Examining the "revisability" benefit of hip resurfacing arthroplasty.

BACKGROUND: Hip resurfacing arthroplasty (HRA) is an alternative to total hip arthroplasty (THA) that is typically reserved for young active patients because it preserves bone. However, the benefits of HRA only hold true if conversion THA after failed HRA provides acceptable outcomes. AIM: To compare patient reported outcomes for conversion THA after HRA failure to primary THA. METHODS: A retrospective review of 36 patients (37 hips) that underwent conversion THA for failed HRA between October 2006 and May 2019 by a single surgeon was performed. Patient reported outcomes [modified Harris Hip Score (mHHS), University of California Los Angeles (UCLA) activity score] were obtained via an email-based responder-anonymous survey. Outcomes were compared to normative data of a primary THA cohort with similar demographics. Subgroup analysis was performed comparing outcomes of conversion THA for adverse local tissue reaction (ALTR) vs all other causes for failure. RESULTS: The study group had a lower mHHS than the control group (81.7 ± 13.8 vs 90.2 ± 11.6, P < 0.01); however, both groups had similar UCLA activity levels (7.5 ± 2.3 vs 7.2 ± 1.6, P = 0.51). Patients that underwent conversion for non-ATLR causes had similar mHHS (85.2 ± 11.5 vs 90.2 ± 11.6, P = 0.11) and higher UCLA activity levels (8.5 ± 1.8 vs 7.2 ± 1.6, P < 0.01) compared to the control group. Patients that underwent conversion for ATLR had worse mHHS (77.1 ± 14.5 vs 90.2 ± 11.6, P < 0.01) and UCLA activity levels (6.1 ± 2.3 vs 7.2 ± 1.6, P = 0.05) when compared to the control group. CONCLUSION: Patient outcomes equivalent to primary THA can be achieved following HRA conversion to THA. However, inferior outcomes were demonstrated for ALTR-related HRA failure. Patient selection and perhaps further studies examining alternative HRA bearing surfaces should be considered.

Guillain-Barré syndrome outbreak in Tapachula temporally associated with the Zika virus introduction in Southern Mexico.

The Guillain-Barré syndrome (GBS) has been previously associated with Zika virus infection. We analysed the data from all the patients with GBS diagnosis that were admitted to a referral hospital, in Tapachula City during the period from January 2013 to August 2016, comparing the incidence of GBS according to the temporality of the Zika outbreak in Southern Mexico. Additionally, we described the clinical and epidemiological characteristics of the GBS patients admitted before or after the Zika outbreak. We observed a sharp increase in the number of patients hospitalised due to GBS from the time the first confirmed Zika cases appeared in Mexico. Clinically we observed GBS cases before zika outbreak had more frequently history of respiratory/gastrointestinal symptoms and GBS during zika outbreak had significantly more frequently recent history of rash/conjunctivitis. Although we cannot affirm that the increased cases of GBS have a specific aetiologic association with Zika, our results suggest that this observed outbreak of in Tapachula, might have been associated to the emerging Zika epidemic, locally and suggests that rare complications associated with acute infections (such as GBS) might be useful in the surveillance systems for emerging infections.

Visceral and renal protection in thoracoabdominal aortic surgery.

Ischemic renal failure and visceral ischemia are two serious complications of the surgery for thoracoabdominal aortic aneurysm. The introduction of left atrial bypass, partial bypass, total circulatory arrest, and selective visceral perfusion has reduced the incidence of these complications over the past two decades. Yet these complications still persist, suggesting the sub-optimal nature of the available strategies.

Perioperative right ventricular function and dysfunction in adult cardiac surgery-focused review (part 2-management of right ventricular failure).

The single most important factor in improving outcomes in right ventricular (RV) failure is anticipating and recognizing it. Once established, a vicious circle of systemic hypotension, and RV ischemia and dilation, occurs, leading to cardiogenic shock, multi-organ failure, and death. RV dysfunction and failure theoretically can occur in three settings-increase in the pre-load; increase in after load; and decrease in contractility. For patients deemed low risk for the development of RV failure, when it occurs, the correction of underlying cause is the most important and effective treatment strategy. Therapy of RV failure must focus on improving the RV coronary perfusion, lowering pulmonary vascular resistance, and optimizing the pre-load. Pre-load and after-load optimization, ventilator adjustments, and improving the contractility of RV by inotropes are the first line of therapy and should be initiated early to prevent multi-organ damage. Mechanical assist device implantation or circulatory support with extracorporeal membrane oxygenation (ECMO) may be needed in refractory cases.

Perioperative right ventricular function and dysfunction in adult cardiac surgery-focused review (part 1-anatomy, pathophysiology, and diagnosis).

Right ventricle (RV) dysfunction and failure are now increasingly recognized as an important cause of perioperative morbidity and mortality after cardiac surgery. Although RV dysfunction is common, RV failure is very rare (0.1%) after routine cardiac surgery. However, it occurs in 3% of patients after heart transplantation and in up to 30% of patients after left ventricular assist device implantation. Significant RV failure after cardiac surgery has high mortality. Knowledge of RV anatomy and physiology are important for understanding RV dysfunction and failure. Echocardiography and haemodynamic monitoring are the mainstays in the diagnosis of RV dysfunction and failure. While detailed echocardiography assessment of right heart function has been extensively studied and validated in the elective setting, gross estimation of RV chamber size, function, and some easily obtained quantitative parameters on transesophageal echocardiography are useful in the perioperative setting. However, detailed knowledge of echocardiography parameters is still useful in understanding the differences in contractile pattern, ventriculo-arterial coupling, and interventricular dependence that ensue after open cardiac surgery. SUPPLEMENTARY INFORMATION: The online version contains supplementary material available at 10.1007/s12055-021-01240-y.

Will Remdesivir Reshape Cardiovascular Practice in COVID 19 Era?

Infection with the novel coronavirus, SARS-CoV2, produces the clinical syndrome COVID-19. COVID-19 is a systemic illness inducing hyperinflammation and cytokine storm affecting multiple organs including the myocardium which is reflected in elevated cardiac biomarkers such as troponin, lactate dehydrogenase, and creatinine kinase MB. Furthermore, COVID-19 has been implicated in increased predilection to thromboembolic phenomena. Hence, mortality in patients with associated cardiovascular disease has been higher compared with the cohort with no cardiovascular comorbidity. It is entirely unknown how remdesivir will change the facet of cardiovascular medicine and surgery. In the present constantly changing climate, this review of remdesivir and its association with cardiovascular disease is comprehensive as of June 17, 2020 and it highlights the science behind this drug and its potential implications to cardiovascular practice.

Fluoroscopically Guided Facet Cyst Rupture: Rate of Conversion to Surgery and Risk Factor Analysis.

STUDY DESIGN: Retrospective case series at a single academic medical center. OBJECTIVE: The aim was to determine if specific clinical, radiologic, and procedural factors are associated with conversion to surgery after fluoroscopically guided cyst rupture. SUMMARY OF BACKGROUND DATA: Percutaneous fluoroscopic rupture of facet cysts can often be the definitive treatment; however, it is unknown before the procedure who will ultimately proceed to formal surgical decompression. Differences in clinical, radiographic, and procedural factors of facet cysts may relate to the difference in efficacy of fluoroscopically guided cyst rupture. METHODS: A continuous cohort of 45 patients who underwent fluoroscopically guided cyst rupture was evaluated. The primary outcome measured rate of conversion to surgery and of those that underwent surgery, the rate of decompression and fusion compared with fusion alone was noted. Secondary outcomes included analysis of clinical, radiologic, and procedural variables to determine if there were risk factors associated with conversion to surgery. RESULTS: Twenty-nine percent of patients eventually underwent a surgical procedure with an average interval to surgery of 95 days after attempted rupture. Thirty-eight percent of patients that underwent surgery had a decompression and fusion. Failure of percutaneous cyst rupture trended toward significance for a future surgical decompression (P=0.08). CONCLUSIONS: Percutaneous facet cyst rupture is potentially a definitive treatment for this condition; however, it is unknown ahead of time who will proceed to definitive surgical decompression. On the basis of the data in this study, less than one-third of patients who had a fluoroscopically guided facet cyst rupture went on to surgery. There were no clinical, radiographic, or procedural details which could be used to robustly predict failure of percutaneous treatment. At this time, it is recommended to continue to attempt this nonoperative treatment intervention when there is a clinical indication after discussion of the risks and benefits with the patient.

Aortic endarterectomy: a useful technique to utilize for aortic valve replacements in hostile aorta.

Calcified aorta poses a significant technical challenge in the performance of surgical aortic valve replacement (AVR). Aortic endarterectomy is a less utilized approach and is suitable in select cases for aortic decalcification during AVR. Here, we report a case of calcified ascending aorta who underwent ascending aortic endarterectomy and AVR with the technical details of the procedure.

Harris Heel View is Inadequate to Visualize Screw Prominence of the Medial Calcaneus: A Case Report and Cadaveric Evaluation.

CASE: A 58-year-old man sustained multiple right foot injuries during a motor vehicle accident that included a calcaneus fracture requiring open reduction and internal fixation (ORIF). The procedure was complicated by a prominent implant inferior to the sustentaculum, which necessitated a return to the operating room. Commonly used fluoroscopic views do not adequately image this area. A cadaveric study was undertaken to identify the optimal 2-dimensional fluoroscopic view that evaluates prominent implants at the medial calcaneus. CONCLUSION: The sustentaculum tunnel view gives a reliable image of prominent medial implants, and use of this technique may limit complications after calcaneus ORIF.

Patient-reported Outcomes Following Surgical Intervention for Adolescent Idiopathic Scoliosis: A Systematic Review and Meta-Analysis.

STUDY DESIGN: This was a systematic review and meta-analysis. OBJECTIVE: This study aims to perform a systematic review and quantitative meta-analysis of patient-reported outcome measures after spinal fusion for adolescent idiopathic scoliosis (AIS). SUMMARY OF BACKGROUND DATA: Radiographic correction of scoliosis is extensively reported in the literature but there is a need to study the impact of spinal fusion on patient-reported outcome measures. Prior reviews lacked homogeneity in outcome measures, did not perform quantitative meta-analysis of pooled effect size, or interpret the results in light of minimally clinically important difference thresholds. MATERIALS AND METHODS: A systematic review of medical databases identified all studies that prospectively reported Scoliosis Research Society (SRS)-22 questionnaire data after spinal fusion for AIS. We screened 2314 studies for eligibility. Studies were included that reported preoperative and postoperative data at 24- or >60-month follow-up. Studies were excluded that failed to report means and SDs which were needed to calculate Cohen d effect sizes and 95% confidence intervals in estimating the magnitude and precision of the effect. RESULTS: A total of 7 studies met eligibility criteria for inclusion in quantitative meta-analysis of effect sizes and 95% confidence intervals. Patients report large improvements in total score, self-image, and satisfaction; and moderate improvements in pain, function and mental health at 2 and 5 years after spinal fusion for AIS. All domains showed statistically significant improvement at all times except function at >60 months. All domains surpassed the minimally clinically important difference at all times except mental health. CONCLUSIONS: Moderate evidence suggests that spinal fusion improves quality of life for adolescents with idiopathic scoliosis in medium and long-term follow-up. Our results may help inform patient expectations regarding surgery. OCEMB LEVEL OF EVIDENCE: Level I-systematic review and meta-analysis of prospective studies.

Rare case of proximal coronary plaque regression after distal arterial grafting.

The metabolically active endothelium of arterial grafts is reported to slow the atherosclerotic process in the distal coronary territories to which they are grafted with improved patency. The literature on arterial grafting causing proximal plaque regression is scant. We report here a case of proximal left anterior descending artery (LAD) plaque regression following distal arterial grafting with a left internal mammary arterial (LIMA) graft to LAD. This rarely documented regression resulted in "stringing" of the arterial graft, while there was a significant progression of atherosclerotic disease in the right coronary with patent venous graft and de novo lesion in circumflex territory necessitating percutaneous coronary intervention, in spite of aggressive medical therapy. The dichotomous progression of disease in two out of three coronary arterial systems and regression of the proximal plaque in LAD grafted with LIMA 12 years ago suggests the protective effect of arterial grafting in reversing the atherosclerotic process.

"Cryptic" mediastinal tuberculosis with myasthenia-thymoma complex.

Mediastinal tuberculosis, although common in endemic areas, is rare in association with myasthenia-thymoma complex. Immunosuppressive therapy for myasthenia with thymoma might increase the susceptibility for mediastinal tuberculosis. Previous reports suggest aggravation of myasthenic symptoms with this association. This rare combination of pathologies adds to the diagnostic dilemma of the surgeon. Further research is warranted in the management aspects of this combination as regards to the timing of radiotherapy, weaning of immunosuppression and anti-tubercular therapy after maximal thymectomy. This case report emphasises the possibility of mediastinal tuberculosis as a differential diagnosis for mediastinal lymphadenopathy in the setting of a preoperative diagnosis of invasive thymoma.

del Nido cardioplegia in adult cardiac surgery - scopes and concerns.

The convenience offered by a single-dose cardioplegia strategy is the avoidance of interruption of the flow of surgery and, more importantly, a significant reduction in the cross-clamp time. del Nido cardioplegia is an extracellular cardioplegic solution which serves these purposes and has been used successfully in pediatric cardiac surgery. The subsequent extrapolation of its use in adult cardiac surgery has returned encouraging results, as evidenced by recent literature. The use of del Nido cardioplegia in adults has been reported to shorten the cross-clamp time, cardiopulmonary bypass time and overall operating time. Intraoperative peak glucose value and insulin requirement have also been reported to be lower with del Nido cardioplegia, which can have prognostic significance. There have been reports of lesser incidence of atrial fibrillation and the number of defibrillations required with use of this technique. However, some unique concerns still remain. The lack of prospective randomized trials, the trend of elevation in CKMB (as reported by one study) and the need for a protocol-based approach to its use in adults are to be given due consideration while adopting its use in adults. This review attempts to have an overview on del Nido cardioplegia, its advantages, the recent studies comparing it with conventional cardioplegia techniques and the potential areas of concern with its use in adult cardiac surgery.

Strategies for the coronary surgeon to remain "competitive and co-operative" in the PCI era.

BACKGROUND: The advent of percutaneous intervention has made surgical treatment of coronary artery disease less favored by patients though the evidence that supports CABG in certain patient subsets is strong. METHODS: Literature review was done using Pubmed, Scopus, Google and Google Scholar with MeSH terms-coronary artery bypass grafting, internal mammary artery, drug eluting stent, stroke, myocardial revascularization. RESULTS: The adoption of evolving techniques like anaortic off pump grafting, bilateral internal mammary artery use, hybrid and minimally invasive coronary revascularization techniques, intra-operative graft assessment, and heart team approach can lead to better outcomes following surgery as is evidenced by recent literature. CONCLUSIONS: Though the adoptability of the newer strategies may vary between centers a close coalition between coronary surgeons and cardiologists would ensure that the management of coronary artery disease is based on evidence for the benefit of the patient.

Emergent endovascular stent grafting for saccular arch aneurysm complicated by aorto-esophageal fistula.

Aneurysms of aortic arch are rare but amenable to endovascular therapy. Arch aneurysm presenting with aorto-esophageal fistula and hematemesis is a feared, but relatively rare complication. The extrapolation of the safety and rapidity of emergent endovascular repair for bleeding arch aneurysms has been infrequently reported. A bovine arch anatomy confers distinct advantages for endovascular therapy often avoiding a preceding debranching surgery. However, its endovascular treatment might be complicated by the nonhealing of fistula and potential risk for mediastinitis. Here, we report a case of a bovine aortic arch cystic aneurysm complicated by bleeding aorto-esophageal fistula, which warranted an emergent endovascular therapy. The prevertebral part of LSCA was plugged to interrupt the retrograde filling and a future endoleak. A nonhealing aorto-mediastinal fistula at follow-up was successfully treated by covered esophageal stenting. This report reiterates the importance of multidisciplinary approach with multispecialty collaboration to such complex spectrum of diseases.

Fuzzy multi-class statistical modeling for efficient total lesion metabolic activity estimation from realistic PET images.

18F-fluorodeoxyglucose (FDG) positron emission tomography (PET) has become the de facto standard for current clinical therapy follow up evaluations. In pursuit of robust biomarkers for predicting early therapy response, an efficient marker quantification procedure is certainly a necessity. Among various PET derived markers, the clinical investigations indicated that the total lesion metabolic activity (TLA) of a tumor lesion has a good prognostic value in several longitudinal studies. We utilize a fuzzy multi-class modeling using a stochastic expectation maximization (SEM) algorithm to fit a finite mixture model (FMM) to the PET image. We then propose a direct estimation formula for TLA and SUVmean from this multi-class statistical model. In order to evaluate our proposition, a realistic liver lesion is simulated and reconstructed. All results were evaluated with reference to the ground truth knowledge. Our experimental study conveys that the proposed method is robust enough to handle background heterogeneities in realistic scenarios.