Flail Segment Research Articles

What's in this issue?

What's in this issue?

Nonresectional Single-Suture Leaflet Remodeling for Degenerative Mitral Regurgitation Facilitates Minimally Invasive Mitral Valve Repair

Both leaflet resection and neochordal construction are effective mitral repair techniques, but they may become incrementally time-consuming when using minimally invasive approaches. We have used a single-suture leaflet-remodeling technique of inverting the prolapsed or flail segment tissue into the left ventricle. This repair is straightforward, expeditious, and facilitates a minimally invasive approach. Ninety-nine patients with degenerative mitral regurgitation (MR) underwent a minimally invasive single-suture repair of the mitral valve from May 2007 through December 2012. Preoperative and perioperative echocardiograms as well as patient outcomes were analyzed and compared with those obtained from patients undergoing minimally invasive mitral valve repair using quadrangular resection at the same institution during the same period. All 99 patients had a successful mitral repair through a sternal-sparing minimally invasive approach. Ninety-one of the 99 patients had zero MR on postoperative echocardiogram, and 8 of 99 had trace to mild MR. Patients in the nonresectional group had significantly shorter cardiopulmonary bypass and cross-clamp times compared with the quadrangular resection group (115.8 ± 41.7 minutes versus 144.9 ± 38.2 minutes; p < 0.001; 76.2 ± 28.1 minutes versus 112.6 ± 33.5 minutes; p < 0.001, respectively). The mean length of stay was 7.5 ± 3 days. All patients were discharged alive and free from clinical symptoms of MR. There have been no reoperations for recurrent MR on subsequent average follow-up of 1 year. An effective, highly efficient, and thus far durable single-suture mitral leaflet-remodeling technique facilitates minimally invasive repair of degenerative MR.

Surgical fixation of bilateral flail segments in severe chest trauma: A clinical report and literature overview

The optimal management of patients with flail chest remains subject of extensive debate. After an era of mainly non-operative treatment we recently witness a revival in thoracic osteosynthesis. The operative fixation of rib fractures, and especially flail segments, can pose a technically challenging problem for both trauma and thoracic surgeons. In this case report we describe a successful simultaneous bilateral flail chest fixation.

Prospective Randomized Controlled Trial of Operative Rib Fixation in Traumatic Flail Chest

Traumatic flail chest injury is a potentially life threatening condition traditionally treated with invasive mechanical ventilation to splint the chest wall. Longer-term sequelae of pain, deformity, and physical restriction are well described. This study investigated the impact of operative fixation in these patients. A prospective randomized study compared operative fixation of fractured ribs in the flail segment with current best practice mechanical ventilator management. In-hospital data, 3-month follow-up review, spirometry and CT, and 6-month quality of life (Short Form-36) questionnaire were collected. Patients in the operative fixation group had significantly shorter ICU stay (hours) postrandomization (285 hours [range 191 to 319 hours] for the surgical group vs 359 hours [range 270 to 581 hours] for the conservative group; p = 0.03) and lesser requirement for noninvasive ventilation after extubation (3 hours [range 0 to 25 hours] in the surgical group vs 50 hours [range 17 to 102 hours] in the conservative group; p = 0.01). No differences in spirometry at 3 months or quality of life at 6 months were noted. Operative fixation of fractured ribs reduces ventilation requirement and intensive care stay in a cohort of multitrauma patients with severe flail chest injury.

Management of Pulmonary Hernia Through a Flail Segment in Closed Thoracic Trauma Using Open Reduction, Internal Fixation and Pectoralis Major Flap Reconstruction: A Case Report

The present article reports on the successful management of a large flail chest with traumatic pulmonary herniation in a patient who could not be weaned from mechanical ventilation following a course of conservative management. Surgical intervention involved open reduction and internal fixation with tubular plates to stabilize the flail segment, followed by a pectoralis major myocutaneous flap to repair the chest wall defect. Following surgical intervention, the patient was able to be weaned from mechanical ventilation and showed remarkable improvement in pulmonary function parameters. To the authors' knowledge, the present report is the first to describe the use of open reduction and internal fixation of the chest wall and flap reconstruction to treat lung herniation with a flail chest segment.

Beating-heart implantation of adjustable length mitral valve chordae: acute and chronic experience in an animal model

This study aimed to determine the acute and chronic performance of a new system designed to conduct beating-heart implantation and off-pump adjustment of neochordal length. In 14 adult sheep (group A) selected to undergo beating-heart cardiopulmonary bypass, the left atrium was opened through a left thoracotomy. Two or more primary chordae in the A2 region were severed to produce a model of a flail leaflet. A chordal adjustment mechanism (V-Chordal, Valtech Cardio Ltd., Or-Yehuda, Israel) was affixed to the head of the papillary muscle. The system includes two adjustable neochordae. The distal end of the neochordae was sutured to the flail segment without estimating the appropriate length. The neochordal length was adjusted off-pump under real-time echo-guidance. The adjustment tool was removed and the atriotomy was closed with a purse-string suture. Control animals (group B, n=4) were implanted with the conventional neochordae. Animals in both groups were sacrificed 3 months after the procedure. In both groups, prior to repair, mitral regurgitation (MR) was severe in all animals. In group A, following adjustment of neochordae, MR was absent in all animals, with the exception of two animals that had residual 2+ MR irresponsive to neochordae adjustments. In group B, MR was 2+ in two of the four animals following repair. At 3 months, mitral competence was stable in all animals. At necropsy, normal healing of the papillary head and leaflet was observed in both the groups. The V-Chordal system simplifies the process of neochordal implantation and precise off-pump adjustment of the neochordal length to correct MR occurring due to a flail leaflet. This technology may improve the technical feasibility for adoption of chordal repair during open or minimally invasive surgical procedures.

Management of pulmonary hernia through a flail segment in closed thoracic trauma using open reduction, internal fixation and pectoralis major flap reconstruction: A case report

Management of pulmonary hernia through a flail segment in closed thoracic trauma using open reduction, internal fixation and pectoralis major flap reconstruction: A case report

Traumatic Diaphragmatic Hernia: An Unusual Complication of Colonoscopy

Purpose: We report a case of diaphragmatic herniation during a colonoscopy, via an occult diaphragmatic weakness from the patient's prior trauma. A 68 y/o male underwent screening colonoscopy with sigmoid polypectomy. The procedure was unremarkable and well tolerated. Five days later, he presented to the hospital with left upper and bilateral lower abdominal crampy pain, associated with nausea, vomiting, loss of appetite, and abdominal distension with no BM for last 5 days. One year prior, he had been involved in a fall, with blunt trauma to his left lateral thorax resulting in multiple rib fractures with flail segment and hemothorax, which was treated with closed thoracostomy drainage. Chest X-ray showed focal elevation of the left diaphragm after treatment for hemothorax. However, the diaphragm appeared intact on CT. Review of systems was remarkable for mild intermittent left upper abdominal pain with early satiety and nausea for several months with worsening of his symptoms for last 5 days since colonoscopy. Physical examination revealed: mild abdominal distension with tympany, tenderness in left upper quadrant and hypoactive bowel sounds. Abdominal-X-ray showed protrusion of the large bowel into the left thoracic cavity along with elevation of the left diaphragm. There was no free air in the peritoneal cavity. Abdominal CT confirmed the herniation of the splenic flexure through a defect in the midportion of the left hemidiaphragm. The proximal colon and terminal ileum were dilated with air-fluid levels consistent with bowel obstruction. Subsequently, the patient underwent exploratory laparotomy which showed left diaphragmatic hernia and incarcerated colon and omentum with colonic obstruction. A reduction repair of the hernia was performed and patient was discharged with an uncomplicated post-op course. Diaphragmatic rupture develops in about 5% of cases of blunt abdominal trauma, and is more frequent on the left side. It may be asymptomatic and diagnosis may be delayed for many years. Because the intraabdominal pressure is higher than intrathoracic pressure, progressive herniation of abdominal contents may occur through the defect. Undiagnosed traumatic diaphragmatic hernia encountered during colonoscopy has been rarely reported. Colon perforation leading to tension pneumothorax has also been described. However, in our case, the patient had no evidence of a diaphragmatic defect after trauma or treatment for left hemothorax. Continuous insufflation of air during the colonoscopy seems to have induced an increase in intra-abdominal pressure, which resulted in conversion of an occult focal diaphragmatic weakness into a true defect leading to sudden herniation of the colon into the thoracic cavity.

Operative stabilization of flail chest injuries: review of literature and fixation options

BackgroundFlail chest injuries cause significant morbidity, especially in multiply injured patients. Standard treatment is typically focused on the underlying lung injury and involves pain control and positive pressure ventilation. Several studies suggest improved short- and long-term outcomes following operative stabilization of the flail segments. Despite these studies, flail chest fixation remains a largely underutilized procedure.MethodsThis article reviews the relevant literature concerning flail chest fixation and describes the different implants and techniques available for fixation. Additionally, an illustrative case example is provided for description of the surgical approach.ResultsTwo prospective randomized studies, five comparative studies, and a number of case series documented benefits of operative treatment of flail chest injuries, including a decreased in ventilation duration, ICU stay, rates of pneumonia, mortality, residual chest wall deformity, and total cost of care. Historically, rib fractures have been stabilized with external plates or intramedullary implants. The use of contemporary, anatomically contoured rib plates reduced the need for intraoperative plate bending. Intramedullary rib splints allowed less-invasive fixation of posterior fractures where access for plating was limited.ConclusionOperative treatment can provide substantial benefits to patients with flail chest injuries and respiratory compromise requiring mechanical ventilation. The use of anatomically contoured rib plates and intramedullary splints greatly simplifies the procedure of flail chest fixation.

Anatomically Contoured Plates for Fixation of Rib Fractures

: Intraoperative contouring of long bridging plates for stabilization of flail chest injuries is difficult and time consuming. This study implemented for the first time biometric parameters to derive anatomically contoured rib plates. These plates were tested on a range of cadaveric ribs to quantify plate fit and to extract a best-fit plating configuration. : Three left and three right rib plates were designed, which accounted for anatomic parameters required when conforming a plate to the rib surface. The length lP over which each plate could trace the rib surface was evaluated on 109 cadaveric ribs. For each rib level 3-9, the plate design with the highest lP value was extracted to determine a best-fit plating configuration. Furthermore, the characteristic twist of rib surfaces was measured on 49 ribs to determine the surface congruency of anatomic plates with a constant twist. : The tracing length lP of the best-fit plating configuration ranged from 12.5 cm to 14.7 cm for ribs 3-9. The corresponding range for standard plates was 7.1-13.7 cm. The average twist of ribs over 8-cm, 12-cm, and 16-cm segments was 8.3 degrees, 20.6 degrees, and 32.7 degrees, respectively. The constant twist of anatomic rib plates was not significantly different from the average rib twist. : A small set of anatomic rib plates can minimize the need for intraoperative plate contouring for fixation of ribs 3-9. Anatomic rib plates can therefore reduce the time and complexity of flail chest stabilization and facilitate spanning of flail segments with long plates.

Pilot study of operative fixation of fractured ribs in patients with flail chest

Flail chest is a serious injury in trauma with a significant mortality rate, and long-term pain and disability. Traditionally, management has consisted of internal pneumatic splinting, leading to prolonged periods of mechanical ventilation, and its attendant complications. The aim of this study was to assess the safety of operative fixation of broken ribs in flail chest using absorbable prostheses. Thirteen consecutive patients with severe flail chest injury were enrolled in this pilot study. Surgery was planned after viewing three-dimensional reconstructions of the computed tomography scans of the chest. The plates were applied to the external cortical surface of the rib after reducing the fracture. Segmentally fractured ribs were usually plated only once to convert the flail segment to simple fractured ribs and correct the paradoxical wall motion abnormality. All patients had a good surgical result. On average, four ribs were fixed per patient. All patients were able to be weaned from mechanical ventilation and all patients were discharged from the hospital. There were no deaths. No plates had to be removed. In all patients, the flail chest was successfully stabilized and paradoxical chest wall movement was eliminated. This pilot study of operative fixation of broken ribs in patients with flail chest, using absorbable plates and screws, has shown the technique to be safe and effective. On the basis of these results, a prospective randomized trial has commenced at The Alfred Hospital, comparing this management strategy with conservative management.

ANATOMICALLY CONTOURED PLATES FOR FIXATION OF RIB FRACTURES

Background : Intraoperative contouring of long bridging plates for stabilization of flail chest injuries is difficult and time consuming. This study implemented for the first time biometric parameters to derive anatomically contoured rib plates. These plates were tested on a range of cadaveric ribs to quantify plate fit and to extract a best-fit plating configuration. Methods : Three left and three right rib plates were designed, which accounted for anatomic parameters required when conforming a plate to the rib surface. The length lP over which each plate could trace the rib surface was evaluated on 109 cadaveric ribs. For each rib level 3-9, the plate design with the highest lP value was extracted to determine a best-fit plating configuration. Furthermore, the characteristic twist of rib surfaces was measured on 49 ribs to determine the surface congruency of anatomic plates with a constant twist. Results : The tracing length lP of the best-fit plating configuration ranged from 12.5 cm to 14.7 cm for ribs 3-9. The corresponding range for standard plates was 7.1-13.7 cm. The average twist of ribs over 8-cm, 12-cm, and 16-cm segments was 8.3 degrees, 20.6 degrees, and 32.7 degrees, respectively. The constant twist of anatomic rib plates was not significantly different from the average rib twist. Conclusions : A small set of anatomic rib plates can minimize the need for intraoperative plate contouring for fixation of ribs 3-9. Anatomic rib plates can therefore reduce the time and complexity of flail chest stabilization and facilitate spanning of flail segments with long plates.

Quadricuspid aortic valve in a patient with mitral valve prolapse

A 72-year-old man was admitted to Yuksek Ihtisas Hospital, Ankara, Turkey, with dyspnea. His medical history was remarkable only for hypertension. On physical examination, his blood pressure was 120/70 mmHg and his pulse rate was 86 beats/min. Cardiac auscultation revealed a grade 3/6 systolic murmur at the apex, and auscultation of the lungs revealed bilateral rales. A 12-lead electrocardiogram showed a normal sinus rhythm. Transthoracic echocardiography demonstrated anterior mitral valve leaflet prolapse with severe mitral regurgitation and a quadricuspid aortic valve with four equal-sized cusps, causing moderate aortic regurgitation, with an X-shaped commissural aspect in diastole. Transesophageal echocardiography demonstrated a quadricuspid aortic valve (Figures 1A and ​and1B)1B) with central moderate aortic regurgitation and a flail segment on the anterior mitral valve leaflet with severe mitral regurgitation. The patient underwent elective mitral valve replacement. Figure 1) A Transesophageal echocardiographic view in the aortic valve plane in diastole. The aortic valve demonstrated a characteristic X pattern with equal-sized cusps. B Transesophageal echocardiographic view in the aortic valve plane in systole. The aortic ... Mitral valve prolapse is a common valvular abnormality. Although the overall prognosis of patients with mitral valve prolapse is excellent, it may cause serious complications, including infective endocarditis, sudden cardiac death, cerebrovascular ischemic events and severe mitral regurgitation (1). The most important complication of mitral valve prolapse is severe mitral regurgitation, which may result from progressive myxomatous degeneration or chordal rupture (1). A quadricuspid aortic valve is a rare congenital malformation of the aortic valve. The main functional abnormality of a quadricuspid aortic valve is insufficiency (2). The structure of a quadricuspid aortic valve varies according to the dimension of each individual valve cusp: four equal cusps, three equal cusps with one minor cusp, or two large cusps with two small cusps (2). In the present case, we presented this rare condition again.

Delayed cardiac tamponade following blunt thoracic trauma

Fatal cardiac tamponade may result from perforation of acardiac chamber, major artery or vein. Delayed cardiactamponade is a rare phenomenon that may appear days orweeks after the initial injury. This case describes cardiactamponade occurring four days after a penetrating cardiacinjury due to a flail segment.

Editorial comment on valve repair for traumatic tricuspid regurgitation

In this chapter of the MMCTS, Malaisrie and coworkers describe a very interesting case of severe post-traumatic tricuspid regurgitation which was successfully corrected by resecting a flail segment of the anterior leaflet of the tricuspid valve w1x. A tricuspid annuloplasty ring (Edwards MC3) was used to treat the associated annular dilatation and stabilize the repair. No residual tricuspid regurgitation was present at the trans-esophageal exam performed before leaving the operating room. Although long-term echocardiographic follow-up is mandatory to confirm the durability of the repair, the Authors have to be congratulated for the excellent early result obtained in this patient in whom, in addition, they used a minimally invasive approach rather than a standard median sternotomy. Surgical correction of traumatic tricuspid regurgitation can be unpredictable and challenging. At the time of surgery it is not unusual to find multiple and different lesions involving the leaflets and the subvalvular apparatus, together with some degree of right ventricular dilatation and dysfunction. The leaflet resection technique, adopted in this case, was certainly a reasonable solution considering that the lesion encountered was represented by an isolated flail of the anterior leaflet. Nevertheless, in the presence of severe right ventricular dilatation, the application of this method can lead to significant residual regurgitation. In fact, in longstanding undiagnosed tricuspid insufficiency, the segmental flail initially caused by the blunt chest trauma is gradually followed by the development of tethering defects of the remaining portions of the valve due to the progressive enlargement of the right ventricular chamber. When this stage has been reached, resection of the flailing segment

Trench entrapment: is ketamine safe to use for sedation in head injury?

A 19-year-old man was buried when the walls of the trench he was digging collapsed. Bystanders exposed the head and chest, and called the emergency services. The paramedic applied a...

Lethal Systemic Air Embolism in a Multi-Trauma Patient

Journal of the American College of Surgeons 206(3):p 591, March 2008. | DOI: 10.1016/j.jamcollsurg.2007.05.037

Post-Traumatic Occlusion of Subclavian Artery With Clavicle Fracture

20-year-old man, who was the driver in a motor ehicle accident, was referred to the Emergency Departent of our hospital. He presented in shock, with a lasgow Coma Scale score of 7. He showed eye opening n response to pain, and had a motor response that ocalized painful stimuli. He had no other significant ead injuries or extremity injuries. He was intubated in he Emergency Department, and was given intravenous uid and placed on inotropic support. Chest examination revealed a flail segment in the left pper chest with extensive subcutaneous emphysema. ight upper limb pulses were normal, whereas the left pper limb pulses (axillary, brachial, radial, and ulnar) ere not palpable. The left upper limb was cold and pale. Chest radiograph revealed a fracture of the left clavcle, left first and second ribs with left hemothorax (Figre 1). Ultrasound of the abdomen did not reveal evience of hemoperitoneum or solid organ injury. A omputed tomography scan of the head was also normal. An emergent digital subtraction angiogram (DSA) of he aorta and its thoracic branches was performed (Figre 2). Thoracic arch aortogram revealed that the brahiocephalic trunk and left common carotid artery were ormal in course and caliber. There was complete occluion of the proximal left subclavian artery, approxiately 2 cm beyond its origin, with compression caused y the displaced medial segment of the fractured left lavicle. Delayed images (Figure 3) demonstrated faint

Emergency surgery after failed device closure of the atrial septal defect

Clinical Summaries PATIENT 1. A 66-year-old woman with chronic atrial fibrillation (AF) and transient ischemic attacks (TIA) underwent closure of a 5-mm ASD with 14-mm Amplatzer device (AGA Medical Corp, Golden Valley, Minn). However, she remained symptomatic, with residual left-to-right shunt. A 25-mm Amplatzer device was placed 6 months later. The devices partially dehisced 2 years later, with large left-to-right shunt with pulmonary artery (PA) systolic pressure of 62 mm Hg. An attempt to place a 35-mm Amplatzer device resulted in further dehiscence of the interlocked devices, with threatening embolization. The patient underwent urgent surgery. Atrial septum was exposed through midline sternotomy. The devices were dehisced from the entire posterior rim of the septum and displaced into the left atrium (LA; Figure 1). The devices were retrieved from the LA, and the ASD was closed with direct suture. Aortic crossclamp (ACC) time was 30 minutes. Cardiopulmonary bypass (CPB) time was 57 minutes. The patient was discharged home on postoperative day 8. She died 30 months later from interstitial lung disease presumably related to amiodarone therapy for chronic AF. PATIENT 2. A 38-year old woman developed syncopal episodes. A sick sinus syndrome was diagnosed, and a permanent pacemaker was required. The echocardiogram demonstrated a 16-mm-diameter ASD. An attempt to place an 18-mm Amplatzer device resulted in the rupture of the inferior rim of the atrial septum. An attempt to place a 36-mm Amplatzer device resulted in further rupture and an insufficient inferior rim to secure the device. The ASD size increased to 2.5 cm 4 cm. A large flail segment of the inferior rim raised the concern of embolization. Emergency surgery was performed through midline sternotomy. The flail segment of the atrial septum was excised, and the ASD was closed with an autologous pericardial patch. ACC time was 21 minutes. CPB was 37 minutes. She was discharged on postoperative day 5 and underwent pacemaker insertion for the sick sinus syndrome. The patient remains asymptomatic at 1-year follow-up. PATIENT 3. A 61-year-old man with several episodes of TIA, hypertension, type 2 diabetes, and 10-mm ASD with left-to-right shunt underwent ASD closure with a 35-mm Helex occluder device (W.L. Gore and Associates, Inc, Flagstaff, Ariz). Upon deployment of the device, the patient developed cardiac tamponade. A pigtail catheter was placed in the pericardial cavity, and continuous autotransfusion of the aspirated blood was performed. Emergency surgery was performed through midline sternotomy. A tear of the atrial septum extending into the left atrial wall was found. The tear and the ASD were closed by direct running suture. ACC was 18 minutes. CPB was 29 minutes. The patient was discharged home on day 5. He remains asymptomatic at 3-year follow-up. PATIENT 4. A 16-year-old asymptomatic woman was considered for device closure of an 18-mm-diameter ASD with shunt of 2:1 and normal PA pressures. An attempt to place a 26-mm Amplatzer device resulted in the tear of the inferior rim of the atrial septum. The device was removed, and a 28-mm Amplatzer device was placed. The second device, however, embolized entirely into the LA, and the patient underwent urgent surgical removal of the device. The device was retrieved from the LA through midline sternotomy with standard CPB. A long tear was found in the inferior rim of the ASD, which measured 1.8 cm 4 cm. The ASD was closed with direct suture. ACC time was 18

Haemothorax with posterior chest wall flail segment due to traumatic spinal cord transection

Haemothorax with posterior chest wall flail segment due to traumatic spinal cord transection