Inverse Relationship of Maximal Exercise Capacity to Hospitalization Secondary to Coronavirus Disease 2019.

OBJECTIVE: To investigate the relationship between maximal exercise capacity measured before severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and hospitalization due to coronavirus disease 2019 (COVID-19). METHODS: We identified patients (≥18 years) who completed a clinically indicated exercise stress test between January 1, 2016, and February 29, 2020, and had a test for SARS-CoV-2 (ie, real-time reverse transcriptase polymerase chain reaction test) between February 29, 2020, and May 30, 2020. Maximal exercise capacity was quantified in metabolic equivalents of task (METs). Logistic regression was used to evaluate the likelihood that hospitalization secondary to COVID-19 is related to peak METs, with adjustment for 13 covariates previously identified as associated with higher risk for severe illness from COVID-19. RESULTS: We identified 246 patients (age, 59±12 years; 42% male; 75% black race) who had an exercise test and tested positive for SARS-CoV-2. Among these, 89 (36%) were hospitalized. Peak METs were significantly lower (P<.001) among patients who were hospitalized (6.7±2.8) compared with those not hospitalized (8.0±2.4). Peak METs were inversely associated with the likelihood of hospitalization in unadjusted (odds ratio, 0.83; 95% CI, 0.74-0.92) and adjusted models (odds ratio, 0.87; 95% CI, 0.76-0.99). CONCLUSION: Maximal exercise capacity is independently and inversely associated with the likelihood of hospitalization due to COVID-19. These data further support the important relationship between cardiorespiratory fitness and health outcomes. Future studies are needed to determine whether improving maximal exercise capacity is associated with lower risk of complications due to viral infections, such as COVID-19.

The minimal access deep plane extended vertical facelift.

BACKGROUND: Modern facelift techniques have benefited from a "repopularization" of shorter incisions, limited skin elevation, and more limited dissection of the superficial musculoaponeurotic system (SMAS) and platysma in order to shorten postoperative recovery times and reduce surgical risks for patients. OBJECTIVES: The authors describe their minimal access deep plane extended (MADE) vertical vector facelift, which is a hybrid technique combining the optimal features of the deep plane facelift and the short scar, minimal access cranial suspension (MACS) lift. METHODS: The authors retrospectively reviewed the case records of 181 patients who underwent facelift procedures performed by the senior author (AAJ) during a two year period between March 2008 and March 2010. Of those patients, 153 underwent facelifting with the MADE vertical technique. With this technique, deep plane dissection releases the zygomatico-cutaneous ligaments, allowing for more significant vertical motion of the midface and jawline during suspension. Extended platysmal dissection was utilized with a lateral platysmal myotomy, which is not traditionally included in a deep plane facelift. The lateral platysmal myotomy allowed for separation of the vertical vector of suspension in the midface and jawline from the superolateral vector of suspension that is required for neck rejuvenation, obviating the need for additional anterior platysmal surgery. RESULTS: The average age of the patients was 57.8 years. The average length of follow-up was 12.7 months. In 69 consecutive patients from this series, average vertical skin excision measured 3.02 cm on each side of the face at the junction of the pre auricular and temporal hair tuft incision (resulting in a total excision of 6.04 cm of skin). Data from the entire series revealed a revision rate of 3.9%, a hematoma rate of 1.9%, and a temporary facial nerve injury rate of 1.3%. CONCLUSIONS: The common goal of all facelifting procedures is to provide a long-lasting, natural, balanced, rejuvenated aesthetic result with few complications and minimal downtime. The MADE vertical facelift fulfills these criteria and often yields superior results in the midface and neck areas, where many short scar techniques fail. Furthermore, this procedure can be performed under local anesthesia, which is a benefit to both patients and surgeons.

Anatomical comparison of platysmal tightening using superficial musculoaponeurotic system plication vs deep-plane rhytidectomy techniques.

OBJECTIVES: To quantify the degree of submental platysmal tightening that can be accomplished with superficial musculoaponeurotic system (SMAS) plication vs deep-plane rhytidectomy techniques in a cadaveric anatomical study to help dictate the need for midline platysmal surgery when using different rhytidectomy techniques. METHODS: The lateral distraction of the medial edge of the platysma muscle was measured during tightening of the SMAS-platysmal complex on 5 cadaver heads. The measurements were taken after the following 3 rhytidectomy techniques: SMAS-platysmal plication, deep-plane rhytidectomy, and extended deep-plane rhytidectomy continuing the flap below the angle of the mandible into the neck with release of the platysma and cervical retaining ligaments. RESULTS: The medial edge of the platysma muscle was distracted laterally 427% more with deep-plane rhytidectomy compared with SMAS-platysmal plication (P < .001). Extending the deep-plane rhytidectomy flap into the neck to release the cervical retaining ligaments resulted in 554% greater lateral distraction of the medial edge of the platysma muscle compared with SMAS-platysmal plication (P < .001). This represents 30% greater advancement compared with the traditional deep-plane technique (P = .05). CONCLUSIONS: Extending a traditional deep-plane rhytidectomy inferiorly to release the lateral platysma and cervical retaining ligaments to the sternocleidomastoid muscle achieves the greatest lateral motion of the midline platysma, theoretically obviating the need for midline platysmal plication except in cases of severe platysmal laxity and banding. Because of the limited platysmal motion during SMAS plication, midline platysmal plication should routinely be used as an adjunct procedure except in cases of no or minimal platysmal laxity.

Expressive aphasia in a patient with recent dual-chamber cardioverter-defibrillator implantation: a preventable complication.

Transvenous pacemaker and/or defibrillator lead placement into the left heart chambers is rarely done. Approximately a third of such cases reported in the literature presented with signs of thromboembolism, mostly neurological deficits. We describe a patient who presented with a cerebrovascular accident three months after inadvertent and unrecognized lead placement into the left atrium and ventricle through a sinus venosus atrial septal defect. Implant techniques to avoid this complication are discussed.

Non-invasive flow measurement of a rotary pump ventricular assist device using quantitative contrast echocardiography.

BACKGROUND: Many implantable ventricular assist devices (VADs) have no direct measurement of pump output. The aim of this study was to test the hypothesis that quantitative contrast echocardiography can be used to measure VAD output. METHODS: Contrast-enhanced Doppler velocity-time integral (VTI) was measured in the VAD inlet and outlet cannulae. Doppler flow (Doppler Q=Doppler VTIxcannula area) was compared with measured flow (Q). A total of 130 flow measurements were made (at 6400 and 12,000 rpm). RESULTS: Doppler Q in the outflow and inflow cannulae showed an excellent correlation with measured Q (outlet Doppler Q=1.0052 xQ+0.048, R2=0.9865; inlet Doppler Q=1.5043 xQ+0.003, R2=0.9904), but inlet Doppler Q was 50% higher. Correcting for the flow profile of the conical inlet tube yielded excellent correlation (inlet Doppler Q=1.0029 xQ+0.002, R2=0.9904). CONCLUSION: Noninvasive Doppler flow techniques can be used to accurately measure VAD flow, but the flow profile in the cannula needs to be taken into account.

Predictive capability of left atrial size measured by CT, TEE, and TTE for recurrence of atrial fibrillation following radiofrequency catheter ablation.

BACKGROUND: Recurrence of atrial fibrillation (AF) after radiofrequency catheter ablation (RFCA) has been well established and is in part related to left atrial (LA) size. The purpose of this study was to assess the predictive capability of LA diameter (LAD) and LA volume (LAV) by echocardiography and computed tomography (CT) to determine success in patients undergoing RFCA of AF. METHODS: Eighty-eight patients with paroxysmal or persistent AF who had undergone RFCA and had a prior transthoracic echocardiogram (TTE), transesophageal echocardiogram (TEE), and CT were enrolled in the study. TTE LADs and LV ejection fraction as well as TEE LADs and LAVs in three views were recorded. CT LAVs were also recorded. Clinical parameters prior to ablation as well as at 1-year follow-up were assessed. RESULTS: A total of 40 (45%) patients with paroxysmal AF and 48 (55%) patients with persistent AF were analyzed. Paroxysmal AF patients had a RFCA success rate of 88% at 1 year with persistent AF patients having a 52% success rate (P < 0.001). A CT-derived LAV >or= 117 cc was associated with an odds ratio (OR) for recurrence of 4.8 (95% confidence interval [CI]=[1.4-16.4], P = 0.01) while a LAV >or=130 cc was associated with an OR for recurrence of 22.0 (95% CI =[2.5-191.0], P = 0.005) after adjustment for persistent AF. CONCLUSIONS: LA dimensions and AF type are highly predictive of AF recurrence following RFCA. LAV by CT has significant predictive benefit over standard LADs in severely enlarged atria even after adjustment for AF type.

Integration of patient-specific paranasal sinus computed tomographic data into a virtual surgical environment.

BACKGROUND: The advent of both high-resolution computed tomographic (CT) imaging and minimally invasive endoscopic techniques has led to revolutionary advances in sinus surgery. However, the rhinologist is left to make the conceptual jump between static cross-sectional images and the anatomy encountered intraoperatively. A three-dimensional (3D) visuo-haptic representation of the patient's anatomy may allow for enhanced preoperative planning and rehearsal, with the goal of improving outcomes, decreasing complications, and enhancing technical skills. METHODS: We developed a novel method of automatically constructing 3D visuo-haptic models of patients' anatomy from preoperative CT scans for placement in a virtual surgical environment (VSE). State-of-the-art techniques were used to create a high-fidelity representation of salient bone and soft tissue anatomy and to enable manipulation of the virtual patient in a surgically meaningful manner. A modified haptic interface device drives a virtual endoscope that mimics the surgical configuration. RESULTS: The creation and manipulation of sinus anatomy from CT data appeared to provide a relevant means of exploring patient-specific anatomy. Unlike more traditional methods of interacting with multiplanar imaging data, our VSE provides the potential for a more intuitive experience that can replicate the views and access expected at surgery. The inclusion of tactile (haptic) feedback provides an additional dimension of realism. CONCLUSION: The incorporation of patient-specific clinical CT data into a virtual surgical environment holds the potential to offer the surgeon a novel means to prepare for rhinologic procedures and offer training to residents. An automated pathway for segmentation, reconstruction, and an intuitive interface for manipulation may enable rehearsal of planned procedures.