Implantation of Left Ventricular Assist Device After Descending Aortic Stent Graft for Mural Thrombus.

In patients with intraluminal thrombus, commonly applied temporary circulatory support modalities are contraindicated secondary to concern regarding distal or proximal (specifically veno-arterial extracorporeal membrane oxygenation) embolization of the thrombus. Therefore, in patients with cardiogenic shock and synchronous intraluminal descending aortic thrombus, support options are quite limited. We report a case of a 66-year-old man in cardiogenic shock, due to an ischemic cardiomyopathy, who also had intramural thrombus with an intraluminal component in the descending thoracic aorta. An endovascular stent graft was inserted inside the aorta over the location of the mural thrombus. This allowed for the placement of an intra-aortic balloon pump (IABP) for pre-operative optimization. After 3 days, a left ventricular assist device (LVAD) was implanted via left anterolateral thoracotomy with hemi-sternotomy, and the IABP was removed. Post-operatively, he had a relatively uncomplicated course without signs of embolic phenomena and ultimately was discharged home. Surveillance computed tomography imaging at 6 months showed no endovascular leak or migration of the stent. This case demonstrates the feasibility of aortic stent graft placement to allow safe insertion of an IABP in the setting of aortic mural thrombus.  Furthermore, it demonstrates the safety and feasibility of LVAD implantation after recent aortic stent graft placement.

Surgical correction of postpneumonectomy syndrome with adjustable saline implants and transoesophageal echocardiography.

Postpneumonectomy syndrome can have a significant clinical impact on a patient. It presents as progressive dyspnoea due to compression of the contralateral bronchus and/or pulmonary veins. Herein, we present a patient who over a 2-year period developed progressive dyspnoea on exertion and eventually also at rest, due to compression of her left mainstem bronchus and her left inferior pulmonary vein. Surgical correction with implantable adjustable saline implants was undertaken to ameliorate her symptoms. Concurrent use of intraoperative transoesophageal echocardiography permitted real-time adjustment of the implants. This allowed objective measurement and demonstration of normalization of pulmonary vein velocity, which resulted in complete symptom resolution.

Mucopolysaccharidoses Causing Valvular Heart Disease: Report and Review of Surgical Management.

Mucopolysaccharidosis type I is a genetic disorder with impaired glycosaminoglycan degradation. Cardiac pathologic involvement in this subset of patients is predominantly valvular heart disease. Valvular heart disease seen in these patients will most likely require surgical intervention in their lifetime. Only a limited amount of reports are dedicated to the cardiac surgical management of mucopolysaccharidoses. We present the case of a 32-year-old female with Hurler-Scheie syndrome who required multiple valve replacements due to progression of valvular dysfunction and decline in the quality of life. Multidisciplinary evaluation and discussion early are crucial for quality of life optimization in this cohort of patients.

Atrial fibrillation after transhiatal esophagectomy with transcervical endoscopic esophageal mobilization: one institution's experience.

BACKGROUND: There have been numerous studies regarding atrial fibrillation (AF) associated with cardiac and pulmonary surgery; however, studies looking at esophagectomy and atrial fibrillation are sparse. The goal of this study was to review our institution's atrial fibrillation rate following esophagectomy in order to better define the incidence and predisposing factors in this patient population. METHODS: A retrospective chart review of all patients undergoing esophagectomy with transcervical endoscopic mobilization of the esophagus (TEEM) at the Medical College of Wisconsin and Affiliated Hospitals from July 2009 through December 2012. RESULTS: Seventy-one patients underwent TEEM esophagectomy during the study period. Of those, 23 (32.4%) patients developed new atrial fibrillation postoperatively. ICU (Intensive Care Unit) length of stay was 7.1 days for those that did not receive amiodarone, compared to 5.3 days for those that did receive amiodarone (p < 0.025). Those that went into AF spent on average 9.3 days in the ICU compared to 4.7 days for their counterparts that did not go into AF (p < 0.006). Total length of stay was not statistically different between populations [15.1 +/- 11.3 days compared to 13.5 +/- 9.4 days for those who did not go into AF (p < 0.281)]. Receiving preoperative amiodarone was found to reduce the overall incidence of AF. There was a trend towards decreased risk of going into AF in those who received preoperative amiodarone with an adjusted hazard ratio of 0.555 (p = 0.057). CONCLUSION: Similar to data reported in previous literature, postoperative atrial fibrillation was found to increase ICU length of stay as well as overall length of hospital stay. Preoperative amiodarone administration displayed a trend toward decreasing the rates of atrial fibrillation in patients undergoing TEEM.

Not just another face in the crowd: society's perceptions of facial paralysis.

OBJECTIVES/HYPOTHESIS: There is a paucity of data showing the perception penalty caused by facial paralysis. Our objective was to measure society's perception of facial paralysis on the characteristic of beauty. We hypothesized that patients with paralysis would be considered by society as less attractive than normals, a difference amplified by smiling. STUDY DESIGN: Randomized controlled experiment. METHODS: Forty subjects viewed photographs of normal and paralyzed faces. They rated attractiveness, identified paralysis if present, its severity, and the feature most affected. RESULTS: There were significant differences in attractiveness scores for normal and paralyzed faces (Wilcoxon rank sum test, z = 16.912; P < .001). A mixed effects regression model was used to explain differences in the scores. The fixed portion of the model shows paralyzed faces were 1 standard deviation less attractive than normal faces. Smiling increased attractiveness for normals (constant, 5.9; smile effect, 0.735; P < .001). The smile × paralysis interaction term was -0.892; P < .001, but not significantly different from the smile term (χ(2) (1) = 0.87; P = .352). The random effects model showed an intersubject rating variability of 1.32. CONCLUSIONS: The attractiveness penalty imposed by facial paralysis is significant, with paralyzed faces considered markedly less attractive than normals. However, the ratings did not change significantly when patients smiled, despite the increased asymmetry that occurs through smiling. Observers were moderately good at identifying the presence of facial paralysis, but less good at distinguishing side of involvement. These results have important implications for patient counseling and management of facial paralysis patients in an evidence-based manner.

How facial lesions impact attractiveness and perception: differential effects of size and location.

OBJECTIVES/HYPOTHESIS: To determine the effect of facial lesion size and location on perceptions of attractiveness and importance for repair. We hypothesized that attractiveness scores and importance for repair would be dependent on lesion size and location. STUDY DESIGN: Randomized controlled experiment. METHODS: Forty-five subjects viewed 35 photographs of normal faces and faces with lesions of different sizes and locations. They rated attractiveness, how disfiguring, how bothered, and how important they considered repair. RESULTS: Iterated factor analysis showed "bothered, disfigured, and important to repair" addressed the same domain, so a disfigured/bothersome/repair factor score (DBRFS) was used. A mixed-effects regression model for attractiveness showed small-central and small-peripheral coefficients were not significantly different, χ(2) (1) = 0.03, P = 1.000; but large-central and large-peripheral differences and small-central and large-peripheral differences were significantly different, χ(2) (1) = 10.34, P = 0.004; and χ(2) (1) = 50.55, P < .001, respectively. DBRFS and attractiveness were poorly correlated (χ = -0.29). A mixed-effects regression for DBRFS showed small-central to large-central and the small-central to large-peripheral coefficients were significantly different, χ(2) (1) = 129.20, P < .001; and χ(2) (1) = 115.25, P < .001; but large-central to large-peripheral coefficients were not, χ(2) (1) = 0.14, P = 1.000. CONCLUSIONS: The attractiveness penalty caused by a lesion was correlated with size but not location. Importance to repair was correlated with how disturbing and bothersome it was but not with how the lesion diminished attractiveness. All large lesions and small central lesions were considered important to repair by observers. These results will help us predict the true impact of lesions and support evidence-based treatment plans.

What faces reveal: impaired affect display in facial paralysis.

OBJECTIVES/HYPOTHESIS: To evaluate affect display in patients with facial paralysis as compared with normal subjects. We hypothesized that patients with facial paralysis would have impaired affect display and be perceived as displaying a negative affect as compared with normal subjects. STUDY DESIGN: Randomized controlled experiment. METHODS: Forty naive observers viewed pictures of patients with facial paralysis and normal faces. Observers classified the affect display of the patients and normal subjects by using a survey containing choices regarding primary emotions and personal attributes. RESULTS: An exploratory latent class analysis was performed on the survey results, and the faces were categorized into three types: positive, negative, and neutral. The probability of interpreting normal smiling faces as positive was 98%; the probability of interpreting those in repose as neutral or positive was 60%. The faces with facial paralysis were much more likely to be regarded as negative or neutral. The probability for classification into the negative class was 73% for the paralyzed faces in repose and 69% for the paralyzed smiling faces. In the latent class regression, smiling normal faces were six times more likely to be classified as positive, and smiling paralyzed faces were three times less likely to be in that class. CONCLUSIONS: Patients with facial paralysis were classified as having a negative affect display the vast majority of the time. Antithetically, normal faces in repose were classified as neutral the majority of the time; they were classified as positive the majority of the time when smiling. These novel results demonstrate the impact of the facial paralysis defect on perception by observers. Laryngoscope, 2011.

The straight truth: measuring observer attention to the crooked nose.

OBJECTIVES/HYPOTHESIS: Quantify attentional distraction to crooked noses pre- and postoperatively as compared with normal noses by using an established metric of attention in a pilot study. STUDY DESIGN: Prospective, randomized, controlled experiment with crossover. METHODS: An eye-tracker system was used to record the eye-movement patterns, called scanpaths, of 40 naive observers gazing at pictures of faces with crooked noses preoperatively or postoperatively and pictures of faces without a crooked nose included as "normals." The fixation durations within the nasal area for each group of faces presented were compared. RESULTS: A mixed-design univariate analysis of variance was performed to test the hypothesis that mean fixation times in the nasal region varied by face group. The results were highly statistically significant, F(2,116) = 20.28, P = .000, η(2) = 0.029. Marginal means were calculated for each nasal area of interest group with confidence intervals (normal, 2.32 [2.26-2.38]; preoperative, 2.66 [2.58-2.75]; postoperative, 2.43 [2.35-2.51]). Post hoc testing with Bonferroni correction for three comparisons showed differences between the normal and preoperative groups (χ(2) 41.38, P = .000) and between the preoperative and postoperative groups (χ(2) 14.41, P = .000) but not between the normal and postoperative groups (χ(2) 4.19, P = .12). CONCLUSIONS: There were highly statistically significant differences in attention paid to the nasal area of crooked noses preoperatively and postoperatively, and there were no differences in attention to the nasal area between the postoperative noses and the normal noses. This represents a novel method for objectively evaluating attention and success of surgical procedures to minimize the appearance of deformities.