysm. The diameter of the aneurysm increased from 50 mm to 65 mm within 2 days (Fig 1). An endovascular approach to exclude the aneurysm was considered first. However, it was

Modified neodymium-YAG laser in rigid bronchoscopy.

The use of laser bronchoscopy in the treatment of tracheobronchial stenosis has been reported in the past. It is generally safe and effective; however, the complications of haemorrhage, airway perforation, or airway fire are relatively frequent among less experienced surgeons. We illustrate a modified technique of laser probe location to simplify the laser ablation procedure.