Aortic Valve Replacement and Exclusion of Sinus of Valsalva Aneurysm With Balloon-Expandable Transcatheter Aortic Valve.

An 85-year-old female with severe aortic valve stenosis presented with heart failure complicated with cardiogenic shock and was found to have a right coronary cusp sinus of Valsalva aneurysm. We report the first case of successful exclusion of a sinus of Valsalva aneurysm during transcatheter aortic valve replacement using a balloon-expandable valve. (Level of Difficulty: Intermediate.).

Acute stroke intervention after transcatheter aortic valve replacement.

Stroke is a devastating complication in patients undergoing transcatheter aortic valve replacement (TAVR). We sought to determine whether early stroke intervention after TAVR would improve the neurological outcomes. Two patients experienced stroke immediately after TAVR, one treated with mechanical thrombectomy and localized lytic therapy and one treated with systemic lytic therapy. Our limited experience showed that early stroke intervention with either treatment option may reduce the risk of complications and improve neurological outcomes.

Frequency of Troponin Testing in Inpatient Versus Outpatient Settings.

Troponin elevation is required to diagnose acute myocardial infarction (AMI), yet elevated values are often encountered in noncardiac disease states. We evaluated inpatient (IP) and outpatient (OP) encounters at 14 hospitals in calendar year 2014 and found that troponin assays were performed during 12% of all OP visits and 29% of all IP visits: 82,853 encounters in all. We employed an expert panel to estimate the likelihood of AMI based on primary International Statistical Classification of Diseases and Related Health Problems, 9th edition diagnoses. We compared IP and OP testing, finding that AMI would not be expected in most IP encounters. Sepsis was the most common diagnosis associated with IP troponin testing. We found an association between troponin testing in patients with sepsis and utilization of electrocardiography, echocardiography, and cardiac catheterization. Our data indicate that troponin testing has expanded beyond patient populations in whom AMI might be expected.

ST-elevation acute myocardial infarction due to arterial thrombosis in a 29-year-old woman with normal coronary arteries.

Acute myocardial infarction (AMI) is rare in young adults. We present a case of a 29-year-old black woman who presented with an acute onset of chest pain while sleeping. Anterior wall ST-elevation AMI was diagnosed based on clinical presentation, electrocardiographic findings, and elevated cardiac biomarkers. Coronary angiography revealed a totally occluded proximal left anterior descending artery. The obstructing lesion, thrombus, was removed. There was no evidence of atherosclerotic disease or dissection. An evaluation for a hypercoagulable state was unrevealing. Echocardiography 1 year later revealed normal left ventricular wall motion and systolic function.

Biomechanical analysis comparing a traditional superior-inferior arthroscopic rotator interval closure with a novel medial-lateral technique in a cadaveric multidirectional instability model.

BACKGROUND: Commonly performed arthroscopic rotator interval closure techniques that imbricate the rotator interval in a superior-inferior direction have been unable to reproduce the stabilizing effects of an open medial-lateral rotator interval imbrication. HYPOTHESIS: The medial-lateral rotator interval closure will allow less inferior and posterior glenohumeral translation than the superior-inferior rotator interval closure, and the medial-lateral rotator interval closure will result in less loss of external rotation than the superior-inferior closure. STUDY DESIGN: Controlled laboratory study. METHODS: Eight match-paired cadaveric shoulders were stretched to 10% beyond the maximum range of motion in 0 degrees and 60 degrees of glenohumeral abduction to create a multidirectional instability model. Shoulders were then repaired using a superior-inferior rotator interval closure or an arthroscopic medial-lateral rotator interval closure with an anchor in the humeral head. Rotational range of motion, glenohumeral translation, and humeral head apex position were measured for intact, stretched, and repaired conditions in both 0 degrees and 60 degrees of glenohumeral abduction. RESULTS: In 0 degrees of abduction, after both rotator interval closure techniques, external rotation decreased significantly (by 4.4%; P < .05) relative to the stretched state and was restored to the intact state. In 60 degrees of abduction, only the medial-lateral rotator interval closure restored range of motion to the intact state. In 60 degrees of abduction, the medial-lateral rotator interval closure was more effective in reducing posterior translation than was the superior-inferior closure (P = .03). CONCLUSION: The medial-lateral rotator interval closure restored range of motion to the intact state better than the superior-inferior closure. Compared with the superior-inferior rotator interval closure, the medial-lateral closure significantly decreased posterior translation with the shoulder in abduction and external rotation. CLINICAL RELEVANCE: Arthroscopic medial-lateral rotator interval closure with a suture anchor in the humeral head can be considered in the surgical treatment of patients with multidirectional instability, especially those with a component of posterior instability, without concern for excessive loss of range of motion.

Electromyographic analysis of forearm muscles in professional and amateur golfers.

BACKGROUND: No fine-wire electromyography studies have been performed to compare the activity of forearm muscles in professional golfers versus amateur golfers. HYPOTHESIS: The fine-wire electromyographic activity of forearm muscles differs between professional and amateur golfers during the different phases of the golf swing. STUDY DESIGN: Controlled laboratory study. METHODS: Ten male right-handed amateur golfers and 10 male right-handed professional golfers without history of elbow symptoms were tested with fine-wire electromyographic electrodes inserted into the flexor carpi radialis, pronator teres, flexor carpi ulnaris, and extensor carpi radialis brevis muscles of both forearms. Electromyographic data were synchronized with video data, and the muscle activity was expressed as a percentage of maximum manual muscle test activity for each phase of the golf swing. RESULTS: Compared with professional golfers, amateur golfers had more muscle activity in the pronator teres of the trail arm (right arm in a right-handed golfer) in the forward swing phase (120.9% maximum manual muscle test vs 57.4% maximum manual muscle test; P = .04) and a trend toward increased activity in the acceleration phase (104.8% maximum manual muscle test vs 53.1% maximum manual muscle test; P = .08). In contrast, professional golfers had more muscle activity in the pronator teres of the lead arm (left arm in a right-handed golfer) in the acceleration phase (88.1% maximum manual muscle test vs 36.3% maximum manual muscle test; P = .03) and a trend toward increased activity in the early follow-through phase (58.1% maximum manual muscle test vs 28.8% maximum manual muscle test; P = .06). CONCLUSION: Pronator teres muscle activity in the golf swing differs significantly between professional and amateur golfers. CLINICAL RELEVANCE: Exercises with an emphasis on stretching and strengthening of the pronator teres may be useful in treating and/or preventing medial epicondylitis in amateur golfers.

Type III acromioclavicular separation: rationale for anatomical reconstruction.

Treatment of acute type III acromioclavicular separation is controversial. In some patients, nonoperative treatment is associated with pain, weakness, and stiffness. Many acromioclavicular joint reconstructions are associated with complications and results not substantially better than those of nonoperative treatment. Use of autogenous free tendon graft to anatomically reconstruct the acromioclavicular and coracoclavicular ligaments offers several advantages over other surgical techniques. These advantages include improved biomechanical properties, no foreign body implantation, biological fixation, anatomical reconstruction, and early rehabilitation.

Improvement in documentation of compartment syndrome with a chart insert.

To improve documentation of compartment syndrome, an educational program was instituted and a chart insert consisting of a preprinted checklist of history and physical examination parameters for at-risk patients was created. From October 2004 to May 2005, a total of 45 consecutive at-risk patients were identified. Progress notes were divided into group 1 (educational program alone) and group 2 (educational program and checklist). Group 2 showed more complete documentation than group 1. The combination of a chart insert and an educational program proved to be more effective than an educational program alone for improving the documentation of compartment syndrome.

Sports hernia: diagnosis and therapeutic approach.

Groin pain is a common entity in athletes involved in soccer, ice hockey, Australian Rules football, skiing, running, and hurdling. An increasingly recognized cause of groin pain in these athletes is a sports hernia, an occult hernia caused by weakness or tear of the posterior inguinal wall, without a clinically recognizable hernia, that leads to a condition of chronic groin pain. The patient typically presents with an insidious onset of activity-related, unilateral, deep groin pain that abates with rest. Although the physical examination reveals no detectable inguinal hernia, a tender, dilated superficial inguinal ring and tenderness of the posterior wall of the inguinal canal are found. The role of imaging studies in this condition is unclear; most imaging studies will be normal. Unlike most other types of groin pain, sports hernias rarely improve with nonsurgical measures; thus, open or laparoscopic herniorrhaphy should be considered.

Clinical assessment of three common tests for traumatic anterior shoulder instability.

BACKGROUND: Although traumatic anterior shoulder instability is common, the usefulness of various physical examination tests as tools for the diagnosis of this condition has been studied infrequently. We hypothesized that (1) such tests would be specific but not sensitive for this condition, (2) the usefulness of the anterior drawer test would be limited because of pain during the test, and (3) an anterior drawer test would be a useful adjunct for making the diagnosis if it reproduced the instability symptoms. METHODS: Between 2000 and 2004, 363 patients underwent a physical examination followed by shoulder arthroscopy. Forty-six patients with traumatic anterior shoulder instability that had been noted arthroscopically or documented radiographically after the trauma were included in our study group, and the remaining patients served as controls. The clinical usefulness of three tests (anterior apprehension, relocation, and anterior drawer tests) performed during the physical examination to make a diagnosis of traumatic anterior instability then was evaluated with statistical methods to assess their sensitivity, specificity, and likelihood ratios. RESULTS: If demonstration (or relief) of apprehension was used as the diagnostic criterion for a positive test, the sensitivity, specificity, and likelihood ratio were 72%, 96%, and 20.2, respectively, for the apprehension test and 81%, 92%, and 10.4, respectively, for the relocation test. If pain (or relief of pain) was used as the diagnostic criterion for a positive test, the values for the sensitivity, specificity, and likelihood ratio of both tests were lower. The anterior drawer test could be performed successfully in the physician's office for 87% of the patients. If reproduction of instability symptoms was used as the criterion for a positive anterior drawer test, the sensitivity, specificity, and likelihood ratio values of that test were 53%, 85%, and 3.6, respectively. CONCLUSIONS: The three physical examination tests for traumatic anterior shoulder instability are specific but not sensitive. Apprehension is a better criterion than pain for a positive apprehension or relocation test. The anterior drawer test (when pain does not prevent it from being performed) is helpful for diagnosing traumatic anterior instability. LEVEL OF EVIDENCE: Diagnostic Level I. See Instructions to Authors for a complete description of levels of evidence.

Extended ex vivo myocardial preservation in the beating state using a novel polyethylene glycolated bovine hemoglobin perfusate based solution.

Cardiac preservation for transplantation is generally limited by ischemic hypothermic storage of 4-6 hours. Earlier studies in the authors' laboratory have demonstrated that hypothermic perfusion preservation using a novel oxygen carrying hemoglobin solution may extend preservation times to 8 hours and decrease ischemic injury. The purpose of this study was to compare extended cardiac function after 12 and 24 hours of continuous hypothermic perfusion with a polyethylene glycolated bovine hemoglobin perfusate (PEG-Hb) solution to the clinical standard of hypothermic ischemic preservation. The hearts of 54 anesthetized and intubated New Zealand White rabbits were harvested after cold cardioplegic arrest. Group I (n = 12) hearts were perfused with a PEG-Hb solution at 20 degrees C and 30 mm Hg for 24 hours. Group II (n = 10) hearts were preserved similarly with PEG-Hb for 12 hours. Group III (n = 12) hearts were preserved for 8 hours with PEG-Hb; Group IV (n = 10) were preserved by cold ischemic storage for 4 hours at 4 degrees C; and Group V (n = 10) were tested after fresh extirpation. Left ventricular (LV) function was measured in the nonworking state at 15 minute, 1 hour, and 2 hour intervals after transfer to a standard crystalloid Langendorff circuit. Developed LV pressure at 0.5 ml LV volume was superior in Group II at early time points, yet it was similar in all preserved groups at 2 hours. +dP/dt(max) at 0.5 ml LV volume was consistent at all time points and greater in PEG-Hb preserved groups compared with Group V. -dP/dt(max) at 0.5 ml LV volume was significantly greater in Groups II and III compared with Group V initially (p < 0.05), but all were similar at the end of testing. Continuous perfusion preservation of rabbit hearts for time increments up to 24 hours with this novel PEG-Hb solution at 30 mm Hg and 20 degrees C yields LV function that is similar to 4 hours of ischemic hypothermic storage. Extended cardiac perfusion preservation with this PEG-Hb solution deserves further investigation in large animal transplant models.