Emergent double valve replacement in Austrian syndrome.

Bi-valvular pneumococcal endocarditis in Austrian syndrome, which includes a triad of pneumococcal endocarditis, pneumonia, and meningitis, is a rare but life-threatening disease. We present a case of a woman found to have Austrian syndrome who presented to the emergency department (ED) with dehydration and radiographical signs of lobar pneumonia and quickly deteriorated to fulminant cardiogenic shock in less than four hours. An early echocardiogram in the ED confirmed a diagnosis of bi-valvular endocarditis with severe aortic and mitral valve insufficiency and large vegetations on the valve leaflets requiring emergent surgical intervention with double valve replacement. Assumed meningitis as a part of the triad of Austrian syndrome was confirmed by imaging the day after hospital admission. Early diagnosis of endocarditis by obtaining the echocardiogram in the ED along with emergent surgical intervention allowed for a favorable outcome for the patient.

Direct Comparison of Outcomes After Transcatheter Aortic Valve Replacement in Veterans and Non-Veterans Using the Transcatheter Valve Therapy Registry.

OBJECTIVES: This study aims to compare veterans and non-veterans undergoing transcatheter aortic valve replacement (TAVR) using data from the Society for Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) registry. METHODS: Patients undergoing TAVR at George Washington University (GWU) and veterans treated at Washington DC Veterans Affairs Medical Center (VAMC) who underwent TAVR at GWU from 2014-2020 were included. All patients were reported in the TVT registry. Emergency and valve-in-valve TAVR were excluded. Cohorts were divided based on veteran status. Operators were the same for both groups. Outcomes were compared at 30 days and 1 year. The primary outcome was mortality and secondary outcomes were morbidity metrics. RESULTS: A total of 299 patients (91 veterans, 208 non-veterans) were included. Veterans had higher rates of hypertension (87.9% vs 77.9%; P=.04), diabetes (46.7% vs 28.9%; P<.01), and lung disease (2.4% vs 11.0%; P<.001). Outcomes were not significantly different between veterans and non-veterans, including 30-day mortality (0% vs 2.9%, respectively; P=.18), 1-year mortality (9.8% vs 10.7%, respectively; P=.61), stroke incidence (0% vs 2.5%, respectively; P=.73), median intensive care unit stay (24 hours in both groups), and overall hospital stay (2 days in both groups). CONCLUSIONS: The affiliation between a VAMC and an academic medical center allowed for direct comparison between veterans and non-veterans undergoing TAVR by the same operators using the TVT registry. Despite significantly higher rates of comorbidities, veterans had equivalent outcomes compared with non-veterans. This may be in part due to the comprehensive care that veterans receive in the VAMC and this institution's integrated heart center team.

Correction to: Thoracic endovascular repair of a rare case of leaking aortic arch intramural hematoma secondary to Giant cell arteritis.

'In the published article (Salaskar et al. 2019) the statement under the subheading 'Consent for publication' is incorrect.

Thoracic endovascular repair of a rare case of leaking aortic arch intramural hematoma secondary to Giant cell arteritis.

BACKGROUND: Traditionally thoracic aortic aneurysms (TAA) secondary to Giant Cell Arteritis (GCA) were treated with resection and open repair. However no prior studies have reported an aortic intramural hematoma (IMH) as a presentation of GCA or outcome of thoracic endovascular aortic repair (TEVAR) in TAA or IMH secondary to GCA. CASE PRESENTATION: A 59 year old female, nonsmoker, non-hypertensive, non-diabetic with a known history of GCA, temporal arteritis on prednisone presented with shortness of breath & chest pain. Chest CT revealed aortic arch IMH and large left hemothorax. CTA confirmed distal aortic arch focal dilation, a focal intimal irregularity in the distal aortic arch and extensive IMH without any active extravasation or signs of aortitis. Patient underwent an urgent TEVAR without oversizing the aortic landing zones. Post TEVAR aortogram showed exclusion of the site of IMH origin and dilated aortic arch segment by the stent and absence of active extravasation. One month post-TEVAR CTA showed patent stent graft with resolution of IMH and hemothorax. One year after TEVAR, patient remained asymptomatic. CONCLUSION: GCA can present as an IMH secondary to underlying chronic vasculitis. When endovascular repair is considered, great care should be taken not to grossly oversize aortic landing zones.

Postpneumonectomy and postlobectomy empyema.

Although similar strategies are used in the management of PPE and PLE, these conditions need to be viewed as two separate entities. For the purpose of devising the appropriate management strategy, PPE should be divided into early and late, with and without mediastinal induration and extensive pleural space contamination. If at all possible, PLE should be managed as a postpneumonic empyema with prolonged chest tube drainage. The key to these conditions is prevention.

Recurrent mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation.

OBJECTIVES: We sought to characterize the temporal return of mitral regurgitation after annuloplasty for functional ischemic mitral regurgitation; to identify its predictors, particularly with respect to annuloplasty type; and to determine whether annuloplasty type influences survival. METHODS: From April 1985 through November 2002, 585 patients underwent annuloplasty alone for repair of functional ischemic mitral regurgitation, generally with concomitant coronary revascularization (95%). A flexible band (Cosgrove) was used in 68%, a rigid ring (Carpentier) in 21%, and bovine pericardial annuloplasty (Peri-Guard) in 11%. Six hundred seventy-eight postoperative echocardiograms were available in 422 patients to assess the time course of postoperative mitral regurgitation and its correlates. Most echocardiograms were performed early after the operation (median, 8 days); 17% were performed at 1 year or beyond. RESULTS: During the first 6 months after repair, the proportion of patients with 0 or 1+ mitral regurgitation decreased from 71% to 41%, whereas the proportion with 3+ or 4+ regurgitation increased from 13% to 28% ( P < .0001); the regurgitation grade was stable thereafter. The temporal pattern of development of 3+ or 4+ regurgitation was similar for Cosgrove bands and Carpentier rings (25%) but substantially worse for Peri-Guard annuloplasties (66%). Small annuloplasty size did not influence postoperative regurgitation grade ( P = .2), although Cosgrove bands were used in most patients receiving 26- and 28-mm annuloplasties. Freedom from reoperation was 97% at 5 years. Annuloplasty type was not associated with survival. CONCLUSIONS: Although initial mitral valve replacement would eliminate the risk of postoperative mitral regurgitation, this strategy has been associated with reduced survival. Therefore the development of additional techniques is necessary to achieve more secure repair of functional ischemic mitral regurgitation.

Craniocervical necrotizing fasciitis of odontogenic origin with mediastinal extension.

We review an interesting case of craniocervical necrotizing fasciitis with thoracic extension in an immunocompetent 44-year-old man. The patient underwent aggressive medical and surgical management during a long hospitalization. Multiple surgical debridements, including transcervical mediastinal debridement, and eventually a thoracotomy for mediastinal abscess were required. The patient eventually recovered, and 3 months later he showed no sign of complications or recurrence. Craniocervical necrotizing fasciitis is a fulminant soft-tissue infection, usually of odontogenic origin, that requires prompt identification and treatment to ensure survival. Broad-spectrum intravenous antibiotics, aggressive surgical debridement and wound care, hyperbaric oxygen, and good intensive care are the mainstays of treatment.

Prolonged use of extracorporeal membrane oxygenation as a rescue modality following traumatic brain injury.

A 21-year-old male trauma patient presented after a motor vehicle crash, witnessed massive aspiration and sustained traumatic brain injury. On postinjury day 3, the patient progressed to adult respiratory distress syndrome (ARDS) refractory to all conventional therapies, prompting the use of extracorporeal membrane oxygenation (ECMO). After 5 days of ECMO support and 3 thrombosed oxygenators, systemic anticoagulation was initiated. After 20 days of ECMO, 15 of which required systemic anticoagulation, the patient was decannulated and transferred to a rehabilitation facility. The patient is currently home without any neurological deficits. Although controversial, ECMO may serve a role as a rescue therapy in ARDS when conventional therapies fail in the brain-injured patient.

From Jacobeaus to the da Vinci: thoracoscopic applications of the robot.

With the increasing recognition of the benefits of minimally invasive surgery, surgical technology has evolved significantly since Jacobeaus' first attempt at thoracoscopy 100 years ago. Currently, video-assisted thoracic surgery occupies a significant role in the diagnosis and treatment of benign and malignant diseases of the chest. However, the clinical application of video-assisted thoracic surgery is limited by the technical shortcomings of the approach. Although the da Vinci system (Intuitive Surgical) is not the first robotic surgical system, it has been the most successful and widely applicable. After early applications in general and urologic surgery, the da Vinci robot extended its arms into the field of thoracic surgery, broadening the applicability of minimally invasive thoracic surgery. We review the available literature on robot-assisted thoracic surgery in attempt to better define the current role of the robot in pulmonary, mediastinal, and esophageal surgeries.

Robot-assisted lobectomy for early-stage lung cancer: report of 100 consecutive cases.

BACKGROUND: Robotics can facilitate dissection during video-assisted thoracoscopic (VATS) lobectomy. This study describes a hybrid minimally invasive lobectomy procedure consisting of two phases: robotic vascular, hilar, and mediastinal dissection, and then VATS lobectomy. METHODS: Over a 54-month period, 100 consecutive patients with stage I and II (T1 or T2N0, and T1 or T2N1) lung cancer (42 men, 58 women; mean age 65 +/- 8 years) underwent robotic VATS lobectomy. RESULTS: Lobectomies were right upper (29), right middle (7), right lower (17), left upper (31), and left lower (16). Mean operating room time was 216 +/- 27 minutes. Tumor type was adenocarcinoma (57), squamous cell carcinoma (25), 7 adenosquamous carcinoma (7), bronchoalveolar (3), large cell (1), poorly differentiated (3), carcinoid (2), mucoepidermoid (1), spindle cell (1). Pathologic upstaging was noted in 17 patients (10 to stage IIB, 7 to stage IIIA). There was no emergent conversion to a thoracotomy. Median hospitalization was 4 days. Complications included atrial fibrillation (13), atelectasis (5), prolonged air leak (4), pleural effusion (3), pulmonary embolus (3), incisional bleeding (1), hydropneumothorax (1), dural leak (1), liver failure (1), pneumonia (1), respiratory failure (1), and cardiopulmonary arrest (1). There was no intraoperative death. Postoperative mortality was 3%. There were no deaths among the last 80 patients. At a median follow-up of 32 months (range, 1 to 59), 1 patient (1%) died of his cancer, 6 (6%) had distant metastases, and 2 (2%) had a second lung primary cancer. There was no local recurrence. CONCLUSIONS: Robotics are feasible for mediastinal, hilar, and pulmonary vascular dissection during VATS lobectomy.

A novel robot-assisted technique for excision of a posterior mediastinal thyroid goiter: a combined cervico-mediastinal approach.

OBJECTIVE: : Intrathoracic thyroid goiter is an uncommon condition. Most goiters are found in the superior and anterior mediastinum, which can be removed either through a cervical approach or through a combined cervicotomy and sternotomy approach. Extension of the goiter into the posterior mediastinum is even less common. Transcervival approach to thyroid goiters in the posterior mediastinum can be difficult, necessitating a thoracotomy, with its associated morbidity. METHODS: : A 69-year-old patient underwent robotic assisted minimally invasive procedure, with the daVinci surgical robotic system to excise a thyroid goiter that extended into the posterior mediastinum. The blood supply of the mediastinal portion of the goiter originated from the right internal thoracic artery. The thoracic and mediastinal portion of the goiter was approached with robot-assisted minimally invasive surgical techniques. Small incisions were used to gain access to the posterior mediastinum via the right pleural cavity, obviating the need for thoracotomy. Using precise movements of the robotic arm, the mediastinal part of the goiter was dissected off vital structures, from within the posterior mediastinum. Total thyroidectomy was then completed using the cervical approach. RESULTS: : The patient tolerated the procedure well, with minimal intraoperative blood loss. The patient was discharged home after a short hospital stay. DISCUSSION: : Robotic surgical techniques for removal of a substernal goiter and other thyroid masses with mediastinal extension, in combination with cervical incision, are effective. Robotic-assisted techniques can complement video-assisted thoracic surgical techniques and broaden the indications for minimally invasive surgery.

Surgery for paroxysmal atrial fibrillation in the setting of mitral valve disease: a role for pulmonary vein isolation?

BACKGROUND: It is unknown whether pulmonary vein isolation or a complete Cox-Maze procedure is needed to ablate paroxysmal atrial fibrillation in patients with mitral valve disease. Our objective was to assess the impact of different surgical treatments for this arrhythmia in patients undergoing mitral valve surgery. METHODS: From July 1993 to January 2004, 152 patients underwent combined surgical treatment of paroxysmal atrial fibrillation and mitral valve disease. Ablation procedures included pulmonary vein isolation alone (n = 31, 20%), pulmonary vein isolation with left atrial connecting lesions (n = 80, 53%), and Cox-Maze (n = 41, 27%). The latter had longer durations of atrial fibrillation than the former (p < 0.0001). Rhythm documented on 1,225 postoperative electrocardiograms was used to estimate prevalence of, and risk factors for, atrial fibrillation across time. Ablation failure was defined as occurrence of atrial fibrillation any time beyond 6 months after operation. RESULTS: Prevalence of postoperative atrial fibrillation peaked at 22% at 2 weeks and declined to 9% at 1 year. Risk factors included older age (p = 0.09), larger left atrium (p = 0.05), and rheumatic (p = 0.003) and degenerative etiologies (p = 0.03). Freedom from ablation failure was 84% at one year. Ablation procedure did not affect prevalence of atrial fibrillation or incidence of ablation failure. CONCLUSIONS: Pulmonary vein isolation alone may be adequate treatment for patients with paroxysmal atrial fibrillation undergoing mitral valve surgery, particularly when it is of short duration. A randomized trial is necessary to examine this strategy, especially in patients with longer duration of paroxysmal atrial fibrillation.