Adjunctive Techniques for Repair of Ischaemic Mitral Regurgitation.

Ischaemic mitral regurgitation is a complex process with debate in the literature as to the optimal treatment pathway. Multiple therapies are available to alleviate mitral regurgitation including medical management, transcatheter edge-to-edge repair, mitral valve repair and mitral valve replacement. Medical management with goal-directed therapy should be utilised in patients with heart failure and mild-to-moderate regurgitation. Transcatheter approaches are typically used in patients with prohibitive operative risk, although their use is expanding, especially in those with functional mitral regurgitation who are not responding to goal-directed medical therapy. It is generally accepted that patients with mild-to-moderate disease can avoid valve intervention if successful revascularisation is performed. A higher consideration should be given to valve replacement over repair in patients with severe mitral regurgitation in the setting of myocardial ischaemia. Operative course must be personalised to each patient, and continues to develop with improving technologies and ongoing research into optimal treatment.

Intraoperative Extracorporeal Membrane Oxygenation in Thoracic Surgery.

Evidence supporting the utilization of extracorporeal membrane oxygenation (ECMO) outside the intensive care unit is limited. We present 3 clinical situations where intraoperative ECMO was beneficial. Peripheral venovenous cannulation was used to augment tracheal surgery in 2 patients, and in 1 patient who did not tolerate lung isolation. After surgery, all patients were de-cannulated and there were no complications observed due to ECMO. Use of this technology can greatly facilitate thoracic surgical procedures with low risk. ECMO should be considered when performing tracheal surgery and in situations of poor tolerance to lung isolation.

Adequacy and accuracy of nontrauma center computed tomography: What are we missing?

BACKGROUND: Timely and appropriate use of computed tomography (CT) scans is critical to the evaluation of traumatic injuries. The objective of this study was to assess the adequacy of CT scans performed at nontrauma centers (NTCs) as they pertain to the management of trauma patients. METHODS: Adult patients transferred to our ACS-verified Level I trauma center from any NTC between May and December 2012 were enrolled prospectively. Available CT images from NTCs were reviewed in a blinded fashion by our facility's trauma radiologist; his interpretations were compared with those from the NTC. Interpretations of the trauma centers (TCs) images were compared with the NTC interpretations. Means and proportions were used to summarize the data. RESULTS: A total of 235 consecutive patients with a complete dataset were included, of which, 203 (86.4%) had a CT scan performed at an NTC. Additional imaging was obtained at the TC in 76% of patients with outside CT (154 of 203), with inadequacy of outside CTs for patient workup based on mechanism of injury (76%) and technical inadequacy of outside images (31%) being the main, nonexclusive reasons to repeat imaging. Image interpretation by the trauma radiologist at the TC using NTC images identified missed injuries in 49% of the patients, and 90% of these missed injuries were deemed clinically significant, meaning the injury would have altered patient care had they been identified. When the same body region was imaged at the TC, 54% had missed injuries, of which 76% were deemed significant. CONCLUSION: This study demonstrates inaccuracy in the interpretation of NTC images, which can lead to inappropriate management of trauma patients. Parameters other than imaging need to be used to identify patients requiring a higher level of care. LEVEL OF EVIDENCE: Therapeutic and care management study, level V.