ABSTRACT
Background: Lemierre's syndrome is an infectious phenomenon characterized by oropharyngeal infection with bacteraemia, thrombophlebitis, and distant septic emboli. Septic emboli are a recognized cause of a Type 2 myocardial infarction, with a left ventricular pseudoaneurysm being a rare but important complication of this. Case summary: A 19-year-old male presented with acute confusion, fevers, and a cough. Blood cultures were positive for Fusobacterium necrophorum and initial imaging showed a cavitating pneumonia. Further evaluation revealed septic emboli in the distal digits and brain. The patient initially responded to antibiotic therapy but developed chest pain with increased troponin levels. An electrocardiogram showed inferolateral ST elevation. A transthoracic echocardiogram (TTE) showed hypokinaesia of the mid to apical lateral wall, and a computed tomography (CT) scan showed a pericardial effusion with a possible purulent effusion or abscess. The patient underwent surgical drainage of a sterile effusion. A post-operative TTE and CT demonstrated a left ventricular pseudoaneurysm that was surgically repaired. The venous thrombus was encountered intra-operatively confirming a diagnosis of Lemierre's syndrome. The patient completed the regimen of antibiotics and showed a good post-operative recovery. Discussion: This is the first case described of left ventricular pseudoaneurysm as a complication of Lemierre's syndrome. It highlights not only the importance of serial, multimodality imaging in both diagnostic workup and identification of complications, but also the importance of a multidisciplinary team in the management of patients with complex and rare presentations.
ABSTRACT
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: does prehabilitation improve outcomes in cardiac surgical patients? Altogether more than 483 papers were found using the reported search, of which 10 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. Four meta-analyses concluded that prehabilitation reduced postoperative pulmonary complications (PPCs). The 6 randomized controlled trials (RCT) included, differed significantly in the type of prehabilitation delivered. There was replication of some RCTs across the meta-analyses. The consensus across the meta-analyses was a reduction in PPCs and 3 of 4 meta-analyses finding a reduction in length of stay (LOS). There were no adverse events or difference in mortality found. Two small RCTs showed feasibility and modest improvements in physiological parameters. Three RCTs demonstrated a reduction in LOS and a reduction in PPCs. One RCT found no difference in quality of life scores, LOS or postoperative atrial fibrillation. None of the RCTs found negative evidence of prehabilitation interventions. We conclude that the prehabilitation is a positive preoperative intervention, most favourably in older patients and in those who are at risk of PPCs. Specifically inspiratory muscle training is the intervention with most favourable evidence.
