A Brief Historical Perspective on Pulmonary Embolism.

Pulmonary embolism is a major cause of mortality worldwide. In this historical perspective, we aim to provide an overview of the rich medical history surrounding pulmonary embolism. We highlight Virchow's first steps toward understanding the pathophysiology in the 1800s. We see how those insights inspired early attempts at intervention such as surgical pulmonary embolectomy and caval ligation. Those early interventions were refined and ultimately led to the development of inferior vena cava filters, the earliest clinical applications of anticoagulation, and even apparently disparate medical advances such as the successful development of cardiopulmonary bypass. We also see how the diagnosis of pulmonary embolism has evolved from rudimentary monitoring of vitals and symptoms to the development of evermore sophisticated tests such as contrast tomography angiography and echocardiography. Finally, we discuss current approaches to diagnosis, classification, and myriad treatments including anticoagulation, thrombolysis, catheter-directed interventions, surgical embolectomy, and extracorporeal membrane oxygenation guided by Pulmonary Embolism Response Teams.

Popliteal artery aneurysm repair-A single center experience.

BACKGROUND: Popliteal artery aneurysms (PAAs) are relatively rare but are one of the most common peripheral arterial aneurysms. Open popliteal artery aneurysm repair (OPAR) has been the standard, but technological advancements have made endovascular popliteal artery aneurysm repair (EPAR) a promising alternative. The aim of this study is to compare EPAR and OPAR efficacy and outcomes over a 10-year period. METHODS: This study retrospectively reviewed 72 patient charts who were diagnosed with PAA or popliteal artery pseudoaneurysm and underwent EPAR or OPAR from 1 January 2010 to 31 December 2019. Endovascular popliteal artery aneurysm repair was used in 37 cases and OPAR in 35 cases. RESULTS: Graft patency <30 days postoperative was 100% in both EPAR and OPAR groups. Graft patency >90 days postoperative was 72.73% in the EPAR group and 82.35% in the OPAR group (p = 0.477). Graft patency >2 years postoperative was 81.25% in the EPAR group and 86.67% in the OPAR group (p = 0.682). Freedom from reoperation 30-day postoperative was 78.38% in the EPAR group and 80% in the OPAR group (p = 0.865). Freedom from amputation 30-day postoperative was 91.43% in the EPAR group and 94.29% in the OPAR group (p = 0.263). The 30-day survival rate was 94.59% in the EPAR group and 100% in the OPAR group. CONCLUSIONS: Endovascular repair represents a promising alternative for PAA repair. Our results demonstrate that EPAR has similar outcomes for asymptomatic, acutely symptomatic, and chronic symptomatic patients. Technological advancements of stent properties and refinement of surgical techniques may further improve endovascular techniques.

The value of COPE therapy in the perioperative care of heart failure patients receiving left ventricular assist device implantation.

Purpose: This pilot study implemented Creating Opportunities for Personal Empowerment (COPE), a cognitive behavioral therapy (CBT) intervention, in the perioperative care of patients with advanced heart failure awaiting left ventricular assist device (LVAD) implantation. Methods: Using a quasi-experimental study design, the patients were screened for anxiety and depression using the Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire-9 (PHQ-9) screening tools. If patients scored 5 or greater on either tool, they received COPE. Patients were re-evaluated following intervention. Results: Average scores for depression and anxiety symptoms pre-intervention were 10.6 and 10.2, respectively. Post intervention, scores decreased to an average of 5.4 and 3.2, respectively. Qualitative data suggests that they felt the intervention was helpful. Conclusion: Results show that it is possible to implement a multi-session CBT intervention in this population. The improvements in the severity of depression and anxiety symptoms in the five participants with LVAD is interesting and needs to be verified in a study with a larger sample size. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01493-9.

Time to Hip Fracture Surgery and Mortality.

OBJECTIVE: This retrospective study explored the impact of time to surgery in acute hip fractures and outcomes in patients with acute hip fractures at a level I trauma center within an academic medical center in the southeastern United States. The objective was to explore the association between time to surgery and 30-day mortality and outcomes in adults 65 years and older undergoing hip fracture surgery for traumatic injuries in 2014-2019. METHODS: The population of this study consisted of patients who presented with a hip fracture and required operative measures. The research team conducted a secondary data analysis of medical records among patients who experienced a hip fracture and subsequent hip surgery to address the injury. RESULTS: Results from this study demonstrated a statistically significant relationship between a delay in surgery and an increase in postoperative complications and morbidity, as well as increased morbidity among male patients. CONCLUSIONS: Incidence of hip fractures is increasing among older adult patients and is cause for concern because of an associated high mortality rate and risk of postoperative complications. The existing body of literature indicates earlier surgical intervention may improve outcomes and reduce postoperative complications and mortality. The results of this study affirm these findings and suggest further examination specifically among males.

Left Atrial Veno-Arterial Extracorporeal Membrane Oxygenation Case Series: A Single-Center Experience.

INTRODUCTION: We aimed to review the characteristics and outcomes of left atrial veno-arterial extra corporeal membrane oxygenation (LAVA ECMO) at our institution over a 4-y period from 2017 to 2020. METHODS: Among 227 adult patients who received VA ECMO support from January 2017 to December 2020, we reviewed 33 of these who underwent transseptal cannulation and were converted to LAVA ECMO. The timing of transseptal cannulation, either at initiation of VA ECMO (n = 25) or with a later transseptal cannulation to treat complications of left ventricular (LV) distention while on VA ECMO (n = 8), was reviewed. The clinical characteristics, indications, echocardiography data, and outcomes were assessed. RESULTS: Duration of LAVA ECMO support ranged from 1 to 13 d, with a median of 5 d. Successful weaning from the LAVA ECMO circuit was achieved for 15 patients (45%). The in-hospital mortality rate was 66%. There were 11 patients (33%) who survived to be discharged from the hospital. CONCLUSIONS: LV distention is a known complication of VA ECMO and impedes the recovery of the heart. LAVA ECMO provides a novel approach to treating LV distention. Additionally, our review shows that this modality may be used as a bridge to durable mechanical circulatory support, cardiac transplantation, or recovery.

Classification and Stratification of Pulmonary Embolisms.

Pulmonary embolism remains a leading cause of cardiovascular mortality. Presentation and outcomes are variable among patients and require rapid risk stratification for assessment and prognosis, as well as selection of appropriate treatment. Over the past several decades, several different models and parameters have become available to assess risk and classify pulmonary embolism into different risk categories. Some patients may be candidates for early discharge or complete outpatient treatment, while some may require invasive diagnostics and intensive monitoring. In this review, we summarize contemporary guidelines and methods for classification and risk stratification in an effort to provide tools for physicians to use in their management of patients with acute pulmonary embolisms.

Lung Cancer in Young Adults: A Single-Center Experience.

OBJECTIVE: This single-center retrospective review examines the unique characteristics of young patients (ages 18 to 40 years) who were diagnosed as having non-small-cell lung cancer (NSCLC) at Markey Cancer Center, the only National Cancer Institute-designated cancer center in the state of Kentucky. METHODS: This retrospective study examines adult patients with NSCLC who were between ages 18 and 40 at diagnosis. Patients diagnosed between 2012 and 2018 were included. The final cohort consisted of 35 patients. The data collected included patient demographic information, tumor topography, clinical stage, cell type, treatment information/dates, metastasis, and survival data. RESULTS: In total, 36 of 3246 total NSCLC cases treated at Markey Cancer Center from 2012 to 2018 were diagnosed in adults aged 18 to 40 (1.11%); 35 of these 36 patients were included in our cohort. The majority (22; 62.86%) presented at an advanced stage of disease (stage III or IV). Furthermore, our cohort consisted of a strong majority of female patients (24; 68.57%). The most common histological type was adenocarcinoma (14; 40.00%). The 5-year survival rate was 47% (standard error 9%). CONCLUSIONS: Lung cancer is rare in young patients; when present, often it presents at the advanced stage. Despite many diagnostic tools and treatment modalities available, long-term survival remains poor. Our experience showed a small proportion of patients with NSCLC aged 18 to 40 at diagnosis; among this unique patient population, there is a predominance of smokers, women, adenocarcinoma, and advanced disease.

Diagnosis and Management of Aortic Valvular Disease in the Elderly.

Aortic valvular disease, including aortic stenosis and aortic regurgitation, is increasingly common with age. Due to the aging population, more elderly patients are presenting with aortic valve pathology and expectations for prompt diagnosis and efficacious treatment. The current paradigm for aortic valve disease is based on surgical or interventional therapy. In this review, we discuss the approach to diagnosing aortic valvular disease and the different options for treatment based on the most recent evidence.

Nutraceuticals in the Management of Cardiovascular Risk Factors: Where is the Evidence?

Cardiovascular disease continues to rise at an alarming rate, and research focuses on possible therapies to reduce the risk and slow down its progression. Several epidemiological studies have indicated that dietary modifications, such as increased consumption of fruits and vegetables play an important role in reducing cardiovascular disease risk factors. Food sources rich in antioxidants, anti-inflammatory, hypolipidemic, and hypoglycemic properties are thought to ameliorate the progression of cardiovascular disease and serve as a potential treatment mode. Many in vivo and in vitro studies using turmeric, cinnamon, mango, blueberries, red wine, chocolate, and extra virgin olive oil have demonstrated significant improvements in cholesterol profiles, toxic reactive oxygen species, inflammation, obesity, and hypertension. In this review, we summarize recent evidence on the cardioprotective effect of different food groups, outline their potential mechanisms involved in slowing down the progression of cardiovascular disease, and highlight the beneficial effects associated with increased consumption.

Does Age Affect the Short- and Long-Term Outcomes of Coronary Bypass Grafting?

The etiology of coronary artery disease (CAD) is multifactorial, stemming from both modifiable and nonmodifiable risk factors such as age. Several studies have reported the effects of age on various outcomes of coronary artery bypass grafting (CABG). This article reviews age-related outcomes of CABG and offers direction for further studies in the field to create comprehensive, evidence-based guidelines for the treatment of CAD. Ninety-two primary sources were analyzed for relevance to the subject matter, of which 17 were selected for further analysis: 14 retrospective cohort studies, 2 randomized clinical trials, and 1 meta-analysis. Our review revealed four broad age ranges into which patients can be grouped: those with CAD (1) below the age of 40 years, (2) between the ages of 40 and 60 years, (3) between the ages of 60 and 80 years, and (4) at or above 80 years. Patients below the age of 40 years fare best overall with total arterial revascularization (TAR). Patients between the ages of 40 and 60 years also fare well with the use of multiarterial grafts (MAGs) whereas either MAGs or single-arterial grafts may be of significant benefit to patients at or above the age of 60 years, with younger and diabetic patients benefitting the most. Arterial grafting is superior to vein grafting until the age of 80 years, at which point there is promising evidence supporting the continued use of the saphenous vein as the favored graft substrate. Age is a factor affecting the outcomes of CABG but should not serve as a barrier to offering patients CABG at any age from either a cost or a health perspective. Operative intervention starts to show significant mortality consequences at the age of 80 years, but the increased risk is countered by maintenance or improvement to patients' quality of life.

Thoracoplasty: Still relevant to current practice.

BACKGROUND: Management of residual pleural space remains a challenge in the practice of thoracic surgery. Options include thoracotomy with muscle flap/wound vac, Eloesser procedure, or thoracoplasty. We examine current practice and short-term outcomes of thoracoplasty in the American College of Surgeons National Surgery Quality Improvement Program (ACS NSQIP). METHODS: A retrospective review of thoracoplasty procedures (by CPT® code 32900, 32905, or 32906) in the ACS NSQIP database from the years 2012 to 2017 was performed. The ACS NSQIP prospectively collects perioperative and rigorous 30-day outcome data for patients undergoing major thoracic surgical nationally. RESULTS: The dataset contained 131 thoracoplasties in patients with an average age of 48 years (SD 19), average BMI of 26 kg/m2 (SD 5), 48% female, and 21% of minority race. Forty percent of patients were ASA class III and 10% class IV-V. Five percent of the patients had muscle flap in addition to thoracoplasty. Median operative duration was 101 min (interquartile range 61-167) and 8% of patients required blood transfusion. The average length of hospital stay was 6 days (SD 9), and 93% of patients were discharged home. There was one death, and 23% experienced other major morbidity. Thirty-day readmission occurred in 8% of patients and 6% returned to the operating room within 30 days. Four percent of patients experienced respiratory failure, 4% sepsis, and 5% developed pneumonia. CONCLUSIONS: Short-term outcomes of current thoracoplasty demonstrate low mortality and morbidity. Thoracoplasty should remain in our armamentarium for managing residual pleural space.

Managing Cardiovascular Risk Factors without Medications: What is the Evidence?

In this era of potent medications and interventional cardiovascular (CV) procedures, the importance of beginning with and including Therapeutic Lifestyle Changes (TLC) is frequently forgotten. A major goal of this review article is to show and emphasize that modification of CV risk with nonmedication approaches makes an essential contribution to CV risk reduction. Available information on TLC and modifiable CV risk factors was reviewed and assessed. Modifiable major CV risk factors include diabetes mellitus, hypertension, hyperlipidemia, tobacco abuse, obesity, stress, and a sedentary lifestyle. Age as a major CV risk factor is, of course, not susceptible to modification. A contribution to the control of CV risk factors can occur without the start of medications and there is proof of benefit for beginning with a non-pharmacological approach. TLC can benefit all of the major modifiable CV risk factors and there is good evidence for the additional benefit of supervised and group TLC. TLC includes physical activity, diet, and smoking cessation. Evidence for the benefits of TLC in reducing CV disease events is well established. However, medications must be added in those patients with higher CV risk to obtain maximum cholesterol reduction (lower is better for the low-density lipoprotein cholesterol) and good blood pressure control. The benefit of TLC is frequently forgotten in this era of potent medications and invasive procedures. The benefits of diet and physical activity are emphasized with supporting data. Many motivated patients can prolong their lives significantly by dedication to TLC. Therapeutic Lifestyle Change (TLC) especially encompasses increased physical activity, a healthy diet, and smoking cessation. There is extensive proof for the benefit of TLC in contributing to cardiovascular (CV) disease prevention. CV diseases have strong metabolic and inflammatory components, both of which can be improved by TLC.

Bitter Melon (Momordica charantia L.) Supplementation Has No Effect on Hypercholesterolemia and Atherosclerosis in Mice.

Bitter melon (BM; Momordica charantia L.) has been reported to ameliorate diet-induced obesity and dyslipidemia. However, the effects of BM on atherosclerosis have not been determined. This study investigated the effects of BM diet-induced atherosclerosis in LDL receptor-deficient mice. A total of 30 female mice (aged 6-8 wk) were fed a saturated fat-enriched diet. In group 1 (n = 10), mice were fed this diet alone, whereas mice in groups 2 and 3 (n = 10/group) were fed the diet supplemented with BM either 0.1% or 1% by weight. After 12 wk, body weight, plasma cholesterol, and atherosclerotic plaque areas were analyzed. No significant differences in body weight and plasma cholesterol concentrations were observed among the groups. Also, BM supplementation did not affect atherosclerosis development. In conclusion, dietary BM has no effect on plasma cholesterol concentration and atherogenesis in hypercholesterolemic mice.

Contemporary Surgical Management of Atrial Fibrillation.

Atrial fibrillation is a common arrhythmia which may cause symptoms that significantly impact quality of life and is associated with increased risk of stroke, heart failure, and sudden death. Over the past three decades many surgical techniques as well as catheter-bases procedures have been developed to treat atrial fibrillation. In this review we describe the indications, treatments, outcomes, surgical techniques, and technical advances reported in the literature.

Genetic Risk, Adherence to a Healthy Lifestyle, and Ischemic Heart Disease.

PURPOSE OF REVIEW: The purpose of this review is to investigate and discuss two aspects of coronary artery disease (CAD)-genetic risk and therapeutic lifestyle change (TLC)-both of which have key importance for patients and their care but which actually receive inadequate attention. RECENT FINDINGS: Genetic risk has generally been relegated to a broad association with the presence of one or more inherited cardiovascular (CV) risk factors such as hypercholesterolemia, family history of atherosclerosis, hypertension, and diabetes mellitus. However, the future of genetic risk is an understanding of specific genes, a genetic risk score, specific genetic loci known as selective nucleotide polymorphisms (SNPs), specific alleles, and microribonucleic acids (miRNAs). Healthy lifestyle is fashionably referred to as TLC and encompasses physical fitness, exercise, behavioral modification, diet, and stress reduction. In the past decade, aggressive treatment of cholesterol with statins has received the major emphasis for CV risk reduction. Genetics, of course, can only be modified by factors that influence epigenetics, and TLC could have an effect on genetics by this mechanism. On the other hand, each individual component of TLC has been shown to contribute to a reduction of CV risk. Although aggressive pharmaceutical approaches are now in vogue, whatever TLC can contribute, depending on the degree of individual patient adherence, should never be forgotten.

Impact of Aortic Valve Replacement on Glycemic Control in Diabetes Mellitus.

Introduction: The Framingham Studies revealed that diabetes mellitus (DM) predisposed subjects to a two- to eight-fold increase in the risk of developing heart failure (HF). However, there is much less information available about the reverse issue; namely, whether there is an increased risk of developing DM in patients with HF. We sought to determine if reversal or partial reversal of HF through aortic valve replacement (AVR) would improve glycemic control in patients with DM at our institution. Methods: The electronic medical records of 57 consecutive diabetic patients were retrospectively analyzed. These patients had undergone AVR at a medium-sized academic medical center from May 2005 through May 2015, and had glycated hemoglobin (HbA1C) measured before and after the procedure. The variables of interest included HbA1C, and echocardiographic parameters such as left ventricular ejection fraction (LVEF), tricuspid regurgitation velocity (TRV), and right ventricular systolic pressure (RVSP) before and after valve replacement. Results: HbA1C decreased significantly during the first year after replacement, from 7.1% (range 4.4 - 13.0%) before surgery to 6.5% in the first year (P < .05). In addition, the calculated RVSP decreased from 44 mmHg (20 - 79 mmHg) to 37 mmHg (P < .05 from the preoperative value). LVEF and TRV did not change significantly. Reductions in HbA1C and RVSP during the first year were greater in patients who experienced an increase of 5% or more in EF at their first postoperative measurement. Patients with higher baseline HbA1C values had a greater decline in glycated Hb during the first year (P < .01). Conclusion: AVR was associated with a reduction of HbA1C and a decrease in pulmonary artery systolic pressure within one year of the procedure.