Caseous necrosis of the mitral annulus masquerading as an intracardiac mass.

Caseous necrosis of the mitral annulus is a rare condition which typically involves the posterior leaflet or annulus. We report the case of a 71-year-old female with extensive comorbidities, presenting with dyspnea and angina, who had an incidental echocardiographic finding of a mass on or near the mitral valve. The mass increased in size over the course of three years and was associated with severe mitral regurgitation. The mass was initially thought to be a myxoma, however, surgical exploration revealed caseous necrosis of the posterior mitral annulus. Following removal of the necrotic tissue and distorted mitral leaflet, a bioprosthetic mitral valve was implanted and the patient recovered uneventfully.

Massive left atrial thrombus evades multimodality imaging as a myxoma in a bicaval heart transplant recipient.

Intracardiac masses are an extremely rare and poorly described complication following a bicaval heart transplantation. We describe the case of an asymptomatic 62-year-old male with a large left atrial mass found incidentally on transthoracic echocardiography 6 years post-transplant. A battery of additional imaging tests was ordered including transesophageal echocardiography, 18 F-fluorodeoxyglucose positron emission tomography/computed tomography, and T1 and T2 magnetic resonance imaging. Although imaging biomarkers were generally nonspecific, the mass was most consistent with a cardiac myxoma. However, intraoperative findings confirmed by pathology revealed a massive organizing thrombus. The patient had an uneventful recovery after surgical removal of the mass. Our case highlights a very rare phenomenon in heart transplant recipients which remains a unique diagnostic challenge even with current advances in imaging.

Pulmonary artery transection for resection of a middle mediastinal paraganglioma.

We report the case of a 65-year-old male patient who presented with chest pain and was found to have a mediastinal paraganglioma between the left atrium and main pulmonary artery. This is the first reported case of a mediastinal paraganglioma resection utilization transection of the main pulmonary artery.

Massive primary cardiac synovial sarcoma of the left atrium: a case report.

BACKGROUND: Synovial sarcomas are tumors typically located in the extremities and characterized by a t(X;18)(p11.2;q11.2) chromosomal translocation. With only around 100 cases reported in the literature, cardiac synovial sarcomas are extremely rare. CASE PRESENTATION: We describe a case of a 59-year-old male who presented to his primary care physician with chest pain, palpitations, and dyspnea and was diagnosed with atrial flutter. Following atrial ablation, a transthoracic echocardiogram incidentally revealed a 5.5 × 5.0 cm heterogeneous mass. Further workup found a heterogeneous mass with mild fluorodeoxyglucose uptake that was abutting the left atrium, left ventricle, and left pulmonary veins. The tumor was resected and confirmed to be a monophasic synovial sarcoma with a SS18-SSX gene fusion. Four months post-operative, the patient had recovered well from surgery. He is currently undergoing concurrent radiation and chemotherapy. CONCLUSIONS: Due to the rarity of this tumor, guidelines on diagnosis and treatment come only from case reports. Our case describes a primary cardiac synovial sarcoma arising from the left atrium in the atrioventricular groove in which diagnosis of atrial flutter preceded detection of the mass.

A Preventative Respiratory Protocol to Identify Trauma Subjects at Risk for Respiratory Compromise on a General In-Patient Ward.

BACKGROUND: Patients are at risk for respiratory complications after sustaining blunt chest trauma, yet contradictory evidence exists about the utility of prophylactic respiratory therapy to reduce respiratory complications in this population. This study assessed the effectiveness of a proactive respiratory protocol on an in-patient ward to identify trauma patients at risk for pulmonary complications, administer appropriate therapies, and prevent deterioration requiring transfer to the ICU. METHODS: Trauma patients received a respiratory therapy evaluation at the time of admission to a general in-patient ward at a Level 1 trauma center. If subjects met protocol inclusion criteria, they received prophylactic respiratory treatments, primarily MetaNeb therapy, Vest therapy, or EzPAP. Multiple phases were included to evaluate the effectiveness of the protocol, with 50 subjects in each phase: a pre-protocol phase before adoption of the protocol; phase 1, which was found to have low physician adherence and overly broad inclusion criteria; and phase 2, with improved adherence and narrower inclusion criteria. Study inclusion criteria mirror the protocol criteria from phase 2: ≥3 rib fractures; pulmonary contusion; exacerbation of COPD, asthma, or other lung disease; or age ≥65 y with expected immobility of ≥48 h. RESULTS: The respiratory protocol was associated with an elimination of unplanned admissions to the ICU. After controlling for injury severity and other important clinical factors, receiving the protocol significantly decreased hospital stay by approximately 1.5 d. More subjects were admitted from the emergency department directly to the ward, avoiding the ICU. Bronchodilator use also decreased, although the result did not reach statistical significance. CONCLUSIONS: Study results suggest that a preventive respiratory protocol had a beneficial effect on patient outcomes; receiving the protocol reduced hospital days and eliminated unplanned admission to the ICU.

High-flow nasal cannula therapy for patients with blunt thoracic injury: A retrospective study.

OBJECTIVE: High-flow nasal cannula (HFNC) has been shown to reduce the need for mechanical ventilation (MV) and to decrease hospital and ICU days for patients with severe respiratory compromise. HFNC has not been evaluated in trauma patients, thus the goal of this study is to describe the use of HFNC in a chest-injured population. METHODS: A retrospective study examined trauma patients with moderate to severe thoracic injury admitted to the ICU at a tertiary hospital between March 2012 and August 2015. HFNC was delivered by the Fisher & Paykel Optiflow system. Primary outcomes were the need for intubation after HFNC for respiratory failure, length of hospitalization, and mortality. RESULTS: During the study period, 105 patients with blunt chest trauma were admitted to the ICU and received HFNC therapy. Eighteen percent received MV prior to HFNC. Overall, 69% of patients who received HFNC never received MV, and 92% of patients were discharged alive. The intubation rate for respiratory failure after HFNC was 18%. For patients who did not receive MV prior to HFNC, delay to first HFNC was correlated with increased hospital days (r s = 0.41, p = 0.001) and ICU days (r s = 0.41, p < 0.001). CONCLUSIONS: Study results suggest that HFNC is comparable with other methods of noninvasive ventilation and may be beneficial for patients with thoracic injury. Additional investigation is warranted to determine if early use of HFNC can deliver effective respiratory support and prevent intubation in this population.

High-Flow Nasal Cannula in a Mixed Adult ICU.

BACKGROUND: Humidified, high-flow nasal cannula (HFNC) enables mucociliary clearance, accurate oxygen measurement, precise control of flow, and low-level positive airway pressure. There is sparse information concerning the timing of HFNC on patient outcomes such as incidence of adverse events during hospitalization, ICU stay, and post-ICU stay. METHODS: This is a retrospective analysis of a heterogeneous population of medical and trauma ICU patients who received HFNC therapy in a critical care setting. The study sample included 145 subjects who were admitted to the ICU and received HFNC therapy between March 2012 and February 2014. HFNC was delivered by the Fisher & Paykel Optiflow system. RESULTS: Of the 145 subjects who received HFNC, 35 (24.1%) received mechanical ventilation before HFNC, 21 (14.5%) received mechanical ventilation after HFNC, and 89 (61.3%) never received mechanical ventilation. Delay to first HFNC was moderately associated with unplanned ICU admission and was strongly correlated with the development of ventilator-associated pneumonia. Subjects with a greater length of time between ICU admission and first use of HFNC experienced significantly longer stays in the ICU and post-ICU periods, even after controlling for adverse events and mechanical ventilation. CONCLUSIONS: Study results provide preliminary evidence that early use of HFNC is beneficial in a medical and trauma ICU population, as it was associated with decreased ICU and post-ICU lengths of stay and reduced incidence of adverse events. This suggests that HFNC should be considered early in the ICU as first-line oxygen therapy.

Cardiac risk stratification and protection.

The goal of preoperative cardiac evaluation is to screen for undiagnosed cardiac disease or to find evidence of known conditions that are poorly controlled to allow management that reduces the risk of perioperative cardiac complications. A careful history and physical examination combined with the procedure-specific risk is the cornerstone of this assessment. This article reviews a brief history of prior cardiac risk stratification indexes, explores current practice guidelines by the American College of Cardiology and the American Heart Association Task Force, reviews current methods for preoperative evaluation, discusses revascularization options, and evaluates perioperative medication recommendations.

Initial tourniquet pressure does not affect tourniquet arterial occlusion pressure.

BACKGROUND: Effective nonelastic strap-based tourniquets are typically pulled tight and friction or hook-and-loop secured before engaging a mechanical advantage system to reach arterial occlusion pressure. This study examined the effects of skin surface initial secured pressure (Friction Pressure) on the skin surface pressure applied at arterial occlusion (Occlusion Pressure) and on the use of the mechanical advantage system. METHODS: Combat Application Tourniquets(®) (CATs; combattourniquet.com) and Tactical Ratcheting Medical Tourniquets (RMTs; www .ratchetingbuckles.com) were applied to 12 recipient thighs with starting Friction Pressures of 25 (RMT only), 50, 75, 100, 125, 150, 175 (CAT only), and 200mmHg (CAT only). The CAT strap was single threaded. Pressure was measured with an air-filled, size #1, neonatal blood pressure cuff under the Base (CAT), Ladder (RMT), and Strap (CAT and RMT) of each 3.8cm-wide tourniquet. RESULTS: Base or Ladder pressure and Strap pressure were related but increasingly different at increasing pressures, with Strap pressures being lower (Friction Pressure, r > 0.91; Occlusion Pressure, r > 0.60). Friction Pressure did not affect Occlusion Pressure for either design. Across the 12 thighs, the correlation coefficient for Strap Friction Pressure versus CAT windlass turns was r = -0.91 ± 0.04, and versus RMT ladder distance traveled was r = -0.94 ± 0.06. Friction Pressures of 150mmHg or greater were required to achieve CAT Occlusion with two or fewer windlass turns. CAT and RMT Strap Occlusion Pressures were similar on each recipient (median, minimum - maximum; CAT: 318mmHg, 260 - 536mmHg; RMT: 328mmHg, 160 - 472mmHg). CONCLUSIONS: Achieving high initial strap tension is desirable to minimize windlass turns or ratcheting buckle travel distance required to reach arterial occlusion, but does not affect tourniquet surface-applied pressure needed for arterial occlusion. For same-width, nonelastic strap-based tourniquets, differences in the mechanical advantage system may be unimportant to final tourniquet-applied pressure needed for arterial occlusion.