Chest Wall Injury Research Articles

Indications for surgical stabilization of rib fractures in patients without flail chest: surveyed opinions of members of the Chest Wall Injury Society.

There are currently no evidence-based indications for surgical stabilization of rib fractures (SSRF) in patients without flail chest. The purpose of this survey was to identify patients for whom there is relative equipoise (operative vs. non-operative) in order to assist in designing a randomized clinical trial. Members of the Chest Wall Injury Society were sent an online survey, in which 18 patient scenarios were presented. The baseline patient had ≥ three displaced, contiguous fractures and had no other contraindications for surgery. This default scenario was then varied based upon patient age, degree of traumatic brain injury (TBI), fracture series location, and number of abnormal pulmonary physiologic variables (oxygen requirement, respiratory rate, incentive spirometry ability, cough, and numeric pain score). Thirty respondents provided a total of 540 answers. Overall, the majority of responses were in favor of SSRF (n=413, 84.1%). Furthermore, the vast majority of responses indicated that some degree of pulmonary compromise was necessary to recommend SSRF (n=44, 90.4%), with ≥ two abnormal parameters being the most common threshold (n=156, 31.8%). Decision to recommend SSRF varied significantly by number of abnormal clinical variables, age, and degree of TBI, but not by fracture series location. Patients aged 85years old and those with moderate TBI were the least likely to be recommended for SSRF, regardless of abnormal pulmonary physiologic variables. The most appropriate cutoff for equipoise appeared to be a patient aged 21-79years old, with no or mild TBI, ≥ two abnormal pulmonary parameters, and regardless of fracture location (44.8% consensus for SSRF). SSRF was recommended for most patients with non-flail, displaced rib fractures. However, this recommendation was contingent upon patient age, degree of TBI, and pulmonary clinical status. Results of this survey may be used to inform inclusion criteria for a future randomized, clinical trial.

Surgical Stabilization of Rib Fractures

Surgical stabilization of rib fractures (aka rib plating) is underutilized, partly due to a perceived lack of evidence of benefit and unfamiliarity with the operation. The goal of this review is to identify and summarize the evidence surrounding surgical stabilization of chest wall injury in flail and non-flail injury patterns and highlight the limitations of our current knowledge. Recent meta-analyses and prior trials have provided evidence that rib fixation in flail chest injuries decreases the need for mechanical ventilation, decreases risk of pneumonia, and decreases mortality. Additionally, the Eastern Association for the Surgery of Trauma and the Rib Fracture Colloquium have provided statements supporting rib fixation in flail injuries. The role of rib plating for patients with non-flail rib fractures remains controversial and requires further study. Surgical stabilization of rib fractures in flail injuries is supported by the evidence and should be utilized in these select patients. More evidence is needed in non-flail injuries before recommendations can be made for rib fixation.

Challenges experienced during rehabilitation after traumatic multiple rib fractures: a qualitative study

Background: People with multiple rib fractures rarely receive rehabilitation aimed specifically at their chest wall injuries. This research explores patient perceptions of rehabilitation and recovery.Materials and methods: A qualitative study exploring how a purposive sample of 15 people with traumatic multiple rib fractures at a Major Trauma Centre in the United Kingdom make sense of their recovery. Data collected during one-to-one interviews 4 to 9 months after injury. Transcripts analysed using Interpretative Phenomenological Analysis.Results: Struggling with breathing and pain: Difficulties with breathing and pain were initially so severe ?it takes your breath away? and people felt scared they may not survive. These symptoms gradually improved but feeling “out of puff” often persisted.Life on hold: Healing was considered a natural process which people couldn't influence, creating frustration whilst waiting for injuries to heal. Many believed they would never fully recover and accepted limitations.Lucky to be alive: All participants expressed a sense of feeling lucky to be alive. The seriousness of injury prompted a change in attitude to make the most of life.Conclusion: Rib fractures can be painful, but also frightening. A rehabilitation intervention promoting pain management, normalises trauma and restores physical activity may improve recovery.Implications for RehabilitationPatients identified challenges with rehabilitation throughout the entire recovery journey, and their rehabilitation needs evolved with time.People find it difficult to regain pre-injury fitness even after their fractures heal and pain subsides.A belief there is nothing that can be done to help rib fractures contributed to people lowering their expectations of achieving a full recovery and developing a sense of “making do”.Rehabilitation and patient education after traumatic multiple rib fractures should focus on improving pain management, respiratory fitness and emotional well-being.

Askin tumour following traumatic rib injury in a young adult

Askin tumour is a form of primitive neuroectodermal tumour arising from the thoracopulmonary region. The patient being reported is a young adult who initially presented in dyspnoea and was found to have hemothorax following chest wall injury. About one year later, he again presented in dyspnoea. But this time he was found to have a mass arising from the previous traumatic site, which was diagnosed as Askin tumour. Such a scenario of Askin tumour arising from a traumatic site is uncommon. Moreover, Askin tumour itself is a rare presentation in adults.Asian Journal of Medical Sciences Vol.8(3) 2017 84-86

Treatment of air leak in polytrauma patients with blunt chest injury

IntroductionPrecise diagnostics and an adequate therapeutic approach are mandatory in the treatment of air leak in polytrauma patients with blunt chest trauma. The aim of this study was to evaluate the incidence, characteristics, and management of air leak following this injury pattern. Patients and methodsData from 110 polytrauma patients was collected retrospectively. Fifty-four patients received initial treatment by chest tube placement for pneumothorax. These patients were classified into two groups, one with severe air leak and one with minor air leak. An evaluation of injury pattern, chest wall injuries in particular, duration of air leak, reason for drainage maintenance in place, hospital length of stay, ICU stay, ventilator duration, type of treatment, and the delay to surgical intervention was performed. ResultsWhereas 4 patients showed severe air leak and were subsequently scheduled for timely surgical intervention, the remaining 50 patients only showed minor air leak. Only 7 patients with minor air leak suffered from prolonged air leak (>5days), which spontaneously resolved in all of them after a mean duration of 7.7days (range 6–12days). Absence of a prolonged air leak resulted in a shorter length of stay and a shorter duration of mechanical ventilation, although no statistical significance was observed. ConclusionsEarly spontaneous cessation of most minor air leaks as well as early surgical intervention for severe air leak lead to very satisfactory patient outcomes with a relatively short hospital stay in our patients. We therefore advocate early surgery for lacerations of the pulmonary parenchyma resulting in severe air leak, whereas minor air leaks can usually be treated conservatively.

Surgical versus non-surgical management for pleural empyema.

Empyema refers to pus in the pleural space, commonly due to adjacent pneumonia, chest wall injury, or a complication of thoracic surgery. A range of therapeutic options are available for its management, ranging from percutaneous aspiration and intercostal drainage to video-assisted thoracoscopic surgery (VATS) or thoracotomy drainage. Intrapleural fibrinolytics may also be administered following intercostal drain insertion to facilitate pleural drainage. There is currently a lack of consensus regarding optimal treatment. To assess the effectiveness and safety of surgical versus non-surgical treatments for complicated parapneumonic effusion or pleural empyema. We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2016, Issue 9), MEDLINE (Ebscohost) (1946 to July week 3 2013, July 2015 to October 2016) and MEDLINE (Ovid) (1 May 2013 to July week 1 2015), Embase (2010 to October 2016), CINAHL (1981 to October 2016) and LILACS (1982 to October 2016) on 20 October 2016. We searched ClinicalTrials.gov and WHO International Clinical Trials Registry Platform for ongoing studies (December 2016). Randomised controlled trials that compared a surgical with a non-surgical method of management for all age groups with pleural empyema. Two review authors independently assessed trials for inclusion and risk of bias, extracted data, and checked the data for accuracy. We contacted trial authors for additional information. We assessed the quality of the evidence using the GRADE approach. We included eight randomised controlled trials with a total of 391 participants. Six trials focused on children and two on adults. Trials compared tube thoracostomy drainage (non-surgical), with or without intrapleural fibrinolytics, to either VATS or thoracotomy (surgical) for the management of pleural empyema. Assessment of risk of bias for the included studies was generally unclear for selection and blinding but low for attrition and reporting bias. Data analyses compared thoracotomy versus tube thoracostomy and VATS versus tube thoracostomy. We pooled data for meta-analysis where appropriate. We performed a subgroup analysis for children along with a sensitivity analysis for studies that used fibrinolysis in non-surgical treatment arms.The comparison of open thoracotomy versus thoracostomy drainage included only one study in children, which reported no deaths in either treatment arm. However, the trial showed a statistically significant reduction in mean hospital stay of 5.90 days for those treated with primary thoracotomy. It also showed a statistically significant reduction in procedural complications for those treated with thoracotomy compared to thoracostomy drainage. We downgraded the quality of the evidence for length of hospital stay and procedural complications outcomes to moderate due to the small sample size.The comparison of VATS versus thoracostomy drainage included seven studies, which we pooled in a meta-analysis. There was no statistically significant difference in mortality or procedural complications between groups. This was true for both adults and children with or without fibrinolysis. However, mortality data were limited: one study reported one death in each treatment arm, and seven studies reported no deaths. There was a statistically significant reduction in mean length of hospital stay for those treated with VATS. The subgroup analysis showed the same result in adults, but there was insufficient evidence to estimate an effect for children. We could not perform a separate analysis for fibrinolysis for this outcome because all included studies used fibrinolysis in the non-surgical arms. We downgraded the quality of the evidence to low for mortality (due to wide confidence intervals and indirectness), and moderate for other outcomes in this comparison due to either high heterogeneity or wide confidence intervals. Our findings suggest there is no statistically significant difference in mortality between primary surgical and non-surgical management of pleural empyema for all age groups. Video-assisted thoracoscopic surgery may reduce length of hospital stay compared to thoracostomy drainage alone.There was insufficient evidence to assess the impact of fibrinolytic therapy.A number of common outcomes were reported in the included studies that were not directly examined in our primary and secondary outcomes. These included duration of chest tube drainage, duration of fever, analgesia requirement, and total cost of treatment. Future studies focusing on patient-centred outcomes, such as patient functional scores, and other clinically relevant outcomes, such as radiographic improvement, treatment failure rates, and amount of fluid drainage, are needed to inform clinical decisions.

Patterns and Short Term Outcomes of Chest Injuries at Mbarara Regional Referral Hospital in Uganda

Background: This study was conducted to establish the causes, injury patterns and short-term outcomes of chest injuries at Mbarara Regional Referral Hospital. Methods: This was a prospective study involving chest injury patients admitted to Mbarara Regional Referral Hospital (MRRH) for a period of one year from April 2014 to 31st March 2015. Results: A total of 71 chest injury patients were studied. Males (91.6%) were the majority and the ages ranged from 8 to 76 years (mean 32.9 years (+/- 14.0). Majority of the patients (57.7%) sustained blunt injury. RTA was the most common cause of injury, affecting 49.3%.The commonest injury patterns were chest wall injuries and lung and pleural injuries accounting for 69.0% and 64.8 respectively. Rib fractures were the commonest chest wall injury (71.4%) while hemopneumothorax was the commonest (34.9%) finding among those with lung and pleural injury. Associated injuries were found in 64.2% and out of these, abdominal injuries were the commonest extra thoracic injury (39.1%) followed by head injury(37.0%),cuts and lacerations(37%) andfractures (28.3%).The commonest abdominal organs injured were spleen(44.4%), liver (27.8%) and stomach (16.7%). Majority of the patients had thoracostomy (47.9%) while 33.8% had non surgical treatment. Laparotomy and thoracotomy were done in 11(15.5%) and 3 (4.2%) of the patients respectively. Complications occurred in 20(28.2%) and the commonest complication was pneumonia 6 (30%).The mean length of stay was 7.14 days, SD=±6.1) and the mortality was 16.9%.The significant determinants of mortality were associated injuries (X2=4.57, F.E=0.046), complications (X2=36.82, F.E=0.000) and severe head injury (X2=13.85, F.E=0.001). Conclusion: The causes, patterns and short-term outcomes of this study are similar to those observed in other developing countries. Chest injury in our setting causes high mortality and measures to reduce road traffic accidents are urgently required.Key words: Chest injury, pattern, outcomes

Usefulness of low dose chest CT for initial evaluation of blunt chest trauma.

We aimed to compare the diagnostic performance and inter-observer consistency between low dose chest CT (LDCT) and standard dose chest CT (SDCT) in the patients with blunt chest trauma.A total of 69 patients who met criteria indicative of blunt chest trauma (77% of male; age range, 16–85) were enrolled. All patients underwent LDCT without intravenous (IV) contrast and SDCT with IV contrast using parameters as following: LDCT, 40 mAs with automatic tube current modulation (ATCM) and 100 kVp (BMI <25, n = 51) or 120 kVp (BMI>25, n = 18); SDCT, 180 mAs with ATCM and 120 kVp. Transverse, coronal, sagittal images were reconstructed with 3-mm slice thickness without gap and provided for evaluation of 3 observers. Reference standard images (transverse, coronal, sagittal) were reconstructed using SDCT data with 1-mm slice thickness without gap. Reference standard was established by 2 experienced thoracic radiologists by consensus. Three observers independently evaluated each data set of LDCT and SDCT.Multiple-reader receiver operating characteristic analysis for comparing areas under the ROC curves demonstrated that there was no significant difference of diagnostic performance between LDCT and SDCT for the diagnosis of pulmonary injury, skeletal trauma, mediastinal injury, and chest wall injury (P > 0.05). The intraclass correlation coefficient was measured for inter-observer consistency and revealed that there was good inter-observer consistency in each examination of LDCT and SDCT for evaluation of blunt chest injury (0.8601–1.000). Aortic and upper abdominal injury could not be appropriately compared as LDCT was performed without using contrast materials and this was limitation of this study.The effective radiation dose of LDCT (average DLP = 1.52 mSv⋅mGy−1 cm−1) was significantly lower than those of SDCT (7.21 mSv mGy−1 cm−1).There is a great potential benefit to use of LDCT for initial evaluation of blunt chest trauma because LDCT could maintain diagnostic image quality as SDCT and provide significant radiation dose reduction. A further study of LDCT with IV contrast for evaluation of aortic and upper abdominal injury is needed.

Aortic valve rupture after blunt chest trauma presenting at a District General Hospital

Traumatic aortic regurgitation is a rare complication of blunt chest wall injury. Cardiovascular decompensation can occur rapidly as the heart struggles to maintain cardiac output. As the condition is often not apparent at the time of injury, these patients may be brought by ambulance to trauma units without cardiothoracic facilities under the care of general and orthopaedic surgeons. Here, we report a case of traumatic aortic regurgitation secondary to a high-speed motor vehicle accident and the management in a district general trauma unit leading to transfer to a cardiothoracic centre. The diagnosis of traumatic aortic regurgitation should be considered in patients who experience blunt chest wall injuries and demonstrate signs of cardiac decompensation.

Mechanisms and Clinical Management of Ventricular Arrhythmias following Blunt Chest Trauma.

Nonpenetrating, blunt chest trauma is a serious medical condition with varied clinical presentations and implications. This can be the result of a dense projectile during competitive and recreational sports but may also include other etiologies such as motor vehicle accidents or traumatic falls. In this setting, the manifestation of ventricular arrhythmias has been observed both acutely and chronically. This is based on two entirely separate mechanisms and etiologies requiring different treatments. Ventricular fibrillation can occur immediately after chest wall injury (commotio cordis) and requires rapid defibrillation. Monomorphic ventricular tachycardia can develop in the chronic stage due to underlying structural heart disease long after blunt chest injury. The associated arrhythmogenic tissue may be complex and provides the necessary substrate to form a reentrant VT circuit. Ventricular tachycardia in the absence of overt structural heart disease appears to be focal in nature with rapid termination during ablation. Regardless of the VT mechanism, patients with recurrent episodes, despite antiarrhythmic medication in the chronic stage following blunt chest injury, are likely to require ablation to achieve VT control. This review article will describe the mechanisms, pathophysiology, and treatment of ventricular arrhythmias that occur in both the acute and chronic stages following blunt chest trauma.

Surgical stabilization of blunt traumatic chest wall bony injuries

Objectives: Conservative management of rib fractures has been the standard of care. Recently, surgical fixation with rib plating is emerging as a superior option for flail chest (FC) and multiple rib fractures. This review details our experience with surgical fixation. Materials and Methods: The medical records of 18 patients with severe chest wall injuries referred to the cardiothoracic surgery service at a level 1 trauma center from January 2010 to December 2015 were retrospectively reviewed. 66.7% were male, mean age 58.4 ± 14.5, Glasgow Coma Score 13.3 ± 3.3, and injury severity score 20.4 ± 11.7. 77.8% (14/18) had multiple rib fractures, half with FC, 22.2% (4/18) sternal fractures, and 61.1% of patients were involved in motor vehicle accident. All patients underwent surgical stabilization except three with isolated sternal fractures treated conservatively. Results: 3.4 ± 0.5 ribs were plated in FC versus 2.4 ± 0.5 in non-FC patients. 64.2% had concomitant decortication and 7.1% lung wedge resection. All FC patients had severe lung contusion and respiratory failure requiring preoperative mechanical ventilation mean 10.7 ± 7.9 days. Postoperative ventilatory support was 7.4 ± 4.9 days in FC versus <24 h in non-FC patients. 57.1% of FC patients required tracheostomy for prolonged intubation. Mean interval to surgery, Intensive Care Unit, and hospital length of stay (LOS) was 13.3 ± 5.3, 22.4 ± 14.9, and 29.7 ± 9.2 in FC versus 5.3 ± 3.8, 10.3 ± 10.4, and 14.3 ± 9.3 days, respectively, in non-FC patients. 85.7% received blood transfusion, mean 5.7 ± 3.7 in FC versus 42.8% mean 3.7 ± 0.6 units in non-FC patients. Morbidity in FC patients were pneumonia 42.8%, empyema 14.2%, ARDS 14.2%, and acute kidney injury (AKI) 14.2% compared to non-FC patients AKI 25.0% and empyema 12.5%. There were no deaths. Conclusions: Rib plating of complicated chest wall injuries may reduce morbidity, hospital LOS, chronic disability, and should be considered in FC and multiple rib fractures.

Chest wall dose assessment in stereotactic ablative radiotherapy delivered with volumetric modulated arc therapy for peripheral lung tumors

BackgroundNo consensus on how to best predict for chest wall injury following SABR exists. We report our experience in chest wall dose assessment when treating peri-pleural lung lesions with stereotactic ablative radiotherapy (SABR) delivered with volumetric modulated arc therapy (VMAT). Methods40 patients with peri-pleural peripheral lung tumors underwent SABR between July, 2012 and February, 2015. Chest wall toxicity, dose distribution, and the influence of chest wall delineation method were investigated. ResultsAfter a median follow up of 16 months, no rib fracture or skin toxicity was observed. 4 patients (10%) reported persistent chest wall pain (grade 1–2). High dose rate's association with chest wall pain trended toward statistical significance (p=0.06). PTV exclusion and reducing chest wall expansion to 1cm led to significant dose reduction in the chest wall dose volume parameters (p<0.05). Only three local failures were observed among 44 lesions treated. ConclusionsThe risk of chest wall pain following SABR delivered with VMAT is low. High dose rate, which is 1400MU/min with flattening filter free (FFF) beams vs. 500–600MU/min with non-flattening filter free (non-FFF) beams, may contribute to it. Chest wall dose volume parameters may vary with PTV exclusion; while chest wall expansion of 1cm may fail to account for some high dose regions in the chest wall.

Rib Fractures, Flail Chest, and Pulmonary Contusion

Blunt chest trauma accounts for a significant proportion of debilitating and life-threatening injuries. Rib fractures are notoriously painful and can lead to prolonged hospitalization, contribute to the development of pneumonia and respiratory failure, and delay outpatient recuperation significantly. Flail chest, along with chest wall deformity, the most severe of chest wall injuries, is associated with significant acute morbidity and mortality. Pulmonary contusion often accompanies blunt chest wall trauma and when diffuse will result in respiratory failure regardless of other injuries. Pulmonary lacerations, pneumatoceles, and even lobar infarction can occur. In this review, we describe the development of current principles of management of rib fractures, flail chest, and pulmonary contusion. Emerging or unclarified strategies include the importance of acute pain control of rib fractures to alleviate the development of chronic pain, the role of rib fracture operative reduction/internal fixation (ORIF) in severe chest wall trauma, and the use of surfactant and dual lung ventilation for severe pulmonary contusion.

Characteristics of chest wall injuries that predict postrecovery pulmonary symptoms: A secondary analysis of data from a randomized trial.

Although thoracic trauma is common, little is known about which factors lead to poor functional outcomes. We sought to determine which characteristics of chest wall injury predict postrecovery pulmonary symptoms or health-related quality of life. We conducted a secondary analysis of data from a randomized trial involving patients with chest wall injuries at a Level I trauma center between December 2007 and July 2012. We evaluated the overall severity of the chest wall injury-characterized primarily by the number of fractured ribs-and rib fracture location (upper, middle, and lower; anterior, lateral, and posterior) as predictors of patient-reported outcomes 60 days after injury: dyspnea burden (0-40), Modified Medical Research Council Dyspnea Scale (MMRC) (0-4), St. George's Respiratory Questionnaire (SGRQ), and normalized Medical Outcomes Study Short-Form 36 (SF-36) scores. Of 189 evaluable subjects, the mean (SD) number of fractured ribs was 5 (4). The number of fractured ribs was not associated with dyspnea burden, MMRC, or SGRQ scores. After adjustment for confounders, each additional fractured rib was associated with worse SF-36 Physical Functioning and Bodily Pain scores (-0.6 units [95% confidence interval (CI), -1.1 to 0.0] and -0.8 units [95% CI, -1.3 to -0.2], respectively). Lower rib fractures were associated with worse dyspnea burden (3.4 units; 95% CI, 1.0-5.9), MMRC score (0.4 units; 95% CI, 0.0-0.8), and SF-36 Physical Functioning, Role-Physical, Role-Emotional, and Physical Component Summary scores (-4 units [95% CI, -8 to 0], -5 units [95% CI, -8 to -1], -4 units [95% CI, -8 to 0], and -4 units [95% CI, -7 to -1], respectively). The overall anatomic severity of chest wall injuries does not predict worse dyspnea symptoms 60 days after injury, but it does predict increased patient perceptions of pain and physical function limitations. Lower rib fractures predict both persistent respiratory symptoms and perception of decreased overall health. Prognostic/epidemiologic study, level III.

Pediatric Blunt Thoracic Trauma.

Thoracic injury in children deserves special attention because, although it accounts for less than 10% of traumatic injuries in children, there is a significant associated morbidity and mortality. This review discusses the anatomic and physiologic factors resulting in such injury severity with blunt thoracic trauma in children. Specific organ injuries, including most common chest wall injuries, hemo- and pneumothoraces, and pulmonary parenchymal injuries, are discussed, encompassing epidemiology, presentation, diagnosis, and management. Rare injuries including tracheobronchial tree injuries, cardiovascular injuries, esophageal injuries, and diaphragmatic injuries are also briefly discussed.

Late complication of a chest wall injury—images of an internal mammary artery pseudoaneurysm

Late complication of a chest wall injury—images of an internal mammary artery pseudoaneurysm

Abstract No. 350 - Cone-beam CT during prostatic artery embolization: a necessary adjunct to DSA to prevent complication

No. 352 Transcatheter arterial embolization for chest wall injury: 10 year experience C. Tingerides, G. Annamalai, S. Kaduri, C. Dey, R. Pugash, E. David; Department of Medical Imaging, Sunnybrook Health Sciences Centre, Toronto, ON, Canada Purpose: To present our experience in Transcatheter Arterial Embolization (TAE) for hemorrhage following chest wall injury, both traumatic and iatrogenic. We provide a pictorial summary of the full range of angiographic findings and embolization techniques utilized. Materials and Methods: Retrospective review of all patients treated with TAE for this indication in a period of 10 years: from August 2004 to August 2014 in our institution, a level I trauma centre. Data was obtained from electronic records, preand post-procedural imaging, procedure reports and laboratory results. Results: A total of thirteen patients were treated during this period. Seven patients had blunt trauma to the chest wall. Four patients had penetrating injury (two stabbings and two gunshot wounds). In four cases the injuries were iatrogenic (three due to chest tube insertion and one blunt injury from cardiopulmonary JVIR ’ Posters and Exhibits S157

Abstract No. 352 - Transcatheter arterial embolization for chest wall injury: 10 year experience

Abstract No. 352 - Transcatheter arterial embolization for chest wall injury: 10 year experience

Current Indications for Rib Fracture Fixation in Unstable Chest Wall Injuries

A flail chest injury occurs when a segment of the thoracic cage is separated from the rest of the chest wall. Such injuries are associated with severe pulmonary restriction; they generally require intubation and mechanical ventilation; and they are associated with high rates of morbidity and mortality. This article discusses flail chest injury data from the National Trauma Databank of North America, the use of open reduction and internal fixation, indications for chest wall repair, as well as the current need for additional trial data.

Epicardial Coronary Artery Compression Secondary to Pericardial Adhesions Demonstrated by Multi-Modality Imaging, and Treated by Coronary Stenting

A 42-year-old female presented with sudden onset severe left-sided chest pain radiating to the left arm while watching a movie at home. She was rushed to the hospital within 10 minutes. She was found having ST elevation myocardial infarction on ECG and ventricular fibrillation arrest 2 times requiring cardiac resuscitation and defibrillation. Retrospectively, the patient recalled some ill-defined episodes of chest pain with exercise in the past few months before the admission. Her past surgical history 20 years previous was significant for video-assisted thoracoscopic surgery and pericardial window for removal of large, nonhemorrhagic pericardial effusion of 1.2 L, which occurred ≈1 week after her chest wall injury from basketball. Bedside transthoracic echocardiography revealed mildly decreased left ventricular systolic ejection fraction of 40% to 45%, and pericardial thickening with small pericardial effusion. The patient underwent emergent cardiac catheterization and coronary …