Medical and Mechanical Circulatory Support of the Failing Right Ventricle.

PURPOSE OF REVIEW: To describe medical therapies and mechanical circulatory support devices used in the treatment of acute right ventricular failure. RECENT FINDINGS: Experts have proposed several algorithms providing a stepwise approach to medical optimization of acute right ventricular failure including tailored volume administration, ideal vasopressor selection to support coronary perfusion, inotropes to restore contractility, and pulmonary vasodilators to improve afterload. Studies have investigated various percutaneous and surgically implanted right ventricular assist devices in several clinical settings. The initial management of acute right ventricular failure is often guided by invasive hemodynamic data tracking parameters of circulatory function with the use of pharmacologic therapies. Percutaneous microaxial and centrifugal extracorporeal pumps bypass the failing RV and support circulatory function in severe cases of right ventricular failure.

Mechanically Ventilated Patients With Coronavirus Disease 2019 Had a Higher Chance of In-Hospital Death If Treated With High-Flow Nasal Cannula Oxygen Before Intubation.

BACKGROUND: The impact of high-flow nasal cannula (HFNC) on outcomes of patients with respiratory failure from coronavirus disease 2019 (COVID-19) is unknown. We sought to assess whether exposure to HFNC before intubation was associated with successful extubation and in-hospital mortality compared to patients receiving intubation only. METHODS: This single-center retrospective study examined patients with COVID-19-related respiratory failure from March 2020 to March 2021 who required HFNC, intubation, or both. Data were abstracted from the electronic health record. Use and duration of HFNC and intubation were examined' as well as demographics and clinical characteristics. We assessed the association between HFNC before intubation (versus without) and chance of successful extubation and in-hospital death using Cox proportional hazards models adjusting for age, sex, race/ethnicity, obesity, hypertension, diabetes, prior chronic obstructive pulmonary disease or asthma, HCO 3 , CO 2 , oxygen-saturation-to-inspired-oxygen (S:F) ratio, pulse, respiratory rate, temperature, and length of stay before intervention. RESULTS: A total of n = 440 patients were identified, of whom 311 (70.7%) received HFNC before intubation, and 129 (29.3%) were intubated without prior use of HFNC. Patients who received HFNC before intubation had a higher chance of in-hospital death (hazard ratio [HR], 2.08; 95% confidence interval [CI], 1.06-4.05). No difference was found in the chance of successful extubation between the 2 groups (0.70, 0.41-1.20). CONCLUSIONS: Among patients with respiratory failure from COVID-19 requiring mechanical ventilation, patients receiving HFNC before intubation had a higher chance of in-hospital death. Decisions on initial respiratory support modality should weigh the risks of intubation with potential increased mortality associated with HFNC.

The Role of Complementary and Alternative Medicine in Facial Plastic Surgery.

Complementary and alternative medicine (CAM) has become increasingly popular among facial plastic surgery patients. Over the last few decades, there has been a surge in the use of CAM. Despite the increasing prevalence of CAM, patients may feel uncomfortable discussing these therapies with their physicians, and physicians feel under-equipped to engage in meaningful discussions regarding these nontraditional therapies. This article reviews recent literature on the use of CAM for skin treatment in an attempt to provide additional resource. To date, the evidence to support statistically significant symptom improvement with use of non-traditional therapies remains limited. While preliminary data supports essential oil therapy in some cases, the results of the studies investigating other CAM therapies (traditional Chinese medicine, Ayurveda, and homeopathy) have been mixed and inconclusive.

Addressing the Nasal Valves: The Endonasal Approach.

The external and internal nasal valves are directly implicated in nasal valve collapse. A variety of endonasal techniques have been developed to address nasal dysfunction while maintaining or improving aesthetic appearance. This review discusses the biomechanics, surgical approach, indications, and evidence of functional and aesthetic results for each maneuver. While the endonasal approach is safe and effective, a thorough understanding of the advantages and limitations is fundamental to selecting the most appropriate surgery for the individual patient.

Facelift Surgery: History, Anatomy, and Recent Innovations.

Facelift surgery has become a beautifully predictable, safe, and extremely effective operation. Our patients can expect natural and long-lasting results as a direct outcome of our improved understanding and applications of surgical facial anatomy. Rhytidectomy, once an operation of simple well-placed elliptical skin excisions, evolved to include longer skin flaps, skin and platysma flaps with various superficial muscular aponeurotic system (SMAS) manipulations, and various deep plane techniques involving the skin and SMAS as a single unit composite flap. Extended deep plane rhytidectomy and vertical vector neck and SMAS lifting have emerged in recent years as techniques that extend the traditional deep plane dissection into the neck in a subplatysmal plane to allow for release of the platysma from the cervical retaining ligaments. This, ultimately, allows for the creation of a dramatically more youthful appearing face, neck, and jawline.

Endonasal FLI Approach for Rhinoplasty with Modified Cottle Low Strip Septoplasty.

To date, an endonasal approach has not been described that combines different incisions to provide exposure of all of the key anatomical structures, allowing for adequate, comprehensive visualization of the nasal architecture including the complete quadrangular cartilage and its extension with the upper lateral cartilages, including the caudal septal border from the ventral border and anterior nasal spine to the anterior septal angle, the scroll, and internal nasal valve.The endonasal approach that Fausto Lopez-Infante designed, the FLI technique, combines several basic known endonasal incisions that together allow excellent access and great visualization of the intranasal surgical field, enables extensive septal work, and preserves the natural anatomy of the dorsum as well as the tip support structures.This technique and approach to nasal surgery are based on an understanding of anatomy, allow standardization of the surgery, and make it reproducible. It is an outstanding option with excellent cosmetic and functional results.

Preservation Rhinoplasty: Evolution and Current State of Practice in the United States.

Classic Joseph hump reduction techniques have been a hallmark of current rhinoplasty practice and teaching. Recently, there has been a renewed global interest in preservation rhinoplasty techniques, although these techniques are not new. The work and techniques of innovative surgeons including Goodale, Lothrop, and Cottle describing preservation concepts from the late nineteenth century and early twentieth century were not as prevalently adopted as open structural approaches. As such, there has been a relative paucity in both research and teaching of preservation techniques-particularly in the United States. A survey of members of the American Academy of Facial Plastic and Reconstructive Surgery and The Rhinoplasty Society (145 respondents) demonstrates that while 15 (10%) of surgeons are not at all familiar with dorsal preservation surgery, 130 (90%) were. In the group that was familiar with dorsal preservation, the majority were only somewhat familiar (84, 65%) with these techniques. Only 11 respondents received any formal training in dorsal preservation techniques during residency or fellowship. 61 (42%) had attended a course or conference in which dorsal preservation techniques were discussed. One-hundred twenty-two survey respondents (84.1%) do not currently implement preservation techniques into their rhinoplasty practice. Twelve (8%) respondents implement it in <25% of cases, 5 (3%) in 25 to 50% of cases, and 6 (4%) in >50% of cases. As research and formal training in preservation rhinoplasty grow, familiarity and implementation of these techniques will likely also grow in the United States.

Allogeneic cardiosphere-derived cells (CAP-1002) in critically ill COVID-19 patients: compassionate-use case series.

There are no definitive therapies for patients with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection. Therefore, new therapeutic strategies are needed to improve clinical outcomes, particularly in patients with severe disease. This case series explores the safety and effectiveness of intravenous allogeneic cardiosphere-derived cells (CDCs), formulated as CAP-1002, in critically ill patients with confirmed coronavirus disease 2019 (COVID-19). Adverse reactions to CAP-1002, clinical status on the World Health Organization (WHO) ordinal scale, and changes in pro-inflammatory biomarkers and leukocyte counts were analyzed. All patients (n = 6; age range 19-75 years, 1 female) required ventilatory support (invasive mechanical ventilation, n = 5) with PaO2/FiO2 ranging from 69 to 198. No adverse events related to CAP-1002 administration were observed. Four patients (67%) were weaned from respiratory support and discharged from the hospital. One patient remains mechanically ventilated as of April 28th, 2020; all survive. A contemporaneous control group of critically ill COVID-19 patients (n = 34) at our institution showed 18% overall mortality at a similar stage of hospitalization. Ferritin was elevated in all patients at baseline (range of all patients 605.43-2991.52 ng/ml) and decreased in 5/6 patients (range of all patients 252.89-1029.90 ng/ml). Absolute lymphocyte counts were low in 5/6 patients at baseline (range 0.26-0.82 × 103/µl) but had increased in three of these five patients at last follow-up (range 0.23-1.02 × 103/µl). In this series of six critically ill COVID-19 patients, intravenous infusion of CAP-1002 was well tolerated and associated with resolution of critical illness in 4 patients. This series demonstrates the apparent safety of CAP-1002 in COVID-19. While this initial experience is promising, efficacy will need to be further assessed in a randomized controlled trial.

Use of the Bedside-Placed Angel Catheter IVC Filter for Venous Thromboembolic Disease in Critically Ill Medical Patients.

Venous thromboembolic disease is a major problem among critically ill patients, with significant associated morbidity and mortality. Many critically ill patients have contraindications to systemic anticoagulation, and inferior vena cava (IVC) filters are an important alternative in preventing pulmonary emboli (PE) in this population. The Angel Catheter (Mermaid, Stenlose, Denmark) is a novel percutaneous and removable IVC filter attached to the end of a triple lumen central venous catheter which has been demonstrated to reduce PE in surgical and trauma patients. This case series describes 18 critically ill medical patients who had an Angel catheter placed either for diagnosed PE or due to high risk for PE; over half had at least submassive PE at the time of Angel catheter placement. None of the patients had a recurrence of PE during Angel catheter use, 29.4% had clot found in the filter via cavogram upon removal, and only one had a minor complication which had no clinical consequence. In 2 patients, the placement of the Angel Catheter resulted in the prevention of PE during catheter-directed thrombolysis of extensive deep vein thrombosis. This case series demonstrates that in a population of critically ill, elderly, and obese medical patients the bedside placement of the Angel IVC filter is feasible, safe, and may be effective for preventing PE.

Septal Deviation after Septorhinoplasty: Causes and Surgical Management.

Revision rhinoplasty exists because the perfect primary rhinoplasty technique does not. The benefit of revision surgery is that it offers us the opportunity to study and identify what did not work well during previous surgery. Thoughtful approaches to technique and outcomes allow us to recognize which maneuvers are dependable and worth repeating, and which are not reliable and therefore worth avoiding. As surgeons seek safer, more predictable results to improve patient outcomes, new techniques emerge which we then apply, study, and modify again, based on what works and what does not over the short term and the long term. There is no substitute for experience or for learning from trusted surgeons' experiences. Revision rhinoplasty presents many challenges including surgically induced anatomical changes, weakened structural support, a lack of available tissue for reconstruction, tissue remodeling responses, and other iatrogenic and wound healing complications. The septum, as the primary source of structural nasal integrity, forms the foundation for functional and aesthetic rhinoplasty. Herein, we describe strategies in septorhinoplasty for patients who have undergone prior nasal septal surgery.

Avoiding the Unhappy Patient by Building Rapport in the Internet Age.

The dynamics of the doctor-patient relationship has been complicated as more patients seem to expect perfection in this age of selfies and Internet postings. The preoperative patient interview is critical to recognize both body language clues and subtle but apparent red flags to avoid rhinoplasty on potentially unhappy patients. This interview should include routine use of a body dysmorphic disorder screening questionnaire since legions of these patients are undiagnosed prior to surgery and few, if any, are ever satisfied with even an excellent surgical result. These patients need diagnosis and psychological intervention-not surgery. Rapport is critical to patient and surgeon's satisfaction; therefore, it is valuable to practice the ABC's of rapport building: 1) active listening, (2) positive body language, and (3) candor.

A pulmonary embolism response team's initial 20 month experience treating 87 patients with submassive and massive pulmonary embolism.

Pulmonary Embolism Response Teams (PERTs) have emerged to provide rapid multidisciplinary assessment and treatment of PE patients. However, descriptive institutional experience and preliminary outcomes data from such teams are sparse. PERT activations were identified through a retrospective review. Only confirmed submassive or massive PEs were included in the data analysis. In addition to baseline variables, the therapeutic intervention, length of stay (LOS), in-hospital mortality, and bleeding rate/severity were recorded. A total of 124 PERT activations occurred over 20 months: 43 in the first 10 months and 81 in the next 10. A total of 87 submassive (90.8%) and massive (9.2%) PE patients were included. The median age was 65 (51-75 IQR) years. Catheter-directed thrombolysis (CDT) was administered to 25 patients, systemic thrombolysis (ST) to six, and anticoagulation alone (AC) to 54. The median ICU stay and overall LOS were 6 (3-10 IQR) and 7 (4-14 IQR) days, respectively, with no association with any variables except a brain natriuretic peptide (BNP) >100 pg/mL ( p=0.008 ICU LOS; p=0.047 overall LOS). Twelve patients (13.7%) died in the hospital, nine of whom had metastatic or brain cancer, with a median overall LOS of 13 (11-17 IQR) days. There were five major bleeds: one in the CDT group, one in the ST group, and three in the AC group. Overall, (1) PERT activations increased after the first 10 months; (2) BNP >100 pg/mL was associated with a longer LOS; (3) rates of mortality and bleeding did not correlate with treatment; and (4) the majority of in-hospital deaths occurred in patients with advanced cancer.

Functional Compromise in the Middle Vault in the Management of Revision Rhinoplasty.

As rhinoplasty procedures become more common, the need for revision surgeries increases as well. Unlike primary rhinoplasties, revision rhinoplasties can be more challenging because of anatomic differences from initial surgery, a lack of available cartilage, tissue remodeling responses, and other complications. As such, surgeons should be prepared to address revision rhinoplasty patients differently from primary rhinoplasty patients. Here, the authors describe a generalizable approach to revision functional rhinoplasty patients and detail some of the surgical techniques that can be employed to achieve optimal outcomes, with particular attention paid to procedures that can be used in the middle vault.

Complications of Polydioxanone Foil Use in Nasal Surgery: A Case Series.

Polydioxanone (PDS) foil is widely recognized as a septal cartilage replacement during rhinoplasties and is thought to be completely resorbable and biodegradable. Since its United States Food and Drug Administration approval in 2010, PDS foil has drawn significant enthusiasm and many surgeons consider it an ideal implantable biomaterial as reflected in numerous studies highlighting its benefits. However, scant literature exists highlighting relevant complications of PDS plates that may potentially lead to cavalier overuse. This descriptive case series assesses the outcomes of PDS foil usage in three patients seen for septoplasty at two independent institutions over the past 5 years. Our results demonstrate that PDS plate usage can lead to septal cartilage loss and resultant saddle nose deformity associated with prolonged postoperative edema and inflammation. To our knowledge, this is the largest case series of this reported phenomenon.

Validation of the Modified Surgeon Periorbital Rating of Edema and Ecchymosis (SPREE) Questionnaire: A Prospective Analysis of Facial Plastic and Reconstructive Surgery Procedures.

Although periorbital edema and ecchymosis are commonly encountered after facial plastic and reconstructive surgery procedures, there is currently no validated grading scale to qualify these findings. In this study, the modified "Surgeon Periorbital Rating of Edema and Ecchymosis (SPREE)" questionnaire is used as a grading scale for patients undergoing facial plastic surgery procedures. This article aims to validate a uniform grading scale for periorbital edema and ecchymosis using the modified SPREE questionnaire in the postoperative period. This is a prospective study including 82 patients at two different routine postoperative visits (second and seventh postoperative days), wherein the staff and resident physicians, physician assistants (PAs), patients, and any accompanying adults were asked to use the modified SPREE questionnaire to score edema and ecchymosis of each eye of the patient who had undergone a plastic surgery procedure. Interrater and intrarater agreements were then examined. Cohen's kappa coefficient was calculated to measure intrarater and interrater agreement between health care professionals (staff physicians and resident physicians); staff physicians and PAs; and staff physicians, patients, and accompanying adults. Good to excellent agreement was identified between staff physicians and resident physicians as well as between staff physicians and PAs. There was, however, poor agreement between staff physicians, patients, and accompanying adults. In addition, excellent agreement was found for intraobserver reliability during same-day visits. The modified SPREE questionnaire is a validated grading system for use by health care professionals to reliably rate periorbital edema and ecchymosis in the postoperative period. Validation of the modified SPREE questionnaire may improve ubiquity in medical literature reporting and related outcomes reporting in future.

A Technique for Bronchoscopic Intubation During High-Flow Nasal Cannula Oxygen Therapy.

Despite preoxygenation, critical hypoxemia can occur during intubation. We describe a technique of high-flow nasal cannula oxygen support during bronchoscopic intubation.

The Conchal Cartilage Butterfly Graft.

Nasal obstruction due to weakening of the nasal sidewall is a very common patient complaint. The conchal cartilage butterfly graft is a proven technique for the correction of nasal valve collapse. It allows for excellent functional results, and with experience and attention to technical detail, it may also provide excellent cosmetic results. While this procedure is most useful for restoring form and function in cases of secondary rhinoplasty following the reduction of nasal support structures, we have found it to be a very powerful and satisfying technique in primary rhinoplasty as well. This article aims to describe the butterfly graft, discuss its history, and detail the technical considerations which we have found useful.

Predictors of Success of Endonasal Septal Perforation Repair: A 10-Year Experience.

Background: There is no consensus on optimal repair technique for nasal septal perforations (NSPs). Objective: To measure success rate and evaluate predictors of success for NSP repair. Methods: Medical records of patients who underwent NSP repair from 2010 to 2020 were reviewed. Included patients had at least 60 days of postsurgical follow-up. Surgical technique involves an endonasal approach; subperichondrial dissection with local flap mobilization; and multilayer closure using cartilage interposition graft, fascia graft, and mucoperichondrial flaps. A chi-squared test or Fisher exact test was used for statistical analysis. Results: Eighty-one repairs were performed with a closure rate of 86%. The median patient age was 46 years (range 13-77); 34.6% of perforations were ≥2 cm. Conchal (77.8%), rib (7.4%), or septal (7.4%) cartilage was used as graft material. A complication rate of 8.6% was reported. Perforation size or graft material had no impact on successful closure rate. Of patients with failed repairs, 55% had perioperative complications or conditions associated with poor healing. Conclusion: An endonasal approach for NSP repair showed a high success rate across diverse presentations; however, NSP repair was significantly more likely to be successful in patients without perioperative complications or pre-existing conditions associated with poor wound healing.

Amanita Mushroom Toxin Poisoning in Los Angeles County.

Mushroom (amatoxin) poisoning from ingestion is a rare but life-threatening medical emergency characterized by gastrointestinal symptoms before progression to multisystem organ failure in severe cases. Many therapies of amatoxin intoxication have been described, including supportive care, medical therapies, detoxification strategies, and liver transplant. The evidence supporting these therapies remains limited due to the rarity of amatoxin poisoning and challenge of a timely diagnosis. We report a case of amatoxin poisoning in Los Angeles causing severe liver injury without acute liver failure treated successfully using medical therapies, gallbladder drainage, and plasma exchange.

Correction to: Amanita Mushroom Toxin Poisoning in Los Angeles County.

[This corrects the article DOI: 10.14309/crj.0000000000001246.].