Giant Aneurysm of Left Main Coronary Artery in a Patient With Prior Operation for 4-Valve Endocarditis.

Left main coronary artery aneurysm is an unusual complication of infective endocarditis. Although this type of aneurysm is often asymptomatic, rupture and thrombus formation that result in myocardial infarction are known complications; therefore, prompt recognition and surgical intervention are warranted. This report describes a patient who presented with a giant left main coronary artery aneurysm 3.5 years after being treated for 4-valve endocarditis. The management and technical aspects of this challenging case are discussed here.

Transmyocardial revascularization (TMR): current status and future directions.

PURPOSE: Cardiac surgeons are increasingly faced with a more complex patient who has developed a pattern of diffuse coronary artery disease (CAD), which is refractory to medical, percutaneous, and surgical interventions. This paper will review the clinical science surrounding transmyocardial revascularization (TMR) with an emphasis on the results from randomized controlled trials. METHODS: Randomized controlled trials which evaluated TMR used as sole therapy and when combined with coronary artery bypass grafting were reviewed. Pertinent basic science papers exploring TMR's possible mechanism of action along with future directions, including the synergism between TMR and cell-based therapies were reviewed. RESULTS: Two laser-based systems have been approved by the United States Food and Drug Administration (FDA) to deliver laser therapy to targeted areas of the left ventricle (LV) that cannot be revascularized using conventional methods: the holmium:yttrium-aluminum-garnet (Ho:YAG) laser system (CryoLife, Inc., Kennesaw, GA) and the carbon dioxide (CO2) Heart Laser System (Novadaq Technologies Inc., (Mississauga, Canada). TMR can be performed either as a stand-alone procedure (sole therapy) or in conjunction with coronary artery bypass graft (CABG) surgery in patients who would be incompletely revascularized by CABG alone. Societal practice guidelines have been established and are supportive of using TMR in the difficult population of patients with diffuse CAD. CONCLUSIONS: Patients with diffuse CAD have increased operative and long-term cardiac risks predicted by incomplete revascularization. The documented operative and long-term benefits associated with sole therapy and adjunctive TMR in randomized trials supports TMR's increased use in this difficult patient population.

An Absorbable Hydrogel Spray Reduces Postoperative Mediastinal Adhesions After Congenital Heart Surgery.

BACKGROUND: Adhesions encountered during reoperative cardiac surgery can prolong operative time and increase operative risk. The purpose of this clinical study was to investigate the antiadhesion property of a synthetic bioabsorbable polymer spray after cardiac reoperations in infants. METHODS: A prospective randomized double-blinded study was designed. Forty infants requiring staged cardiac operations were randomly allocated to a study group (n = 20) or a control group (n = 20). The appropriate volume of the polymer was sprayed onto the mediastinal surfaces before chest closure after the first surgical procedure in the study group. At reoperation, adhesions were evaluated by a blinded investigator following a 5-grade scoring system. Five predetermined anatomic areas were scored. Incision to extracorporeal circulation time was also analyzed. RESULTS: In all, 40 subjects were enrolled into the study. Four babies died before the second operation. Three others were missed for reevaluation. The control group (n = 16) had longer incision to extracorporeal circulation time (38 ± 10 minutes) than the study group (n = 17; 23 ± 6 minutes; p < 0.001). The control subjects had significantly more severe adhesions than the study group at all five mediastinal areas: (1) retrosternal (p < 0.001); (2) base of the heart (large vessels [p < 0.05]); (3) right side (p < 0.01); (4) left side (p < 0.02); and (5) diaphragmatic side of the mediastinum (p < 0.001). CONCLUSIONS: The use of synthetic bioabsorbable polymer sealant spray at the end of primary pediatric cardiac surgery reduces the intensity of mediastinal adhesions and the reentry time in infants undergoing repeat median sternotomy.

The use of thrombolytics in the management of complex pleural fluid collections.

BACKGROUND: To determine the efficacy of thrombolytics for the management of complex pleural fluid collections. METHODS: We reviewed patients that received alteplase for persistent loculated pleural fluid collections after simple tube drainage between July 01, 2007 and November 01, 2012. Our alteplase protocol is 6 mg of alteplase in 50 mL of normal saline injected into the pleural chest tube. The chest tube is clamped for four hours and then opened. Normally this is repeated daily for 2 to 3 days (d). RESULTS: One hundred and three [103] patients were identified with 110 interventions. Sixty-eight (66%) of the patients were male, with ages ranging from 20-91 years (y), mean 57.2 y. Twenty (18.2%) patients were trauma patients, 60 (55%) had hypertension and 32 (35%) were smokers. Most patients had one of the following diagnoses: 79.6% (82/110) loculated pleural fluid collection as a result of an empyema or 20.4% (21/110) retained hemothorax. The mean time from diagnosis to alteplase treatment for a hemothorax was 12.8 days (range, 1-32 days) and 16.2 days (range, 4-48 days) for an empyema. The mean duration of therapy was 2.2±1.4 days (1-11 days). The time from alteplase to chest tube removal was 4.5 days (1-21 days). Eleven of 103 (10.7%) patients required surgery including 3 video assisted decortications. The others had adequate radiographic resolution. Seventeen patients (16.5%) died, in the hospital of: sepsis, respiratory failure, aortic injury, and cardiac arrest. CONCLUSIONS: Alteplase therapy is an effective alternative to surgery in most complex pleural fluid collections.

Post traumatic pulmonary pseudoaneurysm requiring pneumonectomy: a case report.

A 57-year-old male presented with progressive exertional dyspnea, cough, and hemoptysis. He underwent a chest computed tomography (CT) that demonstrated a 27 cm × 20 cm right chest mass that was causing a local mass effect. Pertinent history revealed that the patient had suffered a severe chest trauma from a MVA in 1981. The patient underwent workup including: needle localized biopsy, bronchoscopy and endoscopic biopsy. There was considerable concern for a malignant process and a subsequent right pneumonectomy with en bloc resection of the chest wall and diaphragm was performed. The final pathology concluded the mass to be a large pseudoaneurysm. Pseudoaneurysms after traumas are extremely rare, especially blunt trauma, and should be considered once other etiologies have been excluded.

Hepatolithiasis after Hepaticojejunostomy: Ascaris lumbricoides in the biliary tract.

BACKGROUND: Biliary ascariasis is a common problem in Third World countries and other underdeveloped areas of the world. Ascaris lumbricoides migrates into the biliary tree, where it is apparent commonly on diagnostic imaging. We present a unique case of a patient with chronic right upper quadrant abdominal pain, massive hepatolithiasis, and stricture of a previous hepaticojejunostomy in whom ascariasis was found. METHODS: A 28-year-old female presented to the emergency department with right upper quadrant abdominal pain, syncope, and seizure-like activity. She was found by magnetic resonance cholangiopancreatography to have cholangitis, choledocholithiasis, and bile duct stricture. After multiple radiographic studies, she was taken to the operating room for revision of a hepaticojejunostomy performed 10 years previously. RESULTS: Ascaris lumbricoides was found in the right intrahepatic bile duct, that had not been identified by multiple radiologic modalities. The worm was sent to the pathology department for identification. A Fogarty catheter was passed into the hepatic ducts for successful stone extraction. The hepaticojejunostomy was revised, with catheter placement in the Roux limb to accommodate radiologic stone extraction as necessary. Post-operatively, she was given a single dose of albendazole and discharged on hospital day 19. CONCLUSION: The worm was likely the nidus for the stricture and stone formation. Surgical exploration of the biliary tree was required to diagnose and treat her condition accurately. This case is unique in that typical means of diagnosis failed to identify the causative agent of hepatolithiasis because of the prior Roux-en-Y hepaticojejunostomy.

Implementation and enforcement of ventilator-associated pneumonia prevention strategies in trauma patients.

BACKGROUND: We hypothesized that strict enforcement of ventilator-associated pneumonia (VAP) prevention (VAPP) strategies would decrease the incidence of VAP and improve patient outcomes. METHODS: This retrospective study examined 696 consecutive ventilated patients in a Level One trauma center. Three study groups were compared: Pre-VAPP, VAPP implementation, and VAPP enforcement. Ventilator days were compared with occurrences of VAP, defined by the U.S. Centers for Disease Control and Prevention National Nosocomial Infection Surveillance criteria. Patients with and without VAP were compared to evaluate the effect of VAP on patient outcome. Fisher exact, Kruskal-Wallis, and chi-square analyses were used, and p < 0.05 was considered significant. RESULTS: During the pre-VAPP protocol period, 5.2 cases of VAP occurred per 1,000 days of ventilator support. The number of cases of VAP decreased to 2.4/1,000 days (p = 0.172) and 1.2/1,000 days (p = 0.085) in the implementation and enforcement periods, respectively. However, when including all trauma patients, regardless of head Abbreviated Injury Score (AIS) score, the difference in the rate of VAP was statistically significant in the enforcement period, but not in the implementation period, compared with the pre-VAPP period (p = 0.014 and 0.062, respectively). A significant decrease was seen in the mortality rate (p = 0.024), total hospital days (p = 0.007), intensive care unit days (p = 0.002), ventilator days (p = 0.002), and hospital charges (p = 0.03) in patients without VAP compared with patients having VAP. CONCLUSIONS: There was a statistically significant decrease in the occurrence of VAP with strict enforcement of a VAPP protocol, regardless of head AIS score. Although the difference in patients with a head AIS score <3 was not statistically significant, it was clinically meaningful, decreasing the already-low rate of VAP by half. Strict enforcement of VAPP protocols may be cost efficient for hospitals and prevent decreased reimbursement under the Medicare pay-for-performance strategies.