Outcomes of patients with acute type A aortic dissection and concomitant lower extremity malperfusion.

OBJECTIVE: The occurrence of acute lower limb ischemia (ALLI) is a serious risk within the context of aortic dissection repair. The aim of the present study was to examine the outcomes of patients with acute type A aortic dissection (ATAD) and concomitant lower extremity malperfusion. METHODS: We performed a retrospective medical record review at our tertiary referral center of patients who underwent ATAD repair from January 2002 to June 2018. We used univariate and multivariate analyses to compare the outcomes of patients with and without lower extremity malperfusion. The primary outcomes were 30-day and 1-year mortality. RESULTS: A total of 378 patients underwent ATAD repair during the study period. Their mean age was 57 years, 68% were men, and 51% were White. A total of 62 patients (16%) presented with concomitant ALLI, including 35 (9%) who presented with isolated ALLI and 27 (7%) who presented with ALLI and concomitant malperfusion of at least one other organ. Of the 62 patients with ALLI, 46 underwent only proximal aortic repair. Of the 378 patients, 6 died within the first 24 hours, and their limb perfusion was not assessed. Among the 40 patients who underwent isolated proximal repair and survived >24 hours, 34 (85%) had resolution of their ALLI. Of the 16 patients who underwent concomitant lower extremity peripheral vascular procedures, 10 had bypass procedures and 1 died within 24 hours due to refractory coagulopathy and hypotension. All six patients with adequate follow-up imaging studies had asymptomatic occlusion of the bypass graft with recanalization of the occluded native arteries. Patients who presented with any organ malperfusion had increased 30-day (odds ratio, 1.8; P = .04) and 1-year (odds ratio, 1.8; P = .04) mortality and decreased overall survival (P < .01). For the patients with isolated ALLI, no significant differences were found in 30-day or 1-year mortality or overall survival (P = .57). CONCLUSIONS: Proximal repair of ATAD resolves most cases of associated ALLI, and isolated ALLI does not affect short- or long-term survival. All patients with follow-up in our study who underwent extra-anatomic bypass developed asymptomatic graft occlusion, which could be attributed to competitive flow from the remodeled native arterial system. We believe that rapid and aggressive restoration of flow to the lower extremity is the best method to treat ALLI malperfusion syndrome. Close monitoring for the development of compartment syndrome is recommended.

Combination therapy of modified electroconvulsive therapy and long-acting injectable aripiprazole for dopamine supersensitivity psychosis: a case report.

In the treatment of schizophrenia, long-term pharmacotherapy with D2-receptor antagonists can induce dopamine supersensitivity psychosis (DSP). We report a male patient with schizophrenia with suspected DSP due to excessive polypharmacy. He was hospitalized for several years. Most psychotropic drugs were reduced and subsequently stopped without the exacerbation of symptoms by administering modified electroconvulsive therapy (mECT). Aripiprazole was then selected as the main drug for treatment, which was subsequently changed to the long-acting injection formulation. He was eventually discharged and returned home. Combination therapy with mECT and aripiprazole, especially the long-acting injectable formulation, may help improve and prevent DSP.

Acute Myocardial Infarction Complicated by Cardiogenic Shock: An Algorithm-Based Extracorporeal Membrane Oxygenation Program Can Improve Clinical Outcomes.

Extracorporeal membrane oxygenation (ECMO) in our institution resulted in near total mortality prior to the establishment of an algorithm-based program in July 2010. We hypothesized that an algorithm-based ECMO program improves the outcome of patients with acute myocardial infarction complicated with cardiogenic shock. Between March 2003 and July 2013, 29 patients underwent emergent catheterization for acute myocardial infarction due to left main or proximal left anterior descending artery occlusion complicated with cardiogenic shock (defined as systolic blood pressure <90 mm Hg despite multiple inotropes, with or without intra-aortic balloon pump, lactic acidosis). Of 29 patients, 15 patients were treated before July 2010 (Group 1, old program), and 14 patients were treated after July 2010 (Group 2, new program). There were no significant differences in the baseline characteristics, including age, sex, coronary risk factors, and left ventricular ejection fraction between the two groups. Cardiopulmonary resuscitation prior to ECMO was performed in two cases (13%) in Group 1 and four cases (29%) in Group 2. ECMO support was performed in one case (6.7%) in Group 1 and six cases (43%) in Group 2. The 30-day survival of Group 1 versus Group 2 was 40 versus 79% (P = 0.03), and 1-year survival rate was 20 versus 56% (P = 0.01). The survival rate for patients who underwent ECMO was 0% in Group 1 versus 83% in Group 2 (P = 0.09). In Group 2, the mean duration on ECMO was 9.8 ± 5.9 days. Of the six patients who required ECMO in Group 2, 100% were successfully weaned off ECMO or were bridged to ventricular assist device implantation. Initiation of an algorithm-based ECMO program improved the outcomes in patients with acute myocardial infarction complicated by cardiogenic shock.

Veno-Venous Extracorporeal Membrane Oxygenation (V V ECMO): Indications, Preprocedural Considerations, and Technique.

Veno-venous extracorporeal membrane oxygenation (V V ECMO) has been used for refractory respiratory failure. We describe the indications, technical aspects, and outcomes of placing V V ECMO in adults using a dual-lumen, single-cannula catheter.

Massive Thrombosis of the Transplanted Heart in the Early Postoperative Period.

We experienced a case with the left atrium almost completely filled with a thrombus after orthotopic heart transplantation while the patient was supported on extracorporeal membrane oxygenation for primary graft failure. The patient had recurrent thrombosis even after successful surgical thrombectomy and appropriate anticoagulation. The cardiac thrombosis resolved only after starting plasmapheresis.

Migrated Avalon Veno-Venous Extracorporeal Membrane Oxygenation Cannula: How to Adjust Without Interruption of Flow.

The Avalon dual lumen cannula is presently the cannula of choice for veno-venous extracorporeal membrane oxygenation (VV-ECMO) via right internal jugular cannulation. This cannula establishes VV-ECMO with a single cannulation; however, it requires appropriate positioning to gain adequate oxygenation. Malposition of this cannula can cause inadequate ECMO flow, hypoxia, and structural injury. We have experienced two cases of migration: one into the hepatic vein and the other into the right ventricle. The former was repositioned using echocardiographic guidance without using a guidewire. The latter was repositioned using a guidewire from the femoral vein under fluoroscopy, without antegrade wire placement into the Avalon cannula, discontinuation of ECMO, or bleeding.

Anticoagulation Bridging in Patients With Left Ventricular Assist Device: A Regional Analysis of HeartMate 3 Recipients.

Advances in left ventricular assist device technologies have led to an improvement in pump hemocompatibility and outcomes. Because of concerns of thromboembolic complications in prior generations of left ventricular assist devices, bridging with parenteral anticoagulants was routinely. Management strategies of subtherapeutic INRs and their effects on the current generation of devices deserve review. We performed analysis of the MOMENTUM 3 trial including 6 centers in the mid-America region. Patients with subtherapeutic INRs (INR < 2) occurring after the index admission underwent chart review to determine the management strategies taken by clinicians. Strategies were divided into two groups, bridging or nonbridging. Of the 225 patients included in the analysis, 130 (58%) patients had a total of 235 subtherapeutic international normalized ratio (INR) events. Most (n = 179, 76.2%) of these INRs were not bridged (n = 100 warfarin dose adjustment, n = 79 no change in warfarin dose). Among those INRs (n = 56, 23.8%) treated with bridging, approximately half (n = 30, 53.6%) were treated with subcutaneous agents and other half (n = 26, 46.4%) were treated with intravenous agents. There was no difference in individual outcomes or composite endpoints of death, rehospitalization, CVA, or bleeding events between the groups.

Aortic valve reintervention in patients with failing transcatheter aortic bioprostheses: A statewide experience.

BACKGROUND: Despite the rapid adoption of transcatheter aortic valve replacement since its approval, the frequency and outcomes of aortic valve reintervention after transcatheter aortic valve replacement are poorly understood. METHODS: Valve reinterventions, either surgical transcatheter aortic valve explantation or repeat transcatheter aortic valve replacement, between 2012 and 2019 were queried using the Society of Thoracic Surgeons Database and the Transcatheter Valve Therapy Registry through the Michigan Statewide quality collaborative. The reintervention frequency and clinical outcomes including observed-to-expected mortality ratio using Society of Thoracic Surgeons Predicted Risk of Mortality were reviewed. RESULTS: Among 9694 transcatheter aortic valve replacement recipients, a total of 87 patients (0.90%) received a reintervention, consisting of 34 transcatheter aortic valve explants and 53 repeat transcatheter aortic valve replacement procedures. The transcatheter aortic valve explant group demonstrated a higher Society of Thoracic Surgeons Predicted Risk of Mortality. Reintervention cases increased from 0 in 2012 and 2013 to 26 in 2019. The proportion of transcatheter aortic valve explants among all reinterventions increased and was 65% in 2019. Self-expandable devices had a higher reintervention rate than balloon-expandable devices secondary to a higher transcatheter aortic valve explant frequency (0.58% [23/3957] vs 0.19% [11/5737]; P = .001), whereas repeat transcatheter aortic valve replacement rates were similar (0.61% [24/3957] vs 0.51% [29/5737]; P = .51). Among patients with transcatheter aortic valve explants, contraindications to repeat transcatheter aortic valve replacement included unfavorable anatomy (75%), need for other cardiac surgery (29%), other structural issues by transcatheter aortic valve device (18%), and endocarditis (12%). For transcatheter aortic valve explant and repeat transcatheter aortic valve replacement, the 30-day mortality was 15% and 2% (P = .032) and the observed-to-expected mortality ratio was 1.8 and 0.3 (P = .018), respectively. CONCLUSIONS: Aortic valve reintervention remains rare but is increasing. The clinical impact of surgical device explantation was substantial, and the proportion of transcatheter aortic valve explants was significantly higher in patients with a self-expandable device.

Lung Transplantation for the Treatment of Vaping-Induced, Irreversible, End-Stage Lung Injury.

Recently, there has been a rise in the incidence of E-cigarette/Vaping-Associated Lung Injury (EVALI) in the United States, mostly involving tetrahydrocannabinol. Current treatment strategies for EVALI are aimed at controlling the inflammatory and infectious causes, in addition to supportive care. Although most patients improve with supportive measures, the long-term pulmonary effects of this illness are still not well defined. This report describes a case of EVALI resulting in progressive, irreversible destruction of the lung parenchyma that was treated with double lung transplantation.

Surgical Explantation of Transcatheter Aortic Valve Bioprostheses: A Statewide Experience.

BACKGROUND: Despite the rapid adoption of transcatheter aortic valve replacement (TAVR) since its initial approval in 2011, the frequency and outcomes of surgical explantation of TAVR devices (TAVR-explant) is poorly understood. METHODS: Patients undergoing TAVR-explant between January 2012 and June 2020 at 33 hospitals in Michigan were identified in the Society of Thoracic Surgeons Database and linked to index TAVR data from the Transcatheter Valve Therapy Registry through a statewide quality collaborative. The primary outcome was operative mortality. Indications for TAVR-explant, contraindications to redo TAVR, operative data, and outcomes were collected from Society of Thoracic Surgeons and Transcatheter Valve Therapy databases. Baseline Society of Thoracic Surgeons Predicted Risk of Mortality was compared between index TAVR and TAVR-explant. RESULTS: Twenty-four surgeons at 12 hospitals performed TAVR-explants in 46 patients (median age, 73). The frequency of TAVR-explant was 0.4%, and the number of explants increased annually. Median time to TAVR-explant was 139 days and among known device types explanted, most were self-expanding valves (29/41, 71%). Common indications for TAVR-explant were procedure-related failure (35%), paravalvular leak (28%), and need for other cardiac surgery (26%). Contraindications to redo TAVR included need for other cardiac surgery (28%), unsuitable noncoronary anatomy (13%), coronary obstruction (11%), and endocarditis (11%). Overall, 65% (30/46) of patients underwent concomitant procedures, including aortic repair/replacement in 33% (n=15), mitral surgery in 22% (n=10), and coronary artery bypass grafting in 16% (n=7). The median Society of Thoracic Surgeons Predicted Risk of Mortality was 4.2% at index TAVR and 9.3% at TAVR-explant (P=0.001). Operative mortality was 20% (9/46) and 76% (35/46) of patients had in-hospital complications. Of patients alive at discharge, 37% (17/37) were discharged home and overall 3-month survival was 73±14%. CONCLUSIONS: TAVR-explant is rare but increasing, and its clinical impact is substantial. As the utilization of TAVR expands into younger and lower-risk patients, providers should consider the potential for future TAVR-explant during selection of an initial valve strategy.

What Is the Optimal Blood Pressure on Veno-Arterial Extracorporeal Membrane Oxygenation? Impact of Mean Arterial Pressure on Survival.

Blood pressure management is crucial for patients on veno-arterial extracorporeal membrane oxygenation (VA ECMO). Lower pressure can lead to end-organ malperfusion, whereas higher pressure may compete with ECMO flow and cardiac output. The impact of mean arterial pressure (MAP) on outcomes of patients on VA ECMO was evaluated. Patients who were supported on VA ECMO from September 2010 to March 2016 were retrospectively analyzed for average MAP throughout their course on ECMO, excluding the first and last day. Survival and complications observed during ECMO were investigated by classifying patients into groups based on their average MAP. A total of 116 patients were identified. Average MAP was significantly higher in patients who survived to discharge (82 ± 5.6 vs. 78 ± 5.5 mm Hg, p = 0.0003). There was a positive association between MAP and survival. Survival was best with MAP higher than 90 mm Hg (71%) and worst with MAP less than 70 mm Hg, where no patient survived. MAP was an independent predictor of survival to discharge by multivariate analysis (odds ratio 1.17, p = 0.013). Vasopressors were used more frequently in patients with lower pressure (coefficient -3.14, p = 0.005) without affecting survival (odds ratio 0.95, p = 0.95). Although the MAP did not affect the probability of strokes or bleeding complications, patients with a higher MAP had a lower incidence of kidney injury (p = 0.007). In conclusion, survival of patients on VA ECMO was significantly greater with a higher MAP, without being affected by prolonged vasopressor use.

Meandering pulmonary veins with a common inferior trunk: an anomalous left inferior pulmonary vein entering an anomalous right inferior pulmonary vein.

We report an unusual case of an asymptomatic 56-year-old woman in whom an anomalous left inferior pulmonary vein was noted to drain into the meandering right inferior pulmonary vein and the common inferior vein normally entered the left atrium. These findings were confirmed by three-dimensional computed tomography. To the best of our knowledge, this is the first reported case of meandering pulmonary veins with a common inferior trunk.

Clinical Significance of Spontaneous Echo Contrast on Extracorporeal Membrane Oxygenation.

BACKGROUND: Spontaneous echo contrast (SEC) is known to be a predisposition to thromboembolism and cerebrovascular accident. The aim of this study was to investigate the risk factors and the consequences of SEC in patients who were placed on venoarterial extracorporeal membrane oxygenation (VA-ECMO) because of cardiogenic shock. METHODS: Between January 2011 and December 2014, 98 patients underwent the insertion of VA-ECMO because of cardiogenic shock in our institution. Transthoracic and transesophageal echocardiography was performed and interpreted by National Board of Echocardiography certified cardiologists. Patients were divided into 2 groups based on the presence or absence of SEC. Clinical data, echocardiographic measurements, and outcomes were compared between the 2 groups. RESULTS: Of the 98 patients, 22 patients (22%) had SEC on echocardiography. Patients in the SEC group had a lower ejection fraction (8.0% versus 29%; p < 0.001), a lower pulsatility index (defined by [systolic blood pressure - diastolic blood pressure]/mean blood pressure) while receiving ECMO (0.13 ± 0.14 versus 0.26 ± 0.22; p = 0.009). The SEC group had a higher rate of intracardiac thrombus (46% versus 13%; p = 0.002) and stroke (36% versus 7.9%; p = 0.002). On univariate analysis, intracardiac thrombus, SEC, and low pulsatility were significant risk factors for the development of stroke. On multivariate analysis, SEC was the only independent risk factor for stroke. CONCLUSIONS: SEC on VA-ECMO resulted in an increased risk of intracardiac thrombus and stroke. Maintaining pulsatility while the patient is on ECMO may result in a decreased chance of developing SEC and stroke.

Quality of Life and Mid-Term Survival of Patients Bridged with Extracorporeal Membrane Oxygenation to Left Ventricular Assist Device.

Insertion of a left ventricular assist device (LVAD) improves survival and quality of life (QOL) in patients with class IV heart failure failing medical management. However, QOL and survival of patients bridged to LVAD with extracorporeal membrane oxygenation (ECMO) is unknown. Between July 2008 and June 2014, 213 patients underwent insertion of HeartMate II LVAD at two VAD centers without a bridge with a temporary VAD. Extracorporeal membrane oxygenation was used as a bridge before LVAD insertion in 22 Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) 1 patients (ECMO-VAD group). No bridge was used in 21 INTERMACS 1 patients and 170 INTERMACS 2-4 patients (primary LVAD group). Survival was compared between the ECMO-VAD group and INTERMACS 1 patients who underwent a primary LVAD insertion (INTERMACS 1 group). Quality of life was compared between the ECMO-VAD group and the primary LVAD group as a whole. The in-hospital mortality of the ECMO-VAD and INTERMACS1 groups was 23% and 14%, respectively (P = 0.38). The postimplant QOL scores of the ECMO-VAD group were not different compared with the primary LVAD group. Although the ECMO-VAD group consists of critically ill patients, the QOL and survival after discharge were not significantly different compared with patients who were not bridged with ECMO.

An adult case of bilateral true tracheal bronchi associated with hemoptysis.

The term tracheal bronchus encompasses a variety of bronchial anomalies originating from the trachea or main bronchus and directed to the upper lobe, and a true tracheal bronchus is any bronchus originating from the trachea. In most cases, it is found incidentally during bronchoscopy or tomography. It is often unilateral, and bilateral true tracheal bronchi are very rare. We report a case of a 54-year-old woman who had bilateral true tracheal bronchi associated with hemoptysis.

The Impact of Vascular Complications on Survival of Patients on Venoarterial Extracorporeal Membrane Oxygenation.

BACKGROUND: There are various factors that can influence the survival of patients receiving venoarterial extracorporeal membrane oxygenation (VA ECMO). Vascular complications from femoral cannulation are common and are potentially serious. We analyzed the impact of vascular complications on survival of patients receiving VA ECMO. METHODS: Patients supported with VA ECMO by means of femoral cannulation from October 2010 to November 2014 were enrolled in this study. Data were gathered retrospectively by reviewing our institutional database. Patients were separated into two groups depending on the presence of major vascular complications, defined as patients who required surgical intervention. We evaluated predisposing factors for vascular complications and compared survival of patients in each group. RESULTS: There were 84 patients enrolled in the study. The rates of overall ECMO survival and survival to hospital discharge were 60% and 43%, respectively. Major vascular complications requiring surgical intervention were seen in 17 (20%) patients. Ten patients (12%) had compartment syndrome requiring prophylactic fasciotomy, and 10 patients (12%) had bleeding or hematoma requiring surgical exploration. The only significant predisposing factor for vascular complications was the absence of a distal perfusion catheter (odds ratio, 14.8; p = 0.03). The rate of survival to discharge was 18% and 49% in patients with and without vascular complications, respectively (p = 0.02). Vascular complications were an independent factor of significantly worse survival in patients receiving VA ECMO by multivariate analysis (hazard ratio, 2.17; p = 0.02). CONCLUSIONS: Vascular complications negatively affect survival in patients receiving VA ECMO support by means of femoral cannulation. The utilization of a distal perfusion catheter can decrease the incidence of complications.

Occult cancer detected by positron emission tomography/computed tomography image fusion.

A 60-year-old male in a high-risk group for lung cancer, who also had positive sputum cytology, underwent examination by chest plain radiography, chest computed tomography (CT) and bronchofiberscopy. However, initially no abnormal findings were detected with these diagnostic modalities. Furthermore, thin-section spiral chest CT disclosed only a slight thickness of the right side of the tracheal wall, while consequent re-examination by bronchofiberscopy revealed only a light ulcerative lesion in the same area. However, the existence of a primary tumor was not confirmed using these modalities. Therefore, FDG-PET (positron emission tomography with fluorodeoxyglucose) was performed and demonstrated accumulation corresponding to the anterior mediastinum, although the exact location of the tumor was unclear by FDG-PET alone. Therefore, FDG-PET/CT image fusion was performed and resulted in the detection of a tracheal carcinoma on the outside of the right side of the tracheal wall. The patient then underwent tracheal sleeve resection including the tumor and tracheoplasty accompanied with wrapping using the flap of the thymus right lobe. To the best of our knowledge, this is the first reported case of tracheal carcinoma detected by FDG-PET/CT image fusion with consequent radical resection.

Thoracolithiasis--a mobile calcified nodule in the intrathoracic space: radiographic, CT, and MRI findings.

We present a 74-year-old male patient with a mobile thoracolithiasis of 1x1 cm in diameter in the left intrathoracic space that was visualized by chest radiography and CT examinations. This calcified nodule was thought to have originated from a lipoma that had arisen from the pleura or the peripheral region of the lung, or from pericardial fat, then degenerated, dropped, and entered into the intrathoracic space, where it became calcified. The central core of this nodule showed high intensity on T1- and T2-weighted MR images, suggesting that the core was a soft tissue component, probably fat.

Surgical removal of a large mobile left ventricular thrombus via left atriotomy.

Left ventricular (LV) thrombus is a life-threatening complication of severe LV dysfunction. Ventriculotomy has been a commonly performed procedure for LV thrombus; however, it often further decrease LV function after surgery. We present an alternative approach to thrombectomy in order to minimize the postoperative LV dysfunction. A 37-year-old female with a postpartum cardiomyopathy found to have poor LV function and a large left ventricular apical thrombus (3 cm × 3 cm) attached to the apex by a narrow stalk. Given her severe LV dysfunction, the LV thrombus was approached via left atriotomy under cardiopulmonary bypass. The LV thrombus was easily extracted with gentle traction via the mitral valve. Postoperatively, the patient was discharged home without any embolization event or inotropic support. LV thrombectomy via left atriotomy through the mitral valve could be an alternative option for the patients with poor LV function with a mobile LV thrombus.