Victor X. Mosquera

Minimal traumatic aortic injuries: meaning and natural history

OBJECTIVE Minimal aortic injuries (MAIs) are being recognized more frequently due to the increasing use of high-resolution diagnostic techniques. The objective of this case series review was to report the clinical and radiological characteristics and outcomes of a series of patients with MAI. METHODS From January 2000 to December 2011, 54 major blunt trauma patients were admitted to our institution with traumatic aortic injuries. Nine of them presented with MAI, whereas the remaining 45 patients suffered a significant aortic injury (SAI). RESULTS MAIs accounted for 17% of the overall traumatic aortic injuries in our series. Major trauma patients with MAI and SAI were similar regarding the presence of severe associated non-aortic injuries and the expected mortality calculated by injury severity score, revised trauma score and trauma injury severity score. There were no statistically significant differences in in-hospital mortality between MAI (22.2%) and SAI (30.2%). No death in the MAI group was aortic related, whereas five deaths in the SAI group were caused by an aortic complication. The survival of MAI patients was 77.8% at 1 and 5 years. There was no late mortality among MAI patients. The survival of SAI patients was 69.7% at 1 year and 63.6% at 5 and 10 years. None of the seven surviving patients with MAI presented a progression of the aortic injury. In six patients, the intimal tear completely healed in imaging controls, whereas one patient developed a small saccular pseudoaneurysm. CONCLUSIONS Blunt traumas presenting MAI are as severe as traumas that associate SAI and present similar in-hospital mortality. In contrast to SAI traumas, in-hospital mortality due to MAI is not usually related to the aortic injury, so these injuries are more amenable to a conservative management. It is mandatory to perform a close imaging surveillance to detect early any potential adverse evolution of an MAI. Nevertheless, a balance must be struck between a close serial imaging surveillance and the potentially detrimental effects of obtaining high-resolution additional images.

Blunt traumatic aortic injuries of the ascending aorta and aortic arch: a clinical multicentre study

OBJECTIVE To report the clinical and radiological characteristics, management and outcomes of traumatic ascending aorta and aortic arch injuries. METHODS Historic cohort multicentre study including 17 major trauma patients with traumatic aortic injury from January 2000 to January 2011. RESULTS The most common mechanism of blunt trauma was motor-vehicle crash (47%) followed by motorcycle crash (41%). Patients sustaining traumatic ascending aorta or aortic arch injuries presented a high proportion of myocardial contusion (41%); moderate or greater aortic valve regurgitation (12%); haemopericardium (35%); severe head injuries (65%) and spinal cord injury (23%). The 58.8% of the patients presented a high degree aortic injury (types III and IV). Expected in-hospital mortality was over 50% as defined by mean TRISS 59.7 (SD 38.6) and mean ISS 48.2 (SD 21.6) on admission. Observed in-hospital mortality was 53%. The cause of death was directly related to the ATAI in 45% of cases, head and abdominal injuries being the cause of death in the remaining 55% cases. Long-term survival was 46% at 1 year, 39% at 5 years, and 19% at 10 years. CONCLUSIONS Traumatic aortic injuries of the ascending aorta/arch should be considered in any major thoracic trauma patient presenting cardiac tamponade, aortic valve regurgitation and/or myocardial contusion. These aortic injuries are also associated with a high incidence of neurological injuries, which can be just as lethal as the aortic injury, so treatment priorities should be modulated on an individual basis.

Early atrial septal defect surgery due to a bronchogenic cyst causing congestive heart failure by left atrium compression

We report on an uncommon case of a 10-month-old patient who required early surgical closure of an ostium secumdum atrial septal defect due to the concomitant presence of a big subcarinal bronchogenic cyst compressing the left atrium and, therefore, increasing the left-to-right shunt. It led to refractory congestive heart failure symptoms, establishing thereby an earlier indication of surgical treatment.

Aortic injuries in crush trauma patients: Different mechanism, different management

BACKGROUND The objective of this study is to report the clinical and radiological characteristics and early and long-term survival of a series of acute traumatic aortic injuries (ATAI) in crush trauma patients, and to compare such data with our last 30 years experience managing ATAI in deceleration non-crush trauma patients. METHODS From January 1980 to December 2010, 5 consecutive ATAI in crush trauma and 69 in non-crush trauma patients were admitted at our institution. ISS, RTS and TRISS scores were similar in both groups. RESULTS Overall in-hospital mortality was 24.3%. There was no in-hospital mortality in crush patients and 26.1% in non-crush patients (p=0.32). All aortic-related complications occurred in non-crush patients. Median follow-up was 129 months (range 3-350 months). Non-crush group survival was 76.8% at 1 year, 73.6% at 5 years, and 71.2%% at 10 years. There was no mortality during follow-up in the crush group. Mean (SD) peak creatine phosphokinase was significantly higher in crush group than in non-crush group: 7598 (3690) IU/L vs. 3645 (2506) IU/L; p=0.041. Incidence of acute renal injury was higher in crush trauma patients (100% vs. 36.2%; p=0.018). Low-severity injuries were more common in crush trauma patients (100% in crush patients vs. 43.5% in non-crush patients, p=0.04). CONCLUSIONS Aortic injuries in crush thoracic trauma patients seem to present in a different clinical scenario from aortic injuries in high-speed thoracic trauma thus requiring distinct considerations. When planning the initial management of aortic injuries in crush trauma, the increased risk of rhabdomiolysis and subsequent acute renal failure, as well as a tendency to develop lower-risk aortic wall injuries, must be considered.

Septic necrosis of the odontoid apophysis and cervical spondylodiscitis from Enterococcus faecalis endocarditis: a first report.

We describe a 75-year-old male patient who developed a general syndrome, with a fever of 39 degrees C, weight loss, and cervical pain, during the month following a urological procedure. The presence of positive blood cultures for Enterococcus faecalis, aortic vegetations, and severe aortic regurgitation observed with echocardiogram confirmed the diagnosis of infective endocarditis (IE). Magnetic resonance imaging of the spinal cord showed significant erosion and irregularities of the odontoid apophysis, with hyperintensity of bone marrow in T2-weighted images because of edema and inflammation. These findings suggested an infective necrosis of the odontoid apophysis. Despite the common occurrence of rheumatologic manifestations in IE, with prevalence rates of 25% to 44%, spondylodiscitis is rarely observed (5%-13%). The lumbar region is the most commonly involved. We found only one other reported case of cervical spondylodiscitis. The case we describe is the first report of septic necrosis of the odontoid apophysis associated with IE.

Reconstrucción del tracto de salida del ventrículo derecho con raíz aórtica protésica Medtronic Freestyle

La insuficiencia pulmonar no corregida conduce a la dilatacion y disfuncion del ventriculo derecho a largo plazo en un porcentaje importante de pacientes. Hemos analizado mediante resonancia magnetica cardiaca (RMC) preoperatoria y postoperatoria el efecto del recambio valvular pulmonar con protesis Medtronic Freestyle en la funcion y los volumenes del ventriculo derecho en 9 pacientes con insuficiencia y/o estenosis pulmonar con seguimiento de 26 ± 10 meses. Observamos una disminucion del volumen telediastolico medio desde 143,6 ± 85,1 hasta 74,1 ± 12,6 ml/m2 (p = 0,018), y del volumen telesistolico medio desde 88 ± 50,3 hasta 35,8 ± 19,3 ml/m2 (p = 0,016). La valvulopatia pulmonar requiere un seguimiento exhaustivo mediante RMC para determinar precozmente el grado de dilatacion y disfuncion del ventriculo derecho, y asi decidir el momento idoneo para la sustitucion valvular. La bioprotesis Freestyle en posicion pulmonar es una opcion quirurgica adecuada, con una baja morbimortalidad y excelentes resultados en cuanto a restauracion volumetrica ventricular.

Reemplazo valvular aórtico con bioprótesis no soportada de Cryolife O'Brien

Introduccion y objetivos El xenoinjerto de Cryolife O’Brien es una bioprotesis no soportada, construida por valvas no coronarias de 3 valvulas aorticas porcinas. El objetivo de este estudio es investigar los resultados precoces despues del reemplazo valvular aortico con este xenoinjerto compuesto. Metodos Desde octubre de 1993, la bioprotesis Cryolife O’Brien ha sido implantada en 210 pacientes. La edad media fue de 70,9 ± 7,5 anos (intervalo, 23 y 83 anos). La indicacion fue estenosis aortica en 132 casos, insuficiencia aortica en 25 casos y doble lesion en 53 casos. Se ha estudiado la funcion valvular, mediante ecocardiografia preoperatoria, en el momento del alta y a los 6 y 12 meses del postoperatorio. Resultados La mortalidad a 30 dias fue del 5,2% (11/210). Los gradientes medios se reducen y el indice de area efectiva aortica aumenta con el tiempo. El indice de masa ventricular izquierda, el grosor de la pared y el espesor del septo tambien se reducen de forma precoz en el postoperatorio. Conclusiones El uso de la bioprotesis no soportada de Cryolife O’Brien ha mostrado unos resultados satisfactorios en el seguimiento a un ano. Sera necesario realizar seguimientos futuros para analizar el comportamiento de esta bioprotesis a largo plazo.