Endovascular approach to a complex thrombus in-transit through a patent foramen ovale.

Large atrial thrombi can be managed percutaneously. We present a case of a 76-year-old female patient who presented to our emergency room with an acute stroke and was managed with mechanical thrombectomy. Further work-up revealed a large complex thrombus in-transit trapped in a patent foramen ovale with a large mobile portion in the left atrium. Due to contraindications for thrombolysis and poor surgical candidacy, an endovascular approach was favored. The procedure was performed successfully, and the patient recovered uneventfully. Learning objective: Endovascular approach with mechanical thrombectomy can be a treatment option for patients that present with large thrombus in-transit when other therapies are contraindicated.

Isolated Tricuspid Valve Repair Versus Replacement: Predictors of Mortality on the National Level.

OBJECTIVE: Isolated tricuspid valve surgery (TVR) is rarely performed, and literature reports are confined to small sample sizes and old studies. Thus, the advantage of repair over replacement could not be determined. We aimed to evaluate repair and replacement outcomes along with predictors of mortality for TVR on a national level. METHODS: All adult patients (18+ years old) who underwent TVR from 2011 to 2020 were identified using the National Inpatient Sample dataset. The primary outcome was in-hospital mortality. Secondary outcomes included complications, length of stay (LOS), hospitalization cost, and discharge disposition. RESULTS: Over a 10-year period, 37,931 patients had TVR and predominantly underwent repair (n = 25,027, 66.0%). In comparison with patients who underwent tricuspid replacement, more patients with a history of liver disease and pulmonary hypertension presented for repair surgery, and fewer patients had endocarditis and rheumatic valve disease (P < 0.001). The repair group had less mortality, less stroke, shorter LOS, and reduced cost, while the replacement group had fewer myocardial infarctions (P < 0.05). However, the outcomes were not different for cardiac arrest, wound complications, or bleeding. After excluding congenital TV disease and adjusting for relevant factors, TV repair was associated with a reduced in-hospital mortality by 28% (adjusted odds ratio [aOR] = 0.72, P = 0.011). Older age increased mortality risk by 3-fold, prior stroke by 2-fold, and liver diseases by 5-fold (P < 0.001). Patients undergoing TVR in recent years had a better chance of survival (aOR = 0.92, P < 0.001). CONCLUSIONS: TV repair has better outcomes than replacement does. Patient comorbidities and late presentation play an independently significant role in determining outcomes.

Surgical versus transcatheter aortic valve replacement: Impact of patient-prosthesis mismatch on outcomes.

BACKGROUND: The hemodynamics of most prosthetic valves are often inferior to that of the normal native valve, and a significant proportion of patients undergoing surgical (SAVR) or transcatheter aortic valve replacement (TAVR) have high residual transaortic pressure gradients due to prosthesis-patient mismatch (PPM). As the experience with TAVR has increased and long-term outcomes are reported, a close look at the PPM literature is required in light of new evidence. METHODS: For this review, we searched the Embase, Medline, and Cochrane databases from 2000 to 2022. Articles reporting PPM as an outcome following aortic valve replacements were identified and reviewed. RESULTS: The impact of PPM on clinical outcomes in aortic valve replacement has not been clear as multiple studies failed to report PPM incidence. However, the PPM outcomes after SAVR vary more widely than after TAVR, ranging from 8% to 80% in SAVR and from 24% to 35% in TAVR. Incidence of severe PPM following redo SAVR ranges from 2% to 9% and following valve-in-valve TAVR is from 14% to 33%, however, while PPM is higher in valve-in-valve TAVR, patients had better survival rates. CONCLUSIONS: The gap between valve performance and clinical outcomes in SAVR and TAVR could be reduced by carefully selecting patients for either treatment option. Understanding predictors of PPM can add to the safety, effectiveness, and increased survival benefit of both SAVR and TAVR.

Minimally invasive management of an ascending colonic perforation secondary to distal biliary stent migration: a multidisciplinary, novel laparoendoscopic approach.

Endobiliary stents placed for benign and malignant indications can spontaneously dislocate from the biliary system and migrate to the distal gastrointestinal tract. Stent migration can result in gastrointestinal perforation, with the most common locations in the sigmoid and distal colon, and may require surgical intervention. We describe the case of a 60-year-old female presenting with an ascending colonic perforation secondary to a dislodged plastic biliary stent placed for palliation of her gallbladder carcinoma. The patient was managed with a combined laparoendoscopic approach by a multidisciplinary team-gastroenterology performed an endoscopic stent retrieval and colorectal surgery identified the location of the perforation laparoscopically and performed colonic serosal repairs. The patient had an uneventful postoperative course and was discharged on postoperative day 4. This case demonstrates a novel minimally invasive laparoendoscopic approach at a high-volume academic center for the treatment of ascending colonic perforation secondary to biliary stent migration.

Strategies and outcomes of patients with severely reduced ejection fraction (≤15%) undergoing transvenous lead extraction: A single-center experience.

BACKGROUND: Patients with severely reduced ejection fraction (SREF ≤15%) are deferred from transvenous lead extraction (TLE) owing to fear of intraoperative hemodynamic collapse. When these patients require lead extraction, their management options are limited, and they suffer from high morbidity and mortality. Left ventricular (LV) assist devices provide intraoperative hemodynamic support and facilitate TLE, enabling lifesaving interventions. OBJECTIVE: We present our experience of performing TLE in 245 patients with SREF. Additionally, we report outcomes of 8 patients who received LV support during TLE. METHODS: Between January 2008 and January 2022, we performed TLE in 245 patients with stage D heart failure, SREF, and class I or II indications for extraction. Primary (clinical success and in-hospital mortality) and secondary (length of stay and procedure-associated complications) outcomes were compared between patients with SREF and patients in our registry undergoing extraction with EF < 15%. A subgroup analysis was performed in the SREF group to evaluate outcomes of 8 patients who underwent extraction with LV assist devices. RESULTS: In patients with SREF, clinical success was high (97.6%) and mortality was low (5.3%). There were no statistically significant differences in primary outcomes between groups. Similarly, there were no significant differences in procedural complications between groups. In the SREF group, there were no significant differences in outcomes between the 8 patients undergoing TLE with LV assist devices and patients that did use LV assist devices. CONCLUSION: Lead extraction in patients with SREF can be performed safely and effectively. Adopting a few simple steps, including the early initiation of LV support, can overcome myocardial impairment in patients who decompensate.

Outcomes of Minority COVID-19 patients managed with ECMO: A single-center experience.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has significantly burdened the global healthcare system since December 2019. Minority populations are found to have a higher incidence of hospitalization and higher mortality when compared to Caucasians. Extracorporeal membrane oxygenation (ECMO) is reserved for COVID-19 patients who develop respiratory failure refractory to conventional management. To our knowledge, no data has been reported on outcome differences between Minority COVID-19 patients and Caucasian COVID-19 patients managed with ECMO. We aimed to investigate the outcome differences between these two groups. METHODS: Our retrospective cohort study had 23 adults (aged 18 and older) diagnosed with COVID-19 by polymerase chain reaction. All patients developed acute respiratory distress syndrome (ARDS), refractory to conventional treatment, and were managed on ECMO support. The primary outcome of interest was mortality; the secondary outcome was the rate of ECMO-related complications. RESULTS: The overall mortality rate of our study was higher (70%) than other reports of the COVID-19 population on ECMO. Caucasians in our study had more severe respiratory acidosis with carbon dioxide retention and appeared to have a higher mortality rate of 85.7% compared to Minorities (62.5%). No differences in complication rates between these two groups were identified. CONCLUSIONS: Our cohort revealed a high overall mortality rate of COVID-19 patients on ECMO support. The Caucasian group was observed to have higher mortality than the Minority group. The high overall mortality was likely attributed to the Caucasian group, which had more severe respiratory acidosis before ECMO initiation, a known predictor of poor prognosis in ARDS patients. Our cohort's ethnic composition may also partially explain the high mortality rate since COVID-19 Minorities are reported to have worse outcomes than Caucasians. Larger and randomized studies are needed to investigate further the mortality and complication differences between Minority and Caucasian patients diagnosed with COVID-19 and managed by ECMO.

Acute Presentation of a High-Grade Myxofibrosarcoma Originating in the Thoracic Wall: A Case Report.

We report the first case of a patient with myxofibrosarcoma (MFS) who presented acutely with a rib fracture and developed a rapidly expanding loculated hemothorax after chest trauma. The patient was taken to the operating room for evacuation of hemothorax, and samples and biopsy specimens were taken for cytologic and pathologic examination. Final report with immunohistochemical staining showed a high-grade MFS. After the procedure, there was clinical and radiological improvement, and the patient was followed up as an outpatient. Myxofibrosarcoma is a very rare and aggressive connective tissue neoplasm with variable presentations. Surgical resection is the preferred treatment. Prompt diagnosis and adequate management of these tumors are important to reduce their high local recurrence and distant metastasis rates. Therefore, it is important to be aware of its common and uncommon presentations.

Location of Superior Vena Cava Tears in Transvenous Lead Extraction.

BACKGROUND: Superior vena cava (SVC) tears are rare but potentially lethal complications associated with transvenous lead extraction. When lacerations occur, surgeons need to be prepared for an emergent response. Nonetheless, little is known about the precise whereabouts of these lesions. Understanding the location and injury patterns enables a more anticipated and targeted surgical response. METHODS: We collected data via physician interviews after an SVC laceration occurred. These physicians were identified through the US Food and Drug Administration's Manufacturer and User Facility Device Experience database and independent physician reports of adverse events. We identified 116 reports of SVC tears between July 1, 2016, and July 31, 2018. For an SVC tear to be included in our registry, a cardiothoracic surgeon had to be physically present to confirm the injury via emergent sternotomy. In each case, the surgeon recorded the SVC injury's exact location after a repair was attempted. RESULTS: During the study period, 116 SVC tears were confirmed by sternotomy. Tears occurred in any combination of the following locations: SVC-innominate vein, body of the SVC, and SVC-right atrial junction. The majority of tears (n = 72; 62%) were located in the isolated body of the SVC, followed by the SVC-right atrial junction (n = 23;19.8%) and the SVC-innominate junction (n = 17;14.6%). Combined tears were rare, accounting for only 3.6% (n = 4) of the adverse events recorded. CONCLUSIONS: Most SVC tears occurred in the isolated body of the SVC. The second most common location was the SVC-right atrial junction. The SVC-innominate junction was the third most common location for these injuries. Combined tears were uncommon.

Social Media in Physician Education.

Background Social media has fundamentally changed the practice of medicine. It has taken the medical community by storm, benefited patient care, and has become a leading source for distributing medical information. Social media platforms are a low-cost, low-barrier entry means for health systems to highlight their competitive advantage to patients and providers alike. This study aimed to assess the role of social media in the education of physicians. Methods To evaluate the utility of social media in engaging physicians, four vignettes were utilized to highlight Class 1 indications for transvenous lead extraction (TLE), an electrophysiology procedure aimed at removing infected or damaged cardiac device leads. Individuals, via Twitter, were presented with cases and multiple-choice response options to determine the next best step in management. Results The clinical vignettes were seen by more than 18,000 individuals worldwide. Survey results indicated that 83% of individuals who participated had correctly identified class 1 indications for this life-saving procedure. Sixteen percent to 21% of physicians incorrectly identified the next step in the management of Class 1 indications for lead extraction, representing a need for education and an opportunity to inform and educate. Conclusion Social media may be a useful tool in physician education. However, guidelines and further research are needed to continue to understand the role of social media within the medical field.

Lead-related superior vena cava syndrome: Management and outcomes.

BACKGROUND: Superior vena cava (SVC) syndrome includes the clinical sequalae of facial and bilateral upper extremity edema, dizziness, and occasional syncope. Historically, most cases have been associated with malignancy and treatment is palliative. However, cardiac device leads have been identified as important nonmalignant causes of this syndrome. There are little data on the effectiveness of venoplasty and lead extraction in the management of these patients. OBJECTIVE: The objective of this study was to report the findings associated with the use of balloon angioplasty and lead extraction in the management of 17 patients with lead induced SVC syndrome. METHODS: Data collected from January 2003 to July 2019 identified 17 cases of SVC syndrome at our tertiary center. Their outcomes were compared to a control group of patients without SVC syndrome. A P value of <.05 was considered statistically significant. RESULTS: Of the 17 patients, 13 (76%) underwent transvenous lead extraction and venoplasty. Three patients (18%) were treated with venoplasty alone, and 1 patient (6%) underwent surgical SVC reconstruction. In 10 patients (59%), transvenous reimplantation was necessary. Symptom resolution was achieved in all 17 patients and confirmed at both 6 and 12 months' follow-up. There was no significant difference in the rate of complications associated with transvenous lead extraction for SVC syndrome vs control. CONCLUSION: In patients with SVC syndrome, venoplasty and lead extraction are safe and effective for resolution of symptoms and maintaining SVC patency.

A Unique Case of Elizabethkingia Associated Cardiac Device Infection.

Elizabethkingia is a ubiquitous gram-negative aerobic bacillus that has gained attention in recent years as an emerging nosocomial infection in critically ill patients. We describe a case of bacteremia that developed in a patient who underwent complicated surgery with an extended intensive care unit (ICU) stay. The patient underwent pacemaker extraction with laser lead extraction and treatment with intravenous antibiotics. This case illustrates the importance of lead management strategies in septic patients with cardiac implantable electronic devices (CIED).

Influence of vegetation shape on outcomes in transvenous lead extractions: Does shape matter?

BACKGROUND: Small vegetations (<2.0 cm) associated with infected cardiac device leads can be managed percutaneously, whereas larger vegetations typically are removed via open heart surgery. Unfortunately, many patients with intracardiac vegetations are not candidates for open removal. OBJECTIVE: The purpose of this study was to report our experience in the outcomes associated with the percutaneous management of large vegetations. METHODS: Prospective data from January 2010 to August 2018 identified 826 patients with infections undergoing lead extraction. One hundred nineteen cases had vegetations measured in 2 dimensions (length and width) by transesophageal echocardiogram. Thirty-two patients had 3 characteristics: (1) at least 1 vegetation dimension ≥2.0 cm; (2) not a surgical candidate; and (3) had undergone transvenous lead extraction. The cohort was classified into 2 groups according to shape: (1) globular if the difference between dimensions was <30% between dimensions; and (2) nonglobular if the difference was >30%. The Fisher exact test and Pearson t test were used for analysis. P <.05 was considered significant. RESULTS: Retrospective analysis of a single tertiary cardiac surgery center registry showed a significantly lower chance of being alive at discharge in patients with globular vegetations compared to patients with nonglobular vegetations (P = .002). CONCLUSION: Vegetation size is an important determinant of outcomes in patients who are not surgical candidates undergoing transvenous lead extraction. However, vegetation shape is also a relevant factor, as globular vegetations may predict a worse result compared to nonglobular vegetations.

Barriers to the Effective Management of Gynecomastia in Adolescents.

BACKGROUND: The aim of this study was to explore the impacts of gynecomastia on adolescents, explore the surgical and psychological success of mastectomy, and evaluate the adequacy of insurance guidelines and coverage. METHODS: American College of Surgeons National Surgical Quality Improvement Program (NSQIP) surgical database from 2010 to 2014 was evaluated for current procedural terminology codes 19300 and 19303, representing mastectomies for gynecomastia and complete mastectomies respectively to compare surgical site complications. RESULTS: Of 1132 procedures for mastectomy for gynecomastia 1.5% of patients (n = 17) were associated with postoperative superficial surgical site complications. In the same timeframe, a total of 33,124 procedures for simple, complete mastectomy performed with a postoperative surgical complication rate of 2.2% (n = 721). Results of a Chi-squared goodness of fit χ (1, N = 34,997) = 2.10, P > 0.05 suggests no statistically significant difference between incidence of surgical site complications for a mastectomy for gynecomastia versus typical mastectomy. DISCUSSION: High surgical success rate, coupled with significant improvements in psychosocial functioning suggests that mastectomy is a highly effective intervention for adolescents with gynecomastia. However, due to vague and inadequate coverage and evaluation criteria surgery is often not performed. This paper offers a framework for developing a quantitative system by which to evaluate surgical candidates by adopting well-established guidelines currently in use for reduction mammoplasties and suggests further analysis into a cost/benefit analysis for coverage of the procedure.

Comparison of the Neuroprotective and Anti-Inflammatory Effects of the Anthocyanin Metabolites, Protocatechuic Acid and 4-Hydroxybenzoic Acid.

Anthocyanins are being increasingly investigated for their neuroprotective and antineuroinflammatory effects; however, the overall bioavailability of many anthocyanins is relatively low. In contrast, phenolic acids, metabolites of many polyphenols, including anthocyanins, have been shown to accumulate in tissue at higher concentrations than those of parent compounds, suggesting that these metabolites may be the bioactive components of anthocyanin-rich diets. We examined the neuroprotective capacity of two common phenolic acids, 4-hydroxybenzoic acid (HBA) and protocatechuic acid (PCA), in primary cultures of cerebellar granule neurons. Both HBA and PCA are capable of mitigating oxidative stress induced by hydrogen peroxide, which is thought to contribute to neuronal cell death in neurodegeneration. Under conditions of nitrosative stress, which occur during inflammation in the central nervous system, only PCA was neuroprotective, despite similar structural characteristics between HBA and PCA. Intriguingly, this trend was reversed under conditions of excitotoxicity, in which only HBA was neuroprotective. Lastly, we explored the anti-inflammatory activity of these compounds in microglial cells stimulated with lipopolysaccharide. PCA was an effective anti-inflammatory agent, reducing nitric oxide production, while HBA had no effect. These data indicate that phenolic acids possess distinct neuroprotective and anti-inflammatory characteristics that could make them suitable for the treatment of neurodegeneration.

Radiologic Considerations in Heterotaxy: The Need for Detailed Anatomic Evaluation.

So-called "heterotaxy" is a laterality defect characterized by isomerism of the thoracic organs and random arrangement of the abdominal organs. These findings go beyond anatomic curiosity and have functional implications. It is, thus, of the utmost importance to be able to properly identify these findings. Radiologic studies can be invaluable in determining anomalies in the central nervous, pulmonary, cardiovascular, gastrointestinal, genitourinary, and immunologic systems in patients with isomerism. Here, we review findings associated with isomerism and their importance in the setting of isomerism with the aim of ensuring that radiologists effectively describe findings in these patients and that cardiologists understand the wide variety of congenital malformations that may be present.