Mitral Valve Replacement in Infants Using a 15-mm Mechanical Valve.

BACKGROUND: The 15-mm mechanical valve was approved by the US Food and Drug Administration in March 2018. We review our experience in infants with this valve in the mitral position (MV), focusing on outcomes and timing to repeat MV replacement (MVR). METHODS: Between 2006 and 2017 7 patients underwent eight MVRs (one repeat) with a 15-mm mechanical valve. Retrospective chart review was performed to examine short- and long-term outcomes. RESULTS: There were no operative deaths. Mean follow-up was 5.8 ± 4.8 years (range, 0.72 to 11.1). Six patients underwent an MV operation 53 ± 39 days (range, 9 to 118) before MVR with the 15-mm valve. All patients were on mechanical ventilatory support at the time of operation. Mean age, body weight, and body surface area at time of 15-mm MVR were 0.5 ± 0.3 years (range, 0.2 to 0.9), 5.6 ± 0.8 kg (range, 4.8 to 6.6), and 0.29 ± 0.03 m2 (range, 0.27 to 0.32), respectively. Two patients required pacemaker implantation for atrioventricular block, both after their second MVR. Two patients are well at 16 and 24 months. Four patients underwent repeat MVR because of somatic growth and patient-prosthesis mismatch. Mean time to repeat MVR was 23 months (range, 6 to 40). There were two late deaths, one at 10 months unrelated to the valve in a child with a chromosomal abnormality. The other child had a congenital diaphragmatic hernia, early valve thrombosis, and died of multiple complications after a fourth MVR. CONCLUSIONS: The 15-mm mechanical valve was useful in treating MV disease in infants 2 to 12 months of age. This newly approved smallest available mechanical valve has a predicted mean time to replacement of 23 months in the mitral position.

Motor Evoked Potentials Correlate With Magnetic Resonance Imaging and Early Recovery After Acute Spinal Cord Injury.

BACKGROUND: While the utilization of neurophysiologic intraoperative monitoring with motor evoked potentials (MEPs) has become widespread in surgery for traumatic spine fractures and spinal cord injury (SCI), clinical validation of its diagnostic and therapeutic benefit has been limited. OBJECTIVE: To describe the use of intraoperative MEP at a large level I trauma center and assess the prognostic capability of this technology. METHODS: The SCI REDCap database at our institution, a level I trauma center, was queried for acute cervical SCI patients who underwent surgery with intraoperative monitoring between 2005 and 2011, yielding 32 patients. Of these, 23 patients had severe SCI (association impairment scale [AIS] A, B, C). We assessed preoperative and postoperative SCI severity (AIS grade), surgical data, use of steroids, and early magnetic resonance imaging (MRI) findings (preoperatively in 27 patients), including axial T2 MRI grade (Brain and Spinal Injury Center score). RESULTS: The presence of MEPs significantly predicted AIS at discharge (P< .001). In the group of severe SCI (ie, AIS A, B, C) patients with elicitable MEPs, AIS improved by an average of 1.5 grades (median = 1), as compared to the patients without elicitable MEP who improved on average 0.5 grades (median = 0, P< .05). In addition, axial MRI grade significantly correlated with MEP status. Patients without MEPs had a significantly higher axial MRI grade in comparison to the patients with MEPs (P< .001). CONCLUSION: In patients with severe SCI, MEPs predicted neurological improvement and correlated with axial MRI grade. These significant findings warrant future prospective studies of MEPs as a prognostic tool in SCI.

Failure of Mean Arterial Pressure Goals to Improve Outcomes Following Penetrating Spinal Cord Injury.

BACKGROUND: Increased spinal cord perfusion and blood pressure goals have been recommended for spinal cord injury (SCI). Penetrating SCI is associated with poor prognosis, but there is a paucity of literature examining the role of vasopressor administration for the maintenance of mean arterial pressure (MAP) goals in this patient population. OBJECTIVE: To elucidate this topic and to determine the efficacy of vasopressor administration in penetrating SCI by examining a case series of consecutive penetrating SCIs. METHODS: We reviewed consecutive patients with complete penetrating SCI who met inclusion and exclusion criteria, including the administration of vasopressors to maintain MAP goals. We identified 14 patients with complete penetrating SCIs with an admission American Spinal Injury Association grade of A from 2005 to 2011. The neurological recovery, complications, interventions, and vasopressor administration strategies were reviewed and compared with those of a cohort with complete blunt SCI. RESULTS: In our patient population, only 1 patient with penetrating SCI (7.1%) experienced neurological recovery, as determined by improvement in the American Spinal Injury Association grade, despite the administration of vasopressors for supraphysiological MAP goals for an average of 101.07 ± 34.96 hours. Furthermore, 71.43% of patients with penetrating SCI treated with vasopressors experienced associated cardiogenic complications. CONCLUSION: Given the decreased likelihood of neurological improvement in penetrating injuries, it may be important to re-examine intervention strategies in this population. Specifically, the use of vasopressors, in particular dopamine, with their associated complications is more likely to cause complications than to result in neurological improvement. Our experience shows that patients with acute penetrating SCI are unlikely to recover, despite aggressive cardiopulmonary management. ABBREVIATIONS: ASIA, American Spinal Injury AssociationMAP, mean arterial pressureSCI, spinal cord injury.

A review and update on the guidelines for the acute management of cervical spinal cord injury - Part II.

Acute traumatic spinal cord injury (SCI) is a debilitating worldwide disease with an estimated annual incidence of 10 to 83 affected individuals per million inhabitants. These injuries typically impact younger individuals and reduce quality-adjusted life years with estimated lifetime costs exceeding $4 million per person. Hence it is critical to establish and refine clear practice guidelines for acute management of SCI. In 2013 the Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) released a revision of the 2002 guidelines for Cervical SCI. In the present report we explore seven subsections for management of specific cervical injury types, review key supporting literature, and provide an update on recent studies since the publication of the 2013 guidelines. Our review finds a paucity of Level I and Level II treatment recommendations for cervical spine injuries, with the exception of subaxial cervical spine injury classification and surgical management for Type II odontoid fractures in the elderly. We recommend the systematic implementation of large randomized controlled studies across diverse demographics and ethnicities, injury mechanisms and morphologies to address pressing limitations in the current literature. The cohesive effort to adopt the 2013 AANS/CNS Guidelines and the National Institutes of Health (NIH)/National Institute of Neurological Disorders and Stroke (NINDS) Common Data Elements for SCI as part of a multicenter international approach will enable reproducible data collection and robust analyses toward achieving this goal.

A review and update on the current and emerging clinical trials for the acute management of cervical spine and spinal cord injuries - Part III.

INTRODUCTION: Spinal cord injury (SCI) is a debilitating disease with an average annual incidence of 29.5 persons per million worldwide. Hence, it is critical to refine and bolster evidence to inform standards of care and improve outcomes. EVIDENCE ACQUISITION: In 2013 the American Association of Neurological Surgeons and the Congress of Neurological Surgeons released updated management guidelines for acute cervical spine injuries and SCI; here, we explore cervical SCI treatment trials since the 2013 publication. Of 56 studies published in the Cochrane Library Central Register of Controlled Trials, 19 met inclusion criterion of acute cervical spine injury and are summarized across 4 subcategories: diagnosis, surgical stabilization, scopes/instrumentation, and therapeutic outcomes. EVIDENCE SYNTHESIS: We confirm the utility of computed tomography for diagnosis, and improved outcomes associated with early (<24 hours) decompressive surgery. We describe advances in laryngoscopy and intubation under various SCI indications. We explore the benefits of continuous positive airway pressure protocols for reducing respiratory insufficiency, and patient education standards for transfer and mobility success. We report on ongoing randomized controlled trials (RCT) for surgical and therapeutic approaches for subpopulations of interest, including incomplete cord lesion, canal stenosis, and riluzole pharmacotherapy. We recommend a large, multicenter, prospective confirmatory RCT to assess the impact of timing of surgery versus conservative management in an effort to generate Class I evidence on the topic. CONCLUSIONS: Such a study should utilize shared, common variables as outlined by the National Institutes of Health SCI Common Data Elements to enable international collaboration and data pooling for robust, reproducible analyses.

Complications and outcomes of vasopressor usage in acute traumatic central cord syndrome.

OBJECT The optimal mean arterial pressure (MAP) for spinal cord perfusion after trauma remains unclear. Although there are published data on MAP goals after spinal cord injury (SCI), the specific blood pressure management for acute traumatic central cord syndrome (ATCCS) and the implications of these interventions have yet to be elucidated. Additionally, the complications of specific vasopressors have not been fully explored in this injury condition. METHODS The present study is a retrospective cohort analysis of 34 patients with ATCCS who received any vasopressor to maintain blood pressure above predetermined MAP goals at a single Level 1 trauma center. The collected variables were American Spinal Injury Association (ASIA) grades at admission and discharge, administered vasopressor and associated complications, other interventions and complications, and timing of surgery. The relationship between the 2 most common vasopressors-dopamine and phenylephrine-and complications within the cohort as a whole were explored, and again after stratification by age. RESULTS The mean age of the ATCCS patients was 62 years. Dopamine was the most commonly used primary vasopressor (91% of patients), followed by phenylephrine (65%). Vasopressors were administered to maintain MAP goals fora mean of 101 hours. Neurological status improved by a median of 1 ASIA grade in all patients, regardless of the choice of vasopressor. Sixty-four percent of surgical patients underwent decompression within 24 hours. There was no observed relationship between the timing of surgical intervention and the complication rate. Cardiogenic complications associated with vasopressor usage were notable in 68% of patients who received dopamine and 46% of patients who received phenylephrine. These differences were not statistically significant (OR with dopamine 2.50 [95% CI 0.82-7.78], p = 0.105). However, in the subgroup of patients > 55 years, dopamine produced statistically significant increases in the complication rates when compared with phenylephrine (83% vs 50% for dopamine and phenylephrine, respectively; OR with dopamine 5.0 [95% CI 0.99-25.34], p = 0.044). CONCLUSIONS Vasopressor usage in ATCCS patients is associated with complication rates that are similar to the reported literature for SCI. Dopamine was associated with a higher risk of complications in patients > 55 years. Given the increased incidence of ATCCS in older populations, determination of MAP goals and vasopressor administration should be carefully considered in these patients. While a randomized control trial on this topic may not be practical, a multiinstitutional prospective study for SCI that includes ATCCS patients as a subpopulation would be useful for examining MAP goals in this population.

The Brain and Spinal Injury Center score: a novel, simple, and reproducible method for assessing the severity of acute cervical spinal cord injury with axial T2-weighted MRI findings.

OBJECT: Previous studies that have evaluated the prognostic value of abnormal changes in signals on T2-weighted MRI scans of an injured spinal cord have focused on the longitudinal extent of this signal abnormality in the sagittal plane. Although the transverse extent of injury and the degree of spared spinal cord white matter have been shown to be important for predicting outcomes in preclinical animal models of spinal cord injury (SCI), surprisingly little is known about the prognostic value of altered T2 relaxivity in humans in the axial plane. METHODS: The authors undertook a retrospective chart review of 60 patients who met the inclusion criteria of this study and presented to the authors' Level I trauma center with an acute blunt traumatic cervical SCI. Within 48 hours of admission, all patients underwent MRI examination, which included axial and sagittal T2 images. Neurological symptoms, evaluated with the grades according to the American Spinal Injury Association (ASIA) Impairment Scale (AIS), at the time of admission and at hospital discharge were correlated with MRI findings. Five distinct patterns of intramedullary spinal cord T2 signal abnormality were defined in the axial plane at the injury epicenter. These patterns were assigned ordinal values ranging from 0 to 4, referred to as the Brain and Spinal Injury Center (BASIC) scores, which encompassed the spectrum of SCI severity. RESULTS: The BASIC score strongly correlated with neurological symptoms at the time of both hospital admission and discharge. It also distinguished patients initially presenting with complete injury who improved by at least one AIS grade by the time of discharge from those whose injury did not improve. The authors' proposed score was rapid to apply and showed excellent interrater reliability. CONCLUSIONS: The authors describe a novel 5-point ordinal MRI score for classifying acute SCIs on the basis of axial T2-weighted imaging. The proposed BASIC score stratifies the SCIs according to the extent of transverse T2 signal abnormality during the acute phase of the injury. The new score improves on current MRI-based prognostic descriptions for SCI by reflecting functionally and anatomically significant patterns of intramedullary T2 signal abnormality in the axial plane.