The Advent of Spinoplastics: Easing the Growing Global Disease Burden of Spinal Injury

Epidemiologic studies have demonstrated a growing global disease burden of pathologies affecting the vertebral column. Allograft or implant-based reconstruction and fusion surgeries have been the mainstay of treatment. The efficacy of various surgical methods and the reliability of instrumentation or implants to execute these surgeries continue to be debated in the literature. Advances such as the free-tissue transfer have improved postoperative measures; however, they add high operative risk. The advent of spinoplastics introduces a practical surgical model to augment these spinal surgeries using vascularized bone grafts. As this technique becomes more widespread, it can be utilized to ease the growing disease burden that spinal injury places on both patients and the health care system. Ultimately, it will ameliorate strains on health care resources, reduce health care costs, and improve patient outcomes and quality of life.

New Percutaneous Options for Tricuspid Intervention: How to Identify the Good Clinical Candidate

The tricuspid valve has been neglected for a long time and severe tricuspid regurgitation (TR) was largely undertreated in the past due to a high operative risk. In the last years we observed the development of different less invasive percutaneous options to treat TR. Currently, percutaneous treatments are reserved for high-risk patients presenting with advanced stage disease by which time they are likely to derive a partial benefit at best. There is a limited evidence base, including no randomized trials, to guide the management strategy for severe TR. In the interim we feel that choosing the best device for the most appropriate clinical candidate and with an adequate timing (most probably an “earlier” timing) will be the key combination to improve early and late outcomes of percutaneous treatments.

Pseudoaneurysm Development after Free Wall Rupture Post Myocardial Infarction

Background: According to the World Health Organization, cardiovascular disease is the number one cause of death globally, claiming millions of lives each year with an increasing prevalence. Myocardial infarction (MI) makes up a large sum of these deaths each year. While MI in itself is lethal, there are several complications that can increase the morbidity and mortality of an MI, such as left ventricular wall rupture and aneurysms. Case Presentation: We present a case of an elderly male with an extensive cardiac history who presented with a non-ST segment myocardial infarction (NSTEMI) managed with percutaneous coronary intervention. Hours after, he became hemodynamically unable and was found to have a pseudoaneurysm of the left ventricle. Despite aggressive efforts, his pseudoaneurysm ruptured and he ultimately succumbed to his condition. Conclusions: Left ventricular pseudoaneurysm is usually seen after myocardial infarctions with a rupture rate of up to 45% leading to a mortality rate of about 50%. While cardiac catheterization with left ventriculography is the gold standard for diagnosis, echocardiography can also be used as an alternative. Treatment is emergent cardiac surgery but still holds a high operative risk. Therefore, patients may be medically stabilized and managed prior to ultimate surgical intervention.

Surgical Myocardial Revascularization in Patients with Severe Left Ventricular Dysfunction: Experience in the Cardiac Surgery Department of the Military Hospital Mohammed V of Rabat

Patients with coronary artery disease associated with severe left ventricular dysfunction, candidates for surgical myocardial revascularization, are with high operative risk. The aim of this study was to assess short and long-term morbidity and mortality and to identify their predictive factors. Methods: We conducted a retrospective study in the cardiac surgery department of the Military Instruction Hospital Mohammed V- Rabat, between 2000 and 2015. The statistical analysis was executed by SPSS. There were 74 patients (mean age 74±10 years, ejection fraction [FE]: 30.07%±4 .5, Euroscore: 6.6±2.9). Results: Hospital mortality was 9.5%, with a follow up time of 59.2 ± 36 months. The survival rate at 10 years was 57%. There was also an improvement in their clinical symptoms and echocardiographic parameters (postoperative FE: 40.36%±11.2). Conclusion: In this group of patients with high operative risk, the long-term results of several studies demonstrate the superiority of surgical treatment on medical treatment.

Palliative outpatient parenteral antibiotic therapy: a review of 5 years of patient data

Objectives A review of patients requiring lifelong antibiotics to control, rather than cure, infection was performed [‘palliative outpatient parenteral antibiotic therapy (OPAT)’]. This was to evaluate emerging themes and complications. The aim was to aid in the management of such patients. Methods A retrospective review of the OPAT database over 5 years (2013–17) was performed. Of the 1438 patients, 9 were deemed to have received palliative OPAT. Results The palliative cohort represented 0.6% of the total number of patients on OPAT and 8.6% of the bed days saved. Patients fell into two main groups: those with multiple comorbidities that precluded surgical management and those with a terminal condition. Both groups received IV antibiotics with no clear endpoint. The themes to emerge were: patients often had multiple comorbidities with a high operative risk to control the source of infection; a trial of no or oral antibiotics led to resurgence of the infection; vascular patients appeared to tolerate long-term antibiotics well; and conversely, antibiotic side effects were a significant issue in others. Patients with incurable cancer and a coincident infection can be given additional quality of life with the judicious use of appropriate therapy. Conclusions There are significant issues surrounding antimicrobial stewardship in the palliative OPAT group that should be considered. Excellent communication is required to deal with these often very complicated patients. There are considerable gains to be made both for patients and the number of bed days saved. The small number of patients accounted for a disproportionate number of bed days saved.

Interventionelle Behandlung der Mitralklappe – was gibt es Neues 2019?

Mitral regurgitation (MR) is one of the most common valvular defects in the eldery. In patients suffering from heart failure, secondary MR is common and associated with worse prognosis. Due to the usually very high operative risk these patients are immensely under-treated. This leads to an increased need for interventional treatment strategies. Until now there were no randomized data regarding the prognostic impact of interventional treatment of secondary MR. This article is supposed to sum up evidence derived from recent studies regarding this issue. Finally we will provide an outlook on catheter-based mitral valve prothesis.

Implantation of a stent in a stenotic conduit between the left ventricle and aorta in a patient undergone surgery for a double outlet right ventricle

Reinterventions for surgery complications in adult patients with complex congenital heart disease are often difficult and have a high operative risk. If anatomically possible, a percutaneous approach is an alternative to surgery. We report the case of a 36 year-old patient who underwent surgery for a double outlet right ventricle with transposition of the great arteries and pulmonary stenosis. On the days following the surgery, the patient was hemodynamically unstable due to a stenosis of the intraventricular Dacron conduit between the left ventricle and the aorta. Because of the fragility of the patient, additional surgery was not possible and a percutaneous approach was preferred. A Cheatham Platinum stent mounted on a balloon-in-balloon catheter was implanted with success in the stenotic intraventricular Dacron conduit.

Comparative results of surgical and transcatheter (TAVI) treatment of aortic stenosis in patients over 75 years old

Aim. To assess the results of transcatheter aortic valve implantation (TAVI) in comparison with open surgery for aortic stenosis in patients over 75 years old. Material and methods. We analyzed the results of 33 operations of aortic valve replacement in patients with aortic stenosis performed in the Moscow Municipal Clinical Hospital No. 15 in the period from June 2012 to September 2017. The first group included 21 TAVI operations. In 15 patients TAVI was performed through the femoral artery, 6 — transthoracic through the cardiac apex. All patients with transcatheter intervention were implanted with SAPIEN valves. In the postoperative period all patients showed a decrease in the systolic pressure gradient on the valve to 9,8±4,06 mm Hg. Aortic valve area after the operation has increased on average from 0,72±0,1 cm2 to 1,9±0,3 cm2. For comparison, a control group of 12 patients who underwent aortic valve replacement under cardiopulmonary bypass was formed. All patients had a high operative risk. Euroscore II 6,3±4,9, STS 5,2±3,4.Results. There were no cases of death in the TAVI group. These patients had the following postoperative complications: 3 patients (13,6%) — complete atrioventricular block, which required permanent pacemaker implantation; it was a significantly more frequent complication of transcatheter interventions. Less frequently in the postoperative period patients had severe acute cardiovascular failure (p=0,001), acute renal failure (p=0,05), paroxysmal atrial fibrillation (p=0,001). The volume of intraoperative blood loss was significantly less in the TAVI group: 147,6±84,4 ml and 666,7±322,9 ml (p=0,05). Mortality in the surgical group was 33% (4 patients). In the surgical group in 2 cases the cause of death was multiple organ failure, in two cases — acute cardiovascular failure. Patients from this group patients had the following postoperative complications: bleeding requiring a resternotomy — 2 (16,7%), pneumonia — 1 (8,3%), heart failure in the postoperative period, requiring prolonged cardiotonic support — 9 (75%), one patient underwent mechanical hemodynamic support, renal failure requiring renal replacement therapy in one patient.Conclusion. Even though surgical aortic valve replacement is the “gold standard” for treating patients with aortic stenosis, the results of operations in the older age group is not sufficient due to the high frequency of postoperative complications. TAVI, proposed by Cribier A, et al. in 2002, gives better results in patients over 75 age group due to the lower incidence of complications in the postoperative period, less intraoperative blood loss. We suppose that it is an alternative for patients of the older age group and high operative risk.