Risk Factors for Failure of Splenic Angioembolization: A Multicenter Study of Level I Trauma Centers.

BACKGROUND: Angioembolization (AE) is an adjunct to nonoperative management (NOM) of splenic injuries. We hypothesize that failure of AE is associated with blood transfusion, grade of injury, and technique of AE. METHODS: We performed a retrospective (2010-2017) multicenter study (nine Level I trauma centers) of adult trauma patients with splenic injuries who underwent splenic AE. Variables included patient physiology, injury grade, transfusion requirement, and embolization technique. The primary outcome was NOM failure requiring splenectomy. Secondary outcomes were mortality, complications, and length of stay. RESULTS: A total of 409 patients met inclusion criteria; only 33 patients (8%) required delayed splenectomy. Patients who failed received more blood in the first 24 h (P = 0.009) and more often received massive transfusion (P = 0.01). There was no difference in failure rates for grade of injury, contrast blush on computed tomography, and branch embolized. After logistic regression, transfusion in the first 24 h was independently associated with failure of NOM (P = 0.02). Patients who failed NOM had more complications (P = 0.002) and spent more days in the intensive care unit (P < 0.0001), on the ventilator (P = 0.0001), and in the hospital (P < 0.0001). Patients who failed NOM had a higher mortality (15% versus 3%, P = 0.007), and delayed splenectomy was independently associated with mortality (odds ratio, 4.2; 95% confidence interval, 1.2-14.7; P = 0.03). CONCLUSIONS: AE for splenic injury leads to effective NOM in 92% of patients. Transfusion in the first 24 h is independently associated with failure of NOM. Patients who required a delayed splenectomy suffered more complications and had higher hospital length of stay. Failure of NOM is independently associated with a fourfold increase in mortality.

Acute and chronic response to CRT in narrow QRS patients.

Previous studies suggest that CRT may benefit narrow QRS patients with mechanical dyssynchrony (MD). We conducted an acute and chronic study, evaluating the response of heart failure patients with a narrow QRS to cardiac resynchronization therapy (CRT). ESTEEM-CRT was a multi-center, single-arm, feasibility study that evaluated ICD-indicated, medically-optimized patients with EF ≤ 35%, NYHA class III heart failure, QRS duration <120 ms, and MD as defined by the standard deviation of time to peak systolic velocity of 12 segments (Ts-SD). Sixty-eight patients received a CRT defibrillator, exercise testing, and echo exams, and 47 of these patients underwent invasive hemodynamic testing at implant. Follow-up was at 6 and 12 months. The average maximal improvement in LV dP/dt(max) was minor (2 ± 2%). NYHA and quality of life scores were substantially improved at 6 and 12 months (P < 0.001), while exercise capacity and LV volumes were unchanged. The echo indices of MD were difficult to collect, discordant, and failed to predict clinical outcomes. ESTEEM-CRT patients with a narrow QRS and MD as defined in this study did not improve as measured by acute hemodynamics, chronic exercise performance, or reverse remodeling. These multi-center results support the notion that dyssynchrony indices are ineffective or at least require greater refinement for the selection of narrow QRS patients for CRT.