Aortic pseudoaneurysm - An unusual presentation

Introduction: The esophagus is a frequent site of foreign body impaction, but esophageal perforation and subsequent aortic pseudoaneurysms, and aorto-esophageal fistulas are very rare but potentially life-threatening complications. We present a case of foreign body ingestion, complicated by erosion into the aorta causing a mycotic aneurysm. Case description: We introduce the case of a 60 year-old male with abdominal pain, nausea, fatigue and fevers. Blood cultures grew out gram-positive cocci. A CT scan revealed a distal thoracic aortic saccular aneurysm, with a 2.8 cm linear metallic body penetrating the inferior border of the aneurysm, and intraluminal thrombus formation. CT of the abdomen revealed portal vein thrombosis, splenic and hepatic abscesses. An Esophagogastroduodenoscopy was unremarkable. The patient was started on the appropriate antibiotic therapy. He was then taken to the operating room for an open thoracoabdominal aortic aneurysm repair with an interposition cryopreserved graft, with an intercostal muscle flap. A metal bristle was removed. He had an uneventful postoperative course and was discharged home on post-operative day 17. Follow-up CTA showed resolution of the infection and satisfactory repair. Post-operative esophagram showed no esophageal injury. Conclusion: We describe a case of a bristle from a metallic barbeque brush that was ingested. This penetrated the esophagus causing a mycotic aneurysm with septic embolization to the spleen and liver. Our successful treatment approach involved open aortic repair with an interposition cryopreserved graft, and an intercostal muscle flap.https://scholarlycommons.henryford.com/merf2020caserpt/1100/thumbnail.jp

Right Ventricular Failure Following Left Ventricular Assist Device Implant: An Intermacs Analysis

Purpose: Right heart failure (RHF) management following LVAD include inotropes, right ventricular mechanical support and heart transplant. We analyzed the outcomes of severe RHF following implant of a fully magnetically levitated or hybrid magnetic centrifugal durable LVAD. Methods: In this INTERMACS analysis we identified patients who developed severe RHF following LVAD from 2013 until 2020 as bridge to recovery or transplant. Patients were categorized in three groups based on RHF treatment strategy: inotrope support (group 1), temporary mechanical support (group 2), and durable centrifugal RVAD (group 3). Kaplan Meier and Cox-regression survival analysis between groups was undertaken. Logistic regression analysis for new onset dialysis was conducted. Results: 2509 patients developed severe RHF after LVAD. 2199 (87.6%) patients were managed with inotropes (group 1), 233 (9.3%) with temporary RVAD (group 2) and 77 (3.1%) with durable RVAD (group 3). Group 1 had fewer patients with INTERMACS profile 1 and 2 (21.6%, p\u3c0.001). One year survival was 84.6%, 59.3%, and 63.8% in groups 1,2, and 3 (mortality HR=2.4 and 3.3 for groups 2 and 3 vs. group 1, p\u3c0.05). One year survival to transplant was 27%, 36.5%, and 53.6% in groups 1, 2, and 3, respectively (p\u3c0.05). Group 2 had higher incidence of new onset dialysis (42.6%, p=0.049). Conclusion: Survival with RHF following LVAD implant varies based on treatment strategy; inotrope support is associated with increased survival. Patients with durable RVAD are more likely to survive to transplant. Patient selection studies for durable RVAD with contraindications for transplant are necessary

Repair of Bronchial Anastomosis Following Lung Transplantation

BACKGROUND: Bronchial anastomotic complications are reported in 2 to 18% of patients after lung transplantation. The majority of complications can be managed with bronchoscopic intervention. When extensive dehiscence is present, surgical intervention can be entertained. MATERIALS AND METHODS: Between March 1, 2006, and December 31, 2019, our program performed 244 lung transplantations. We conducted a retrospective review of our patient cohort and identified patients who suffered from significant anastomotic complications that required surgical interventions. RESULTS: Twenty-eight and 216 patients underwent single and bilateral lung transplantations, respectively. Eighteen patients developed airway complications (7.4%). The incidence of anastomotic complications was 5.2% (24 complications for a total of 460 bronchial anastomoses). Four patients were managed conservatively. The majority of the bronchial anastomotic complications were managed endoscopically (eight patients). Four patients with associated massive air leak underwent repair of the bronchial anastomosis and two patients were retransplanted because they developed severe distal airway stenosis. CONCLUSION: Bronchial anastomotic complications are a major cause of morbidity in lung transplantation. The majority of cases can be managed bronchoscopically. In more severe cases associated with massive air leak or imminent massive hemoptysis from bronchopulmonary arterial fistula, surgical intervention is necessary. Aortic homograft interposition along with vascularized pedicle wrapping may be a viable option to re-establish airway continuity when tension-free bronchial anastomotic revision is not possible. In cases with smaller bronchial defects, primary repair with utilization of a vascularized flap can be effective as treatment option

Indications for LVAD Explant and Predictors of Mortality after Explant in IMACS

Purpose: As support durations increase, patients’ risk for requiring LVAD device explant (Exp) to address complications also increases. The aims of this analysis were to better understand indications and outcomes associated with LVAD explant. Methods: Patients enrolled into IMACS requiring continuous flow LVAD explant (Exp) for nontransplant indications were identified. Survival in those with and without device Exp and by Exp indication were estimated with Kaplan-Meier methods, and correlates of mortality within the combined Exp dysfunction+other cohort were examined with Cox Regression. Results: Of 16,842 patients on CF-LVAD in IMACS, 1,579 patients underwent LVAD Exp. Indications for Exp included non-urgent (83.1%) and urgent (1.5%) device malfunction; LV recovery (12.0%); elective (0.25%) and urgent (0.32%) pump thrombosis; and “other” (3.1%). Median time to explant for “other” causes was shortest at 1.2 [0.0, 14.5] months compared with 8 [2.6,17] months for device dysfunction-Exp and 10.9 [7.5,16.3] months for recovery-Exp (p\u3c0.05). Early survival in patients undergoing Exp for any reason was better than those without a history of Exp (figure), findings likely related to statistical “survivorship bias” and excellent survival in recovery patients. Patients undergoing Exp for device malfunction-Exp (61±1.7%) or other causes (62±8.2%) had clinically similar 3 year survivals, but survivals were worse than those undergoing Exp for recovery (91±4.9%). Age at implant (HR 1.016 [1.008-1.024] per year), centrifugal flow device (HR 1.6 [1.2-2.1]), prior cardiac surgery (HR 1.4 [1.1-1.7]) and Profile 1-2 (HR 1.3 [1.0-1.5]) were correlates for mortality in those undergoing Exp for device dysfunction or other indications. Conclusion: Survival was similar for those with device Exp due to malfunction and other indications in IMACS. Older patients and those with a history of multiple sternotomies do poorly after Exp. In the elderly, shared decision-making and engagement of palliative care should be undertaken prior to Exp

Chronic narcotic use increases mortality rates in heart transplantation

Purpose: In kidney and liver transplantation, chronic narcotic use pre and posttransplant has been associated with an increased risk for rejection and early graft loss. There is a paucity of information on the adverse clinical outcomes associated with chronic narcotic use in heart transplant (HT) recipients. Methods: We conducted a retrospective chart review of adults who underwent HT at our institution from January 1, 2007 to June 30, 2016 using electronic medical records. Patients were stratified into groups by narcotic use. Chronic narcotic use (CNU) was defi ned as positive or negative at 6 months prior to transplant (pre transplant) and 6 months post-transplant. Univariate two-group comparisons were carried out using independent two-group t-tests for continuous variables, and chisquare tests for categorical variables. Survival distributions were compared between groups using log-rank tests. Results: 115 underwent HT, 81% were male, mean age 53.8 ±11 years, 48% white and 43% black. CNU pre transplant (N=26) had more illicit drug use (58% vs 28% p=.005), psychiatric history (77% vs 49% p=.013) and criminal history (38% vs 16% P=.012) than those without narcotic use pre-transplant. CNU post-transplant (N=32) had more illicit drug use (50% vs 29% p=.033), psychiatric history (75% vs 48% p=.010) and criminal history (38% vs 14% P=.006) than those without narcotic use post-transplant. No differences were observed in the rate of rejection amongst the groups. Table 1 contains the median survival time in months along with 1-, 3-, and 5-year survival probabilities with their standard errors (SE) of both groups. The 1-, 3-and 5-year survival is worse in patients with CNU post-transplant. Table 1: Survival by Narcotics Variable Median survival time in months (95% CI) 1-year survival probability (SE) 3-year survival probability (SE) 5-year survival probability (SE) P-Value No narcotics pre transplant 119.6 (109.6, N/A) 0.898 (0.03) 0.835 (0.041) 0.835 (0.041) 0.098 Narcotics pre transplant N/A (20.5, N/A) 0.769 (0.08) 0.690 (0.09) 0.690 (0.09) No narcotics post-transplant 119.6 (109.6, N/A) 0.916 (0.03) 0.887 (0.04) 0.887 (004) 0.002 Narcotics post-transplant N/A (19.2, N/A) 0.750 (0.08) 0.625 (0.09) 0.590 (0.09) Conclusion. Patients without CNU post-transplant have higher survival probabilities at each of the three time points than those with CNU post-transplant. Additional studies are warranted to confi rm observed associations

Baseline cognitive functioning in LVAD patients and anticoagulation time in range

Background: Left ventricular assist devices (LVAD) are accepted therapy for end stage heart failure, but optimal patient selection remains challenging. Our group and others have shown that baseline cognitive impairment is associated with worse outcomes post LVAD, particularly an increased risk of hospitalization. The mechanism(s) underlying this association is unknown, but it has been suggested that cognitive impairment is associated with poor medical adherence post-LVAD. The purpose of this study was to explore the impact of cognitive impairment on adherence, specifically anticoagulation time in range. Methods: A retrospective review was conducted on 100 consecutive patients who received continuous fow LVADS over a three year period (2011 and 2014) who were administered The Montreal Cognitive Assessment (MoCA) at the time of their pre-surgical psychological evaluation. Those who did not survive to discharge were excluded. Demographic information, MoCA scores and all International Normalized Ratio (INR) values between 1 month and 1 year post-implantation were collected. The primary endpoint of interest was time in therapeutic INR range (2-3). We tested the association of MoCA score (dichotomized at the median) with time in range. Results: The average age was 55.6 (± 12.29), 22 patients were female, 42 were non-white race and 69 were destination therapy. Median MoCA was 24 (IQR 22-26). MoCA did not differ by race, gender, or INTERMACS, but did differ by indication (22.8 vs. 24.2 for DT vs. BTT, p=0.049). Patients with MoCA scores below the median had a lower percentage of days within therapeutic INR range than those with higher scores (56% vs. 66%, p=0.045), representing approximately 15% less likelihood of being therapeutic. Conclusion: LVAD patients with lower baseline cognitive functioning are less likely to maintain therapeutic INR levels. This suggests that adherence to medical regimen is a key mediator of the association between poor cognitive status and worse clinical outcomes after LVAD. Interventions to improve attention and adherence in these high-risk patients are needed

Baseline cognitive functioning in LVAD patients and anticoagulation time in range

Background: Left ventricular assist devices (LVAD) are accepted therapy for end stage heart failure, but optimal patient selection remains challenging. Our group and others have shown that baseline cognitive impairment is associated with worse outcomes post LVAD, particularly an increased risk of hospitalization. The mechanism(s) underlying this association is unknown, but it has been suggested that cognitive impairment is associated with poor medical adherence post-LVAD. The purpose of this study was to explore the impact of cognitive impairment on adherence, specifically anticoagulation time in range. Methods: A retrospective review was conducted on 100 consecutive patients who received continuous fow LVADS over a three year period (2011 and 2014) who were administered The Montreal Cognitive Assessment (MoCA) at the time of their pre-surgical psychological evaluation. Those who did not survive to discharge were excluded. Demographic information, MoCA scores and all International Normalized Ratio (INR) values between 1 month and 1 year post-implantation were collected. The primary endpoint of interest was time in therapeutic INR range (2-3). We tested the association of MoCA score (dichotomized at the median) with time in range. Results: The average age was 55.6 (± 12.29), 22 patients were female, 42 were non-white race and 69 were destination therapy. Median MoCA was 24 (IQR 22-26). MoCA did not differ by race, gender, or INTERMACS, but did differ by indication (22.8 vs. 24.2 for DT vs. BTT, p=0.049). Patients with MoCA scores below the median had a lower percentage of days within therapeutic INR range than those with higher scores (56% vs. 66%, p=0.045), representing approximately 15% less likelihood of being therapeutic. Conclusion: LVADpatients with lower baseline cognitive functioning are less likely to maintain therapeutic INR levels. This suggests that adherence to medical regimen is a key mediator of the association between poor cognitive status and worse clinical outcomes after LVAD. Interventions to improve attention and adherence in these high-risk patients are needed

Mycotic Aneurysm After Metallic Foreign Body Ingestion

Objective: The esophagus is a frequent foreign body impaction site. We present a case of foreign body ingestion complicated by erosion into the aorta, causing a mycotic aneurysm. Methods: We introduce the case of a 60-year-old man with abdominal pain, nausea, fatigue, and fevers. Blood cultures grew out gram-positive cocci. A computed tomography (CT) scan revealed a distal thoracic aortic saccular aneurysm, with a 2.8-cm linear metallic body penetrating the inferior border of the aneurysm, and intraluminal thrombus formation (Fig, A). CT of the abdomen revealed portal vein thrombosis and splenic and hepatic abscesses. Esophagogastroduodenoscopy was unremarkable. Results: The patient was started on the appropriate antibiotic therapy. He was then taken to the operating room for an open thoracoabdominal aortic aneurysm repair with an interposition cryopreserved graft, with an intercostal muscle flap (Fig, B). A metal bristle was removed (Fig, C). He had an uneventful postoperative course and was discharged home on postoperative day 17. Follow-up CT angiography showed resolution of the infection and satisfactory repair (Fig, D). Postoperative esophagram showed no esophageal injury. Conclusions: We describe a case of a bristle from a metallic barbecue brush that was ingested. This penetrated the esophagus, causing a mycotic aneurysm with septic embolization to the spleen and liver. Our successful treatment approach involved open aortic repair with an interposition cryopreserved graft and an intercostal muscle flap