Supraclavicular Subclavian access for Sapien Transcatheter aortic valve replacement- a novel approach.

BACKGROUND: Within the trans-subclavian approach, procedural techniques can vary widely, and reported access generally refers to an infraclavicular axillary approach. We describe and report the use of a novel supraclavicular true subclavian approach for transcatheter aortic valve replacement (TAVR) exclusively for implantation of Sapien 3 valves. CASE PRESENTATION: We report our first five consecutive patients undergoing TAVR with a Sapien 3 valve using a standardized subclavian approach at a single center. In-hospital and 30-day complications were reported. The use of this approach resulted in successful implantation in 100% of patients in a safe manner with 0% mortality, stroke, and vascular injury during hospitalization and at 30 day follow-up. The in-hospital pacemaker implantation rate was 20%. The average length of stay was 3 days. CONCLUSIONS: TAVR with Sapien implant can be safely performed with a standardized supraclavicular subclavian approach in patients with unfavorable femoral access.

The impact of preoperative imaging for atypical atrial myxoma locations.

BACKGROUND: Atrial myxomas are the most common primary cardiac neoplasm. The majority (75%-80%) are located in the left atrium at the base of the foramen ovalis. Surgical removal can prevent dangerous obstructive or thromboembolic sequelae. HYPOTHESIS: Atypically located tumors may present technical challenges requiring case-specific surgical adaptations when visualization or surrounding cardiac structures are compromised. METHODS: We describe 3 cases of atypically located atrial myxomas that required preoperative transesophageal echocardiography and computed tomography to afford the optimal surgical approach. CONCLUSIONS: These cases highlight the potential need for multimodality imaging of atypically located atrial myxomas to determine the optimal technical approach for excision.

Complex aortic valve repair following excision of a papillary fibroelastoma.

Complex aortic valve repair after mass lesion resection, in an otherwise normal, thin leafleted valve, is rarely described in the literature. We present a 68-year-old woman who underwent resection of an asymptomatic aortic valve papillary fibroelastoma. Due to extensive involvement of her left coronary cusp, the resection resulted in a significant defect in the leaflet, requiring a complex repair to preserve her otherwise normal aortic valve. We describe the operative findings, repair technique, and associated literature.

Pleural findings in a patient with persistent pulmonary effusions from systemic amyloidosis.

Persistent pleural effusions (PPE) occur in 1-2% of cases of systemic amyloidosis and have been postulated to result from direct disruption of the pleura by amyloid deposits. Patients are typically treated with percutaneous pleural drainage techniques. Pleural biopsies, done most commonly via percutaneous techniques, are infrequently obtained. The macroscopic and histologic pleural findings identified via video assisted thoracoscopic surgery (VATS) for these patients are lacking in the literature. In this case, we present the macroscopic and microscopic pleural findings in a patient who had VATS for the aetiologic diagnosis of PPE. The diagnosis of systemic amyloidosis was made from histologic analysis of the pleural biopsy.

Modified ultrafiltration attenuates pulmonary-derived inflammatory mediators in response to cardiopulmonary bypass.

Cardiopulmonary bypass (CPB) stimulates systemic and pulmonary inflammation. Modified ultrafiltration (MUF) mitigates deleterious CPB effects by unclear mechanisms. We evaluated pulmonary inflammation in piglets undergoing CPB followed by MUF. Twenty-four piglets underwent 60 min of hypothermic CPB. MUF subjects (n=12) underwent hemoconcentration postCPB to the target hematocrit. Pulmonary vascular resistance (PVR), proinflammatory cytokine concentrations, and transpulmonary thromboxane gradients were determined at baseline, following CPB, and at end of the study (EOS) in MUF and control (n=12) groups. PVR significantly increased postCPB in both groups but decreased after MUF. MUF and control groups were similar in regards to systemic cytokine concentrations. Bronchoalveolar lavage concentrations of IL-6 and IL-8 significantly increased in controls throughout the study. Alveolar IL-6 and IL-8 were unchanged at EOS in MUF subjects, and IL-6 concentrations were significantly less than controls at EOS (P=0.015). Similarly, transpulmonary thromboxane gradient was significantly less at EOS in MUF subjects compared with controls (P=0.04). MUF removed circulating inflammatory mediators, lessened pulmonary hypertension, and reduced pulmonary-derived inflammatory markers, providing further evidence that MUF ameliorates pulmonary-based inflammation. These findings lend insight into mechanisms behind salutary clinical benefits of MUF after CPB.

Percutaneous tracheostomy: one center's experience with a new modality.

BACKGROUND: A retrospective review of our experience with percutaneous tracheostomy was performed to determine our complication rate and pattern of use since this modality was introduced at our institution. METHODS: A retrospective chart review captured all patients in whom tracheostomy was performed or supervised by a trauma/critical care faculty member. Dates of hospital admission, ICU admission, intubation, discontinuation of mechanical ventilation, type and location of procedure, procedural complications, Injury Severity Score, charges, and patient demographics were collected. Percutaneous tracheostomy (PT) and open tracheostomy (OT) experiences were compared. RESULTS: Three hundred sixty-eight tracheostomies were performed (190 OT and 178 PT). The average time to tracheostomy (TTT) for PT patients decreased from 12.7 to 7.4 days. The average TTT for OT patients remained stable at 14.0 days. The complication rate was 3.5%, with 4 complications (1.5%) associated with OT and 9 complications (5.1%) associated with PT. All complications in the PT group occurred before using a single dilator system. The 9 complications in the PT group occurred among 5 surgeons, all before their 11th attempt. PT saves 444 dollars in charges per procedure. CONCLUSION: OT continues to be a safe method of performing tracheostomies. PT has a steep learning curve but can be mastered quickly. Benefits include a shorter time to tracheostomy, elimination of patient transport, and saving in charges. Initial PT attempts should be supervised by an experienced surgeon.

Trauma surgery malpractice risk: perception versus reality.

OBJECTIVE: We set out to compare the malpractice lawsuit risk and incidence in trauma surgery, emergency surgery, and elective surgery at a single academic medical center. SUMMARY AND BACKGROUND DATA: The perceived increased malpractice risk attributed to trauma patients discourages participation in trauma call panels and may influence career choice of surgeons. When questioned, surgeons cite malpractice risk as a rationale for not providing trauma care. Little data substantiate or refute the perceived high trauma malpractice risk. We hypothesized that the malpractice risk was equivalent between an elective surgical practice and a trauma/emergency practice. METHODS: Three prospectively maintained institutional databases were used to calculate and characterize malpractice incidence and risk: a surgical operation database, a trauma registry, and a risk management/malpractice database. Risk groups were divided into elective general surgery (ELECTIVE), urgent/emergent, nontrauma general surgery (URGENT), and trauma surgery (TRAUMA). Malpractice claims incidence was calculated by dividing the total number of filed lawsuits by the total number of operative procedures over a 12-year period. RESULTS: Over the study period, 62,350 operations were performed. A total of 21 lawsuits were served. Seven were dismissed. Three were granted summary judgments to the defendants. Ten were settled with payments to the plaintiffs. One went to trial and resulted in a jury verdict in favor of the defendants. Total paid liability was 4.7 million dollars(391,667 dollars/year). Total legal defense costs were 1.3 million dollars(108,333 dollars/year). The ratio of lawsuits filed/operations performed and incidence in the 3 groups is as follows: ELECTIVE 14/39,080 (3.0 lawsuits/100,000 procedures/year), URGENT 5/17,958, (2.3 lawsuits/100,000 procedures/year), and TRAUMA 2/5312 (3.1/100,000 procedures/year). During the study period, there were an estimated 49,435 trauma patients evaluated. The incidence of malpractice lawsuits using this denominator is 0.34 lawsuits/100,000 patients/year. CONCLUSIONS: These data demonstrate no increased risk of lawsuit when caring for trauma patients, and the actual risk of a malpractice lawsuit was low.

Relative hyperoxia augments lipopolysaccharide-stimulated cytokine secretion by murine macrophages.

BACKGROUND: Increased systemic levels of inflammatory mediators are seen after open abdominal operations. Macrophages that are exposed to lipopolysaccharide secrete cytokines. Peritoneal macrophages normally reside in a pO(2) of 40 mm Hg. We hypothesize that exposure of lipopolysaccharide-stimulated macrophages to "non-physiologic" pO(2) augments cytokine secretion. METHOD: Murine macrophages were preconditioned to a pO(2) of 40 mm Hg for 24 hours. The medium then was discarded and exchanged for a medium containing a pO(2) of 40, 150, or 440 mm Hg. Macrophages were incubated in the desired pO(2) for 6 and 24 hours while stimulated with lipopolysaccharide (0 to 100 ng/mL). The effect of pO(2) was compared. Supernatant tumor necrosis factor (TNF) and interleukin-6 were measured with enzyme-linked immunosorbent assay. Statistics were performed with analysis of variance. RESULTS: We found dose-dependent lipopolysaccharide-stimulated TNF and interleukin-6 production with macrophages incubated at physiologic pO(2). Higher pO(2) did not stimulate TNF and interleukin-6 in the absence of lipopolysaccharide. However, a pO(2) of 150 and 440 mm Hg significantly (P <.05) increased lipopolysaccharide-stimulated TNF and interleukin-6 production versus 45 mm Hg. CONCLUSION: Our data suggest synergy between increased pO(2) and lipopolysaccharide for macrophage TNF and interleukin-6 production. Similar pO(2) elevations may occur with an open peritoneum or high supplemental O(2). Cytokines from peritoneal macrophages may contribute to the increased systemic inflammation after open operations.