The Development and Natural History of Hiatal Hernias: A Study Using Sequential Barium Upper Gastrointestinal Series.

OBJECTIVE: The aim of this study was to use barium upper gastrointestinal series (UGI) to evaluate the development and natural history of a hiatal hernia. SUMMARY OF BACKGROUND DATA: Hiatal hernias are common but the natural history of sliding and paraesophageal type hernias is poorly understood. METHODS: We reviewed UGI reports from 1987 to 2017 using a word scanning software program to identify individuals that had a hiatal hernia. Only those with at least 2 UGI studies 5 or more years apart were selected. The studies were then reviewed. RESULTS: There were 89 individuals that met inclusion criteria. Twenty-one people had no hiatal hernia on initial UGI and over a median of 99 months a sliding hiatal hernia (SHH) developed in 16 and a PEH developed in 5 people. A SHH was present on initial UGI in 55 people and at a median of 84 months subsequent UGI showed the SHH was stable in 11 (20%), increased in size in 30 (55%), and changed to a PEH in 14 people (25%). In 13 people a PEH was present on initial UGI and over a median of 97 months it was stable in 5 and increased in size in 8 people (62%). CONCLUSIONS: We showed that both SHH and PEH can develop over time and that the majority of both increased in size on follow-up UGI study. Further, 25% of SHH became a PEH over time. Recognizing an increase in size or change in type of a hiatal hernia may be clinically relevant to help understand changing or worsening symptoms in an individual.

Heparin-Induced Thrombocytopenia After Mitral Valve Replacement.

Background: Heparin-induced thrombocytopenia (HIT) is a rare autoimmune reaction that involves a decrease in platelet count following heparin exposure and can be associated with life-threatening thrombosis. Because of their prolonged heparin exposure, patients undergoing cardiac surgery are at risk of HIT, with an incidence of 0.1% to 3%. Case Report: A 65-year-old male with severe mitral regurgitation and preoperative ejection fraction of 20% to 25% underwent mitral valve bioprosthetic replacement with coronary artery bypass graft surgery. Heparin anticoagulation was started on postoperative day (POD) 1. Respiratory failure resulted in prolonged mechanical ventilation and heparinization without the ability to initiate warfarin. While the patient was on heparin, his platelet count declined on POD 2 and then steadily increased to above the preoperative level on POD 7. On POD 10, the patient's platelet count dramatically decreased, and on POD 13 he developed acute common femoral artery occlusion necessitating embolectomy. Intraoperative transesophageal echocardiography revealed heavy thrombus burden across the mitral bioprosthesis. HIT was confirmed with a positive heparin-induced platelet antibody and serotonin release assay. Heparin was stopped and argatroban initiated. The patient underwent reoperative bioprosthetic mitral valve replacement on POD 18 using bivalirudin intraoperatively. Despite resolution of HIT, the patient developed sepsis and died on POD 59. Conclusion: The diagnosis of HIT is challenging in patients who undergo cardiopulmonary bypass. Platelet counts often decrease 40% to 60% during the first 72 hours postoperatively, and the frequency of nonspecific anti-platelet factor 4/heparin antibody formation is high. These findings can mask early signs of HIT and delay diagnosis.

Transcatheter aortic valve replacement after valve-sparing aortic root surgery.

The use of transcatheter aortic valves for aortic regurgitation presents unique challenges. Although studies describe their successful off-label use, there is a paucity of literature on transcatheter aortic valve replacement after valve-sparing aortic root surgery. We present a patient with severe aortic regurgitation following valve-sparing aortic root replacement that was treated with an oversized transcatheter aortic valve.

Does Elective Sternal Plating in Morbidly Obese Patients Reduce Sternal Complication Rates?

BACKGROUND: Although the literature shows rigid plate fixation has superior outcomes over wire cerclage techniques, a patient population clearly benefitting from initial sternal plating over standard closure has not been identified. Data on plating as primary sternal closure in the morbidly obese patient remains sparse. METHODS: A single-center retrospective study was performed on 564 consecutive patients undergoing complete median sternotomy from July 2014 to July 2017. Postoperative outcomes of patients with a body mass index of 35 kg/m2 or more were compared between sternotomies with standard wire cerclage closure and those with sternal plate reinforcement. The primary endpoint was postoperative sternal complication defined as deep sternal wound infection, acute sternal dehiscence, chronic sternal disunion, or noninfectious sternal wound complication requiring operative intervention. RESULTS: In all, 32.6% of sternotomies (184 of 564) were performed on patients with a body mass index of 35 kg/m2 or greater. Of this group, 31.5% (58 of 184) underwent sternal closure with titanium plate reinforcement and 68.5% (126 of 184) underwent traditional chest closure. The overall sternal complication rate was 4.9% (9 of 184), consisting of 6 of 126 nonplated patients and 3 of 58 plated patients (4.8% vs 5.2%, P = .80). CONCLUSIONS: Sternal plate reinforcement for sternotomy closure of patients with a body mass index 35 kg/m2 or greater produced no difference in postoperative sternal complication rates.