Minimally Invasive Mitral Valve Repair Complicated By Intraoperative Right Coronary Artery Occlusion

Introduction: Iatrogenic injury of coronary arteries can complicate mitral valve replacement or repair. Direct injury to the circumflex coronary artery can occur due to the proximity of these vessels to the mitral valve. Acute injury of the right coronary artery on the other hand is seen during tricuspid valve repairs and is almost never seen with mitral valve surgery given its distance from the mitral valve. Case: We describe an interesting case of minimally invasive mitral valve repair which was complicated by intraoperative right coronary artery occlusion. It was managed by angiography and percutaneous intervention. Conclusion: While myocardial infarctions are rare in patients undergoing valvular surgery with normal preoperative coronary angiography, it must be suspected in patients with difficulty weaning from cardiopulmonary bypass and sudden reductions in cardiac function. In minimally invasive procedures with thoracotomy incisions, intraoperative angiography can be an indispensable tool. Swift intervention for revascularization and the use of postoperative cardiac assist devices can lead to favorable outcomes.https://scholarlycommons.henryford.com/sarcd2021/1002/thumbnail.jp

Large expert-curated database for benchmarking document similarity detection in biomedical literature search

Document recommendation systems for locating relevant literature have mostly relied on methods developed a decade ago. This is largely due to the lack of a large offline gold-standard benchmark of relevant documents that cover a variety of research fields such that newly developed literature search techniques can be compared, improved and translated into practice. To overcome this bottleneck, we have established the RElevant LIterature SearcH consortium consisting of more than 1500 scientists from 84 countries, who have collectively annotated the relevance of over 180 000 PubMed-listed articles with regard to their respective seed (input) article/s. The majority of annotations were contributed by highly experienced, original authors of the seed articles. The collected data cover 76% of all unique PubMed Medical Subject Headings descriptors. No systematic biases were observed across different experience levels, research fields or time spent on annotations. More importantly, annotations of the same document pairs contributed by different scientists were highly concordant. We further show that the three representative baseline methods used to generate recommended articles for evaluation (Okapi Best Matching 25, Term Frequency-Inverse Document Frequency and PubMed Related Articles) had similar overall performances. Additionally, we found that these methods each tend to produce distinct collections of recommended articles, suggesting that a hybrid method may be required to completely capture all relevant articles. The established database server located at https://relishdb.ict.griffith.edu.au is freely available for the downloading of annotation data and the blind testing of new methods. We expect that this benchmark will be useful for stimulating the development of new powerful techniques for title and title/abstract-based search engines for relevant articles in biomedical research.Peer reviewe

PERCUTANEOUS CLOSURE OF POST-TRAUMATIC PULMONARY ARTERIOVENOUS FISTULA

Background: Acquired pulmonary arteriovenous fistulas (PAVF) are very rare and have been reported as complications of thoracic surgery, infections, and lung trauma. PAVFs can cause significant dyspnea and hypoxia from right-to-left shunting. Therapeutic options include surgical resection or percutaneous closure. Case: A 43-year-old man with history of gunshot wound to the chest requiring emergent thoracotomy at age 19 presented with progressive dyspnea and fatigue. He was profoundly hypoxic. CT chest demonstrated a fistula between the distal left main PA and superior left pulmonary vein (PV). Pulmonary angiogram confirmed a large AVF measuring 13mm x 14mm in diameter between left PA and left superior PV. Shunt run confirmed R to L shunting with Qp/Qs ratio of 0.75. Decision-making: The Heart Team evaluated the patient and felt that he was at prohibitive surgical risk given his prior surgical history, and thus he was scheduled for percutaneous intervention. CT with 3-D reconstruction of the heart provided accurate fistula dimensions and allowed for 3-D printed model used for septal occluder sizing. The procedure was performed under transesophageal echocardiographic guidance. Femoral access was obtained and through a PA catheter, an Amplatz super stiff wire was advanced to left PA. The PA catheter was exchanged for JR 4 catheter through which a Glidewire Advantage wire was used to cross the fistula. Trans-septal puncture into the LA was performed using a BRK XS needle and a 12Fr SL1 sheath was advanced into the left upper PV. An Amplatz wire was advanced across the fistula into the right ventricle over which the SL1 sheath was advanced through the fistula to the left PA and into the RV. A 30mm GORE CARDIOFORM septal occluder was advanced through the trans-septal access to the pulmonary A-V fistula and deployed. Pulmonary artery angiogram confirming cessation of flow through the fistula. Conclusion: Percutaneous closure of pulmonary AV fistula is a feasible alternative therapeutic option to surgery. Use of 3-D printed modeling ad 3-D reconstruction provided accurate fistula dimensions and customization of accurately sized occluder device, such as the one used in this case

Remote ischemic preconditioning for renal protection in patients undergoing transcatheter aortic valve interventions

Background: Severe aortic stenosis remains a major source of morbidity and mortality of the elderly with an estimated nearly 27,000 patients becoming candidates for transcatheter aortic valve interventions (TAVI) annually. Pre-procedural CT scans are routinely performed for planning. Despite use of pre-hydration strategies, contrast induced nephropathy (CIN) remains a major source of concern particularly in this aging population with baseline renal dysfunction. We sought to evaluate the effects of remote ischemic preconditioning (RIPc) on prevention of CIN post TAVI. Methods: Single center, randomized controlled trial enrolling 46 patients from February 2018 to October 2018. Selected patients had an estimated glomerular filtration rate (eGFR) less than 60ml/min indicating advanced chronic kidney disease stage 3 based on the modified diet in renal disease (MDRD) equation. Following procedural sedation RIPc was initiated and completed prior to valve implantation. The control group received the sham with manual blood pressure cuff inflations to 40 mmHg for 5 minutes, followed by 5 minutes of reperfusion for a total of 4 cycles. The intervention group received manual blood pressure cuff inflations to 200 mmHg for 5 minutes, followed by 5 minutes of reperfusion for a total of 4 cycles. Labs were ordered for 48-72 hours post procedure. CIN was defined as a serum rise in creatinine (Cr) of 0.5 mg/dl or a 25% relative rise in Cr 48-72 hours after contrast exposure. Results: Of the 46 patients enrolled, 26 were randomized to the intervention group and 20 to the control group. The average age of study participants was 80. In the intervention group, the average eGFR was 43 ml/min, average Cr was 1.39 mg/dl, and average contrast load was 120 mL. In the control group, the average eGFR was 41 ml/min, average Cr was 1.49 mg/dl, and average contrast was load 99 ml. One patient developed CIN in the intervention group however, they did not require renal replacement therapy. Otherwise, there was no change or a decrease in measured Cr post intervention. Conclusions: This study was designed as a pilot study to evaluate the effects of RIPc on renal function post TAVI. In this study, there was no trend towards benefit and no signals towards harm however, a larger sample size is needed

Remote ischemic preconditioning for renal protection in patients undergoing transcatheter aortic valve interventions

Background: Severe aortic stenosis remains a major source of morbidity and mortality of the elderly with an estimated nearly 27,000 patients becoming candidates for transcatheter aortic valve interventions (TAVI) annually. Pre-procedural CT scans are routinely performed for planning. Despite use of pre-hydration strategies, contrast induced nephropathy (CIN) remains a major source of concern particularly in this aging population with baseline renal dysfunction. We sought to evaluate the effects of remote ischemic preconditioning (RIPc) on prevention of CIN post TAVI. Methods: Single center, randomized controlled trial enrolling 46 patients from February 2018 to October 2018. Selected patients had an estimated glomerular filtration rate (eGFR) less than 60ml/min indicating advanced chronic kidney disease stage 3 based on the modified diet in renal disease (MDRD) equation. Following procedural sedation RIPc was initiated and completed prior to valve implantation. The control group received the sham with manual blood pressure cuff inflations to 40 mmHg for 5 minutes, followed by 5 minutes of reperfusion for a total of 4 cycles. The intervention group received manual blood pressure cuff inflations to 200 mmHg for 5 minutes, followed by 5 minutes of reperfusion for a total of 4 cycles. Labs were ordered for 48-72 hours post procedure. CIN was defined as a serum rise in creatinine (Cr) of 0.5 mg/dl or a 25% relative rise in Cr 48-72 hours after contrast exposure. Results: Of the 46 patients enrolled, 26 were randomized to the intervention group and 20 to the control group. The average age of study participants was 80. In the intervention group, the average eGFR was 43 ml/min, average Cr was 1.39 mg/dl, and average contrast load was 120 mL. In the control group, the average eGFR was 41 ml/min, average Cr was 1.49 mg/dl, and average contrast was load 99 ml. One patient developed CIN in the intervention group however, they did not require renal replacement therapy. Otherwise, there was no change or a decrease in measured Cr post intervention. Conclusions: This study was designed as a pilot study to evaluate the effects of RIPc on renal function post TAVI. In this study, there was no trend towards benefit and no signals towards harm however, a larger sample size is needed

Continuity of Care Following Intraoperative Cardiac Arrest due to Thymoglobulin®-induced Anaphylaxis

Rabbit anti-thymocyte globulin (Thymoglobulin®, Sanofi-Aventis, Quebec, Canada) a purified gamma immune globulin obtained from the serum of rabbits immunised against human thymocytes, is widely used as an immunosuppressant agent to prevent acute rejection during solid organ transplantation. Anaphylaxis after first-time exposure to the drug is rare, but may be associated with devastating consequences. We present the case of a patient undergoing renal transplantation who developed intraoperative cardiac arrest due to severe allergic reaction immediately after initiation of Thymoglobulin® intravenous infusion. The patient was successfully resuscitated, but developed chronic chest pain from left-sided rib fractures sustained during chest compressions, and was evaluated by the same senior staff anaesthesiologist as an outpatient in the pain clinic. A high level of suspicion from anaesthesia providers is paramount in the diagnosis and management of intraoperative drug-induced severe allergic reactions, furthermore there is an opportunity for continued care of these patients by anaesthesia providers beyond the return of spontaneous circulation. [ABSTRACT FROM AUTHOR] Copyright of Journal of Clinical & Diagnostic Research is the property of JCDR Research & Publications Private Limited and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder\u27s express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.

Comparison of Patient Outcomes of Transfemoral Transcatheter Aortic Valve Replacement Using Pre-Sedation Radial Versus Post-Sedation Femoral Arterial Sites for Blood Pressure Monitoring

OBJECTIVE: To compare outcomes among patients with and without preprocedural radial arterial catheters who underwent transfemoral transcatheter aortic valve replacement (TF-TAVR) under deep intravenous (IV) sedation and to assess predictive variables for preprocedural placement. DESIGN: Single-center, retrospective, cohort analysis. SETTING: Department of Anesthesiology, Pain Management and Perioperative Medicine, Henry Ford Hospital, which is a tertiary care, university-affiliated hospital. PARTICIPANTS: The study comprised 157 patients. The primary focus was the 106 patients who underwent TF-TAVR when routine placement of preprocedure radial arterial catheters was abandoned. They were analyzed for hospital length of stay, 30-day mortality, and predictive factors of preprocedure placement. The remaining patients served as historical controls when routine radial artery catheter placement was practiced. INTERVENTIONS: Patient, procedure, and provider factors were analyzed. The transitional period consisted of 169 consecutive days from April 13 to September 28, 2017. A reference group of historical patients served as a control. MEASUREMENTS AND MAIN RESULTS: Seventy-five of 106 patients did not have a preprocedural radial arterial catheter. The primary outcome measures of length of stay and 30-day mortality within the transitional group were not different. Secondary outcome measures included identification of predictive variables for preprocedure placement and outcome comparisons between the transitional and historical groups. Anesthesia provider (p = 0.015) and ejection fraction (p = 0.039) were significant factors. There were no differences in outcome measures. CONCLUSION: There was no difference in primary outcomes in patients with or without radial arterial catheters for TF-TAVR. The findings of this study suggest anesthesia provider and ejection fraction were significant factors for preprocedural placement