Odynophagia after Cardiac Catheterization: A Rare Complication in the Presence of Aberrant Subclavian Artery.

BACKGROUND: Vascular complications from transradial cardiac catheterization are uncommon. Mediastinal hematoma is a rare complication with life-threatening potential. We present a case of a patient who underwent cardiac catheterization and subsequently experienced odynophagia from injury to an aberrant subclavian artery that led to a mediastinal hematoma. Case Report. A 59-year-old female with past medical history of coronary artery disease presented with complaints of angina and underwent a transradial cardiac catheterization. Immediately after the procedure, the patient complained of chest pain and odynophagia. EKG and echocardiogram were unremarkable, and a CT scan of the chest demonstrated an ill-defined fluid collection present in the superior mediastinum and an aberrant right subclavian artery. The patient was closely monitored in the Intensive Care Unit, and the patient remained hemodynamically stable throughout the admission. The patient was subsequently discharged home in good condition and did well on outpatient follow-up. CONCLUSION: Vascular injuries associated with delivery of standard radial catheters in the subclavian artery are rare, with very few cases reported in the literature. We presented the case of a patient who had a previously unidentified right aberrant subclavian artery with a retroesophageal course which precipitated the hematoma and subsequently resulted in odynophagia despite an uncomplicated catheterization. This rare complication of a commonplace procedure necessitates prompt recognition, appropriate hemodynamic management, and possible repair of the injured vessel to appropriately manage a potentially life-threatening condition.

Appropriate Use of Transesophageal Echocardiogram for Infective Endocarditis: A Single Center Experience.

BACKGROUND: Transesophageal echocardiogram (TEE) is a valuable tool in healthcare today with its ease of use, ability to visualize important structures not seen on transthoracic echocardiogram (TTE), and the relatively lower cost of TEE, high yield, and no significant radiation exposure. The American Society of Echocardiography (ASE) has developed an appropriate use criteria for use of TTE and TEE, which outline various scenarios where a TEE is indicated as an initial diagnostic testing modality and when it is useful as an adjunctive test in hopes of decreasing inappropriate use. Using these criteria as a guide, we devised a quality assessment study to investigate how well TEEs performed at our institution fit the appropriate use criteria specifically for the diagnostic workup of infective endocarditis. METHODS: A retrospective chart review was performed for all TEEs performed in 2017 with the indication of endocarditis. Baseline patient characteristics, presence of bacteremia, and the quality of the TTE preceding the TEE were noted, as well as whether a vegetation, abscess, or perforation was visualized. We also determined if there was a cardiology consultation placed prior to TEE and if the patient had met the definition for endocarditis as defined by the Duke criteria. Finally, we made note of the TEE findings and assessed whether the TEE met appropriate use criteria developed by the American Society of Echocardiography. RESULTS: A total of 50 patients who underwent TEE with the indication of "endocarditis" were identified. 36% of the TTEs prior to the TEE were rated as good quality, 40% as adequate, 4% as fair, 4% as suboptimal, 12% as technically difficult, and 4% were not rated. Vegetations were visualized on 12% of TTEs, 6% of patients had a prosthetic valve, and 6% had a cardiac device. In 20% of the cases, there was no cardiology consultation prior to the TEE and in 20% of the cases, there was no documented bacteremia. 26% of patients met the Duke criteria for endocarditis prior to TEE. Only 36% of TEEs revealed evidence of infection and of the patients with no evidence of infection, only 38% met appropriate use criteria. Overall, only 56% of patients met appropriate use criteria for TEE. CONCLUSION: Transesophageal echocardiography is a valuable tool in a modern physician's arsenal for managing a variety of diseases and conditions. However, the procedure is not without associated risks and its ease of use and widespread adoption has led to frequent questionable appropriateness of use of the test. Only 56% of the TEEs performed in our analysis met appropriate use. More awareness and education is needed for the appropriate use criteria for transesophageal echocardiography as outlined by the ASE to help reduce patient exposure to procedure related complications and to decrease medical costs on unnecessary procedures.

Characterization of laryngeal muscle stem cell survival and proliferation.

OBJECTIVES/HYPOTHESIS: Laryngeal muscle and skeletal muscle stem cells (MSC) have been shown to differ in physiological basal activity and responsiveness to stimuli. Given these differences, it is the purpose of this investigation to characterize the in vitro proliferation and survival of laryngeal and skeletal MSC to determine whether intrinsic differences exist that may account for differences noted in vivo. STUDY DESIGN: Basic science experiment utilizing rat MSC. METHODS: Cultures of both laryngeal and skeletal MSC were harvested and equal numbers from both groups were expanded under similar conditions, quantifying cellular population to determine proliferation rate for each population. Increased proliferative potential was confirmed using Western blot analysis of extracellular signal-regulated kinase phosphorylation. As per standard survival assay protocol, cultures were placed in serum-deprived medium and cell survival was assessed by terminal uridine deoxynucleotidyl transferase-mediated dUTP nick end labeling assay at 72 hours. RESULTS: Our results demonstrated increased proliferation of laryngeal MSC relative to the skeletal MSC when cultured under similar conditions. Western blot demonstrated increased activation of the proliferation pathway, extracellular signal-regulated kinase, in the laryngeal group. There was no detectable difference in the MSC survival between the two groups. CONCLUSIONS: Compared with skeletal MSC, laryngeal MSC demonstrate increased proliferation and regenerative capacity. This may explain some of the differences in physiological role and responses involved in each cell population's tissue of origin.

Optimization of autologous muscle stem cell survival in the denervated hemilarynx.

OBJECTIVE: Current treatments for vocal fold paralysis are suboptimal in that they fail to restore dynamic function. Autologous muscle stem cell (MSC) therapy is a promising potential therapy for vocal fold paralysis in that it can attenuate denervation-induced muscle atrophy and provide a vehicle for delivery of neurotrophic factors, thereby potentially selectively guiding reinnervation. The goal of this project was to characterize optimal conditions for injected autologous MSC survival in the thyroarytenoid (TA) muscle following recurrent laryngeal nerve (RLN) injury by local administration of adjuvant factors. STUDY DESIGN: Animal experiment. METHODS: Unilateral RLN transection and sternocleidomastoid muscle (approximately 1 g) biopsies were performed in 20 male Wistar rats. One month later, 10 autologous MSCs labeled via retroviral-enhanced green fluorescent protein (EGFP) transduction were injected into the denervated hemilarynx of each animal with one of four adjuvant therapies: cardiotoxin [(CTX) 10 M], insulin-like growth factor-1 [(IGF- 1) 100 microg/mL], ciliary neurotrophic factor [(CNTF) 50 microg/mL], or saline. Animals were euthanized 1 month later and larynges harvested, sectioned, and analyzed for MSC survival. RESULTS: All specimens demonstrate extensive MSC survival, with fusion of the MSCs with the denervated myofibers. Based on mean fluorescent intensity of the laryngeal specimens, IGF-1 and CNTF had the greatest positive influence on MSC survival. Myofiber diameters demonstrated myofiber atrophy to be inversely related to MSC survival, with the least atrophy in the groups having the greatest MSC survival. CONCLUSIONS: Autologous MSC therapy may be a future treatment for vocal fold paralysis. These findings support a model whereby MSCs genetically engineered to secrete CNTF and/or IGF-1 may not only promote neural regeneration, but also enhance MSC survival in an autocrine fashion.

Injection of autologous muscle stem cells (myoblasts) for the treatment of vocal fold paralysis: a pilot study.

OBJECTIVE: Autologous muscle stem cell (myoblast) therapy may be an ideal treatment for vocal fold paralysis because of its technical ease (administered by injection), its potential to restore muscular defects and dynamic function, and its autologous origin. The goal of this project was to determine whether autologous myoblast injection into the thyroarytenoid (TA) muscle after recurrent laryngeal nerve (RLN) injury could attenuate TA muscle atrophy and enhance spontaneous reinnervation. STUDY DESIGN: This was an animal experiment. METHODS: Unilateral RLN transection and sternocleidomastoid muscle (approximately 1 g) biopsies were performed in 16 male Wistar rats. Biopsies were used to create myoblast cultures for each animal. One month later, 10(6) autologous myoblasts labeled with fluorescent cell membrane marker (PKH26) were injected into the denervated TA of each study animal, with saline injected into controls. Animals were euthanized at 2 weeks and 2 months after myoblast injection. Outcomes included myoblast survival, TA fiber diameter and volume, and reinnervation status (motor endplate to nerve contact staining). RESULTS: All denervated TA study specimens demonstrated viable myoblasts under fluorescent microscopy, with the myoblasts demonstrating fusion with the TA myofibers at 2 months. The myoblast-treated group had greater mean TA fiber diameter than denervated TA controls at 2 months (25.1 vs. 21.1 microm; P = .04) but not at 2 weeks (25.7 microm vs. 23.5 microm; P = .06). Mean TA volumes were greater in the myoblast-treated groups at both time points. Two of the animals in the myoblast-treated group demonstrated adductor motion at 2 months, whereas none of the 2 week study animals or controls recovered adduction. Reinnervation was not significantly different between the myoblast-treated groups and the denervated controls. CONCLUSIONS: Autologous myoblast therapy may be a future treatment for vocal fold paralysis, with current findings demonstrating myoblast survival with attenuation of TA muscle atrophy.