Vertebrobasilar insufficiency after subclavian flap aortoplasty for aortic coarctation.

The mainstay of treatment of pediatric aortic coarctation is open surgery. One option for repair includes subclavian flap aortoplasty, first described by Waldhausen and Nahrwold in 1966. Within this technique, several modifications have been made over the years as long-term follow-up data became available. Early outcomes revealed little concern for left upper extremity limb ischemia or subclavian steal syndrome. These complications are rare but can have a significantly delayed presentation years after coarctation repair. We present a case of subclavian steal syndrome with lifestyle-limiting vertebrobasilar symptoms experienced by a patient 36 years after subclavian flap aortoplasty for aortic coarctation.

Prognostic indicators for early mortality after tracheostomy in the intensive care unit.

BACKGROUND: Tracheostomy is indicated for patients requiring prolonged mechanical ventilation. The aim of this study is to identify prognostic indicators for early mortality after tracheostomy to potentially avoid futility in the intensive care unit. METHODS: Patients who underwent tracheostomy and died within 30 d of admission (futile group) were compared with patients who underwent tracheostomy and survived more than 30 d after admission (nonfutile group). Categorical data were analyzed using chi-square and Fisher's exact tests. Continuous variables were analyzed using T-tests and Mann-Whitney U tests. Prognostic factors were evaluated with univariable and multivariable logistic regression analyses. RESULTS: Overall, 88.3% of patients underwent nonfutile tracheostomy, while 11.7% underwent futile tracheostomy. Serum albumin level (1.5 g/dL versus 1.9 g/dL, P = 0.040) and mechanical ventilation duration before procedure (10 versus 12 d, P = 0.029) were significantly less in the futile group. Hypoalbuminemia (<2 g/dL) and preoperative mechanical ventilation ≤10 d were also predictive of futile tracheostomy in multivariable analysis. CONCLUSIONS: Hypoalbuminemia may serve as a prognostic indicator and risk factor for early mortality after tracheostomy. In patients with hypoalbuminemia, treatment of underlying disease processes and trending serum albumin level recovery in response to treatment may provide some insight to clinicians with regard to timing of tracheostomy. Better prognostic tools are still needed for critically ill patients to avoid futility in the intensive care unit. In this cohort, 88.3% of patients undergoing tracheostomy survived past 30 d.