Clinical course and outcomes of critically ill patients with Middle East respiratory syndrome coronavirus infection.

BACKGROUND: Since September 2012, 170 confirmed infections with Middle East respiratory syndrome coronavirus (MERS-CoV) have been reported to the World Health Organization, including 72 deaths. Data on critically ill patients with MERS-CoV infection are limited. OBJECTIVE: To describe the critical illness associated with MERS-CoV. DESIGN: Case series. SETTING: 3 intensive care units (ICUs) at 2 tertiary care hospitals in Saudi Arabia. PATIENTS: 12 patients with confirmed or probable MERS-CoV infection. MEASUREMENTS: Presenting symptoms, comorbid conditions, pulmonary and extrapulmonary manifestations, measures of severity of illness and organ failure, ICU course, and outcome are described, as are the results of surveillance of health care workers (HCWs) and patients with potential exposure. RESULTS: Between December 2012 and August 2013, 114 patients were tested for suspected MERS-CoV; of these, 11 ICU patients (10%) met the definition of confirmed or probable cases. Three of these patients were part of a health care-associated cluster that also included 3 HCWs. One HCW became critically ill and was the 12th patient in this case series. Median Acute Physiology and Chronic Health Evaluation II score was 28 (range, 16 to 36). All 12 patients had underlying comorbid conditions and presented with acute severe hypoxemic respiratory failure. Most patients (92%) had extrapulmonary manifestations, including shock, acute kidney injury, and thrombocytopenia. Five (42%) were alive at day 90. Of the 520 exposed HCWs, only 4 (1%) were positive. LIMITATION: The sample size was small. CONCLUSION: MERS-CoV causes severe acute hypoxemic respiratory failure and considerable extrapulmonary organ dysfunction and is associated with high mortality. Community-acquired and health care-associated MERS-CoV infection occurs in patients with chronic comorbid conditions. The health care-associated cluster suggests that human-to-human transmission does occur with unprotected exposure. PRIMARY FUNDING SOURCE: None.

Repair of aortic arch atresia with diffuse hypoplasia of the descending thoracic aorta.

We report successful repair of a rare combination of aortic arch atresia and diffuse long-segment hypoplasia of the descending aorta in a 2-month-old infant with PHACES association. Intraoperative findings and surgical techniques are discussed.

Surgical Reconstruction of Peripheral Pulmonary Arteries: Strategies, Outcomes, and New Classification.

BACKGROUND: Pulmonary artery stenosis (PAS) is classified as central (types 1 and 2) and peripheral (type 3 affects proximal part of lobar arteries, type 4 affects proximal part of segmental arteries, and type 5 affects distal part of segmental arteries). In this study, we examine the outcomes of surgical reconstruction of peripheral PAS. METHODS: We reviewed 31 patients with peripheral PAS who underwent surgical repair. Median age was 30 months. Patients with intact ventricular septum (24 patients) presented with severe right ventricular dilation and dysfunction and mean right ventricular to left ventricular pressure (RVSP/LVSP) ratio was 0.96 ± 0.25, 1.14 ± 0.23, and 1.43 ± 0.07 for types 3, 4, and 5, respectively (p = 0.03). Pulmonary artery reconstruction was achieved in single stage in 19 patients (61%). RESULTS: Six patients (19%) had type 3, 22 patients (71%) had type 4, and 3 patients (10%) had type 5. mean number of angioplasties per patient was 18 ± 8. There was no early mortality. Mean postoperative RVSP/LVSP ratio decreased to 0.27 ± 0.08, 0.36 ± 0.05, and 0.96 ± 0.06, for types 3, 4, and 5, respectively (p < 0.001). The median follow-up was 48 months. Patients with type 3 and 4 showed marked improvement in functional status after surgery. Patients with type 5 showed clinical evidence of improved cardiac output despite modest decrease in RVSP. No surgical re-intervention was needed, while balloon dilation was performed in 1 patient with type 5 lesions. CONCLUSIONS: Surgical reconstruction of diffuse peripheral PAS is feasible and associated with excellent hemodynamic and functional outcomes in patients where there is no involvement of the distal part of segmental arteries.

Successful repair of blunt injury of aortic arch branches in the setting of bovine arch.

Intrathoracic great vessels injuries are usually fatal and represent a special surgical challenge. We report a successful surgical repair for blunt disruption of the three aortic arch branches in the setting of bovine arch anatomy. The repair was achieved without the use of cardiopulmonary bypass or arterial shunts. There was no clinical or radiologic evidence of neurologic abnormality after the repair.

Left ventricular unloading in a patient with end-stage cardiomyopathy and medically unresponsive pulmonary hypertension.

Severe, medically unresponsive pulmonary hypertension (PHT) is considered to be a contraindication for orthotopic heart transplantation (OHT). Chronic left ventricular (LV) unloading using a left ventricular assist device (LVAD) might result in reversal of the elevated pulmonary vascular resistance (PVR), allowing successful OHT in such patients. In this study, we present a patient with end-stage ischemic cardiomyopathy and fixed, elevated PVR (7.1 Wood units) who underwent implantation of a Novacor LVAD (Baxter Healthcare Corp., Deerfield, IL, U.S.A.), with a subsequent reduction in PVR to 1.2 Wood units and successful OHT eleven months post-LVAD implantation. Three years after heart transplant, the patient still leads an active life with no right heart failure. In conclusion, OHT is not contraindicated in patients with end-stage heart failure and medically unresponsive PHT in the presence of elevated left atrial pressure. Left ventricular unloading should be considered in these patients to allow reversal of the elevated PVR before OHT.