Transfemoral Transcatheter Mitral Valve Implantation With a Dedicated Device in a Rheumatic Mitral Stenosis Patient.

A 65-year-old obese woman with rheumatic heart disease and restrictive lung disease presented with decompensated heart failure. Evaluation demonstrated severely thickened mitral valve leaflets, severe mitral stenosis, and moderate mitral regurgitation. She underwent successful transfemoral transseptal transcatheter mitral valve replacement with a dedicated valve resulting in improved functional status. (Level of Difficulty: Advanced.).

Thromboelastography after Cardiopulmonary Bypass: Does it Save Blood Products?

INTRODUCTION: This study aimed to determine if thromboelastography (TEG) is associated with reduced blood product use and surgical reintervention following cardiopulmonary bypass (CPB) compared to traditional coagulation tests. METHODS: A retrospective review was conducted of 698 patients who underwent CPB at a tertiary-care, community-based, university-affiliated hospital from February 16, 2014 to February 16, 2015 (Period I) and from May 16, 2015 to May 16, 2016 (Period II). Traditional coagulation tests guided transfusion during Period I and TEG guided transfusion during Period II. Intraoperative and postoperative administration of blood products (red blood cells, fresh frozen plasma, platelets, and cryoprecipitate), reoperation for hemorrhage or graft occlusion, duration of mechanical ventilation, hospital length of stay, and mortality were recorded. RESULTS: Use of a TEG-directed algorithm was associated with a 13.5% absolute reduction in percentage of patients requiring blood products intraoperatively (48.2% vs. 34.7%, p < 0.001). TEG resulted in a 64.3% and 43.1% reduction in proportion of patients receiving fresh frozen plasma (FFP) and platelets, respectively, with a 50% reduction in volume of FFP administered (0.3 vs. 0.6 units, p < 0.001). Use of TEG was not observed to decrease postoperative blood product usage or mortality significantly. The median length of hospital stay was reduced by one day after TEG guided transfusion was implemented (nine days vs. eight days, p = 0.01). CONCLUSIONS: Use of TEG-directed transfusion of blood products following CPB appeared to decrease the need for intraoperative transfusions, but the effect on clinical outcomes has yet to be clearly determined.

Efficacy of Intravenous Acetaminophen as Adjunct Post-Operative Analgesic in Cardiac Surgery: A Retrospective Study.

INTRODUCTION: The dose-dependent adverse events associated with post-operative opioid use may be reduced when opioids are used in conjunction with intravenous acetaminophen. The purpose of this study was to compare outcomes in median sternotomy patients receiving intravenous acetaminophen in addition to intravenous opioids versus intravenous opioids only. METHODS: A retrospective study was conducted on 122 adult patients undergoing median sternotomy at a regional tertiary-referral center. Data collected included patient demographics, length of stay, opioid and intravenous acetaminophen use, adverse effects, and transition time to oral pain medication. RESULTS: There was no difference between groups in demographics, preoperative risk scores, operative procedures, intravenous opioid consumption, transition time to oral pain medications, or length of stay. Acetaminophen use was associated with lower rates of atrial fibrillation (7.0% vs. 24.6%, p = 0.009) and nausea/vomiting (8.9% vs. 32.3%, p = 0.002), but higher rates of urinary retention (15.8% vs. 3.1%, p = 0.014), constipation (50.0% vs. 20.0%, p = 0.001) and respiratory depression (7.1% vs. 0.0%, p = 0.043). CONCLUSION: Intravenous acetaminophen was not associated with a reduction in length of stay or opioid consumption, but was associated with lower rates of atrial fibrillation, nausea, and vomiting. Additional studies are needed to determine if intravenous acetaminophen administration reduces atrial fibrillation in this population.

Carotid stenosis: change of treatment plan based on repeat duplex ultrasonography.

BACKGROUND: This study was conducted to evaluate the change in the treatment plan observed when clinical decisions are made based on initial carotid duplex ultrasonography (DU) performed at an outside center before surgical consultation versus those made based on DU performed in a dedicated vascular laboratory. METHODS: A prospective study of patients who underwent initial DU at an outside facility and repeat DU in a dedicated vascular laboratory for evaluation of carotid stenosis was performed. Initial DU was compared with repeat DU to evaluate clinical impact. RESULTS: Ninety-six consecutive patients were evaluated. Disagreement between initial DU and repeat DU was observed in 27.1% of patients. This disagreement led to a change of treatment plan in 23 of 146 (15.8%) carotid arteries studied. CONCLUSIONS: Reliance on 1 DU in clinical practice, when performed outside a dedicated vascular laboratory, may lead to both unnecessary surgery and missed opportunities for surgery to prevent stroke.

Confirmation of surgical decompression to relieve migraine headaches.

BACKGROUND: Surgical decompression of various trigger sites has been shown by two authors to relieve migraine headaches. The purpose of this study was to evaluate the effectiveness of surgical decompression of multiple migraine trigger sites in a clinical practice setting, and to compare the results to those previously published. METHODS: A retrospective, descriptive analysis was performed on 18 consecutive patients who had undergone various combinations of surgical decompression of the supraorbital, supratrochlear, and greater occipital nerves and zygomaticotemporal neurectomy performed by a single surgeon. All patients had been diagnosed with migraine headaches according to neurologic evaluation and had undergone identification of trigger sites by botulinum toxin type A injections. RESULTS: The number of migraines per month and the pain intensity of migraine headaches decreased significantly. Three patients (17 percent) had complete relief of their migraines, and 50 percent of patients (nine of 18) had at least a 75 percent reduction in the frequency, duration, or intensity of migraines. Thirty-nine percent of patients have discontinued all migraine medications. Mean follow-up was 16 months (range, 6 to 41 months) after surgery. One hundred percent of participants stated they would repeat the surgical procedure. CONCLUSIONS: This study confirms prior published results and supports the theory that peripheral nerve compression triggers a migraine cascade. The authors have verified a reduction in duration, intensity, and frequency of migraine headaches by surgical decompression of the supraorbital, supratrochlear, zygomaticotemporal, and greater occipital nerves. A significant amount of patient screening is required for proper patient selection and trigger site identification for surgical success.