Thoracic Aortic Surgery Research Articles

The innominate artery-The forgotten cannulation site for thoracic aortic surgery.

Journal of Cardiac SurgeryVolume 33, Issue 12 p. 826-826 INVITED COMMENTARY The innominate artery—The forgotten cannulation site for thoracic aortic surgery Harold L. Lazar MD, Corresponding Author harold.l.lazar@gmail.com From the Division of Cardiac Surgery, the Boston University School of Medicine, Boston, Massachusetts Correspondence Harold L. Lazar, MD, From the Division of Cardiac Surgery, the Boston University School of Medicine, 80 E Concord Street, Boston MA 02118. Email: harold.l.lazar@gmail.comSearch for more papers by this author Harold L. Lazar MD, Corresponding Author harold.l.lazar@gmail.com From the Division of Cardiac Surgery, the Boston University School of Medicine, Boston, Massachusetts Correspondence Harold L. Lazar, MD, From the Division of Cardiac Surgery, the Boston University School of Medicine, 80 E Concord Street, Boston MA 02118. Email: harold.l.lazar@gmail.comSearch for more papers by this author First published: 12 December 2018 https://doi.org/10.1111/jocs.13961Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume33, Issue12December 2018Pages 826-826 RelatedInformation

Developing skills for thoracic aortic surgery with hypothermic circulatory arrest

ObjectivesTo examine the performance curves of 8 early-career aortic surgeons with the use of hypothermic circulatory arrest (HCA) and to analyze the impact of the learning curve on perioperative outcomes. MethodsA total of 1025 consecutive patients who underwent aortic reconstruction with HCA between 2002 and 2017 were analyzed for mortality and 5 other complications (stroke, reoperation for bleeding, dialysis, prolonged ventilation, and sternal wound complications), subdivided into 3 consecutive time periods. This cohort represents the complete inaugural experience of 8 Canadian academic aortic surgeons. A risk-adjusted cumulative sum analysis was used to evaluate the performance curve with respect to predetermined 80% alert and 95% alarm boundary lines. ResultsMean age was 62 ± 13 years, 71% of patients were male, and 24% presented nonelectively. Hemiarch repair was performed in 80% and total arch replacement in 20%. There was a reduction in the incidence of the primary composite outcome over time (P1: 26%, P2: 23%, and P3: 16%; P = .010). Overall in-hospital mortality was 5% and remained stable throughout the 3 periods. Rates of stroke were lower in the late period (P1: 4%, P2: 6%, and P3: 2%; P = .035). Risk-adjusted cumulative sum analysis demonstrated that all surgeons remained within the 95% reassurance boundary throughout their experience, with 6 surgeons performing as expected and 2 performing better than expected. ConclusionsEarly-career surgeons can safely perform operations with HCA from the initiation of their practice. The cumulative sum analysis method is valuable for monitoring competence in aortic surgery and could prove useful in structuring training programs.

True Lumen Stabilization to Overcome Malperfusion in Acute Type I Aortic Dissection

Acute type I aortic dissection (AD) complicated by true lumen (TL) collapse and malperfusion downstream is associated with devastating prognosis. The study reports an institutional mid-term experience with TL stabilization by uncovered stents to restore perfusion as a supplement to proximal thoracic aortic surgery. Between January 2007 and May 2017, 181 out of 270 acute type A AD patients were operated on type I AD. Eighteen uncovered stents (10%) were used to expand the aortic TL in presence of visceral and/or peripheral malperfusion. The procedures took place in a hybrid operating room and were combined with proximal aortic surgery. During follow-up (mean ± standard deviation 3.44 ± 2.1 years), the fate of AD was evaluated by computed tomography. Indication for TL stenting included visceral (44%) or peripheral malperfusion (11%) or both (45%). Stenting of aortic branches followed in 33%. All patients underwent proximal repair and were combined with frozen elephant trunk (67%) or retrograde descending aorta stent grafting (11%). Thirty-day mortality was 16.7%. Two-year survival was 71.8%. The false lumen around the uncovered stents remained patent in 89% and the aortic diameter increased 0.1 cm/y. No intimal rupture or occlusion of arteries occurred. In 1 patient, the stented aortic lumen was visualized after 6.3 years and neointima ingrowth covering the nitinol frame was found. In acute type I AD, combined endovascular-surgical procedures in a hybrid operation room setting can be used safely to resolve distal malperfusion. Encapsulation of uncovered stents within the intimal wall provides a stable fundament for endovascular techniques to close entry tears and false lumen.

Association Between Motor-Evoked Potentials and Spinal Cord Damage Diagnosed With Magnetic Resonance Imaging After Thoracoabdominal and Descending Aortic Aneurysm Repair

The authors investigated the association between intraoperative motor-evoked potential (MEP) changes and the severity of spinal cord infarction diagnosed with magnetic resonance imaging (MRI) to clarify the discrepancy between them, which was observed in patients with postoperative motor deficits after thoracic and thoracoabdominal aortic surgery. A multicenter retrospective study. Motor-evoked potential <25% of control values was deemed positive for spinal cord ischemia. The severity of spinal cord infarction was categorized into grades A to D based on previous studies using the most severe axial MRI slices. The associations between MRI grade, MEP changes, and motor deficits were examined using logistic regression. Twenty-three of 1,245 patients (from 1999 to 2013, at 12 hospitals in Japan) were extracted from medical records of patients who underwent thoracic and thoracoabdominal aortic repair, with intraoperative MEP examinations and postoperative spinal MRI. No intervention (observational study). Motor-evoked potential <25% of control value was associated significantly with motor deficits at discharge (adjusted odds ratio [OR], 130.0; p = 0.041), but not with severity of spinal cord infarction (adjusted OR, 0.917; p = 0.931). Motor deficit at discharge was associated with severe spinal cord infarction (adjusted OR, 4.83; p = 0.043), MEP <25% (adjusted OR, 13.95; p = 0.031), and combined deficits (motor and sensory, motor and bowel or bladder, or sensory and bowel or bladder deficits; adjusted OR, 31.03; p = 0.072) in stepwise logistic regression analysis. Motor-evoked potential <25% was associated significantly with motor deficits at discharge, but not with the severity of spinal cord infarction.

Spinal Cord-derived Neural Precursor Cells as a Preventive Therapy for Spinal Cord Injury.

Background:Spinal cord injury (SCI) as one of the most important diseases of central nervous system (CNS) without any definite treatment is still growing in incidence. In addition to trauma, some surgeries such as cardiac and thoracic aorta surgery may result in SCI as a complication. In last years, a promising approach has shed light on this CNS injury thanks to stem cell technology. Stem cell therapy could be considered as a good candidate for transplantation and enhancing neural regeneration in SCI. In this study, we identified the effects of spinal cord-derived neural precursor cells (NPCs) transplantation on SCI in after and before injury injection.Materials and Methods:NPCs were isolated from the adult rat spinal cord and cultured in vitro using complete culture media. After neurosphere formation, the cells were differentiated to neurons, oligodendrocytes, and astrocyte. The cells were transplanted to the rat model of SCI in 1 day before and 1 day after injury. The animals were followed for 12 weeks to assess their neurological performance. In addition, histological study and inflammatory cytokines levels have been studied.Results:Our results indicate that NPCs infusion both pre- and post-SCI could decrease the level of inflammatory cytokines. In addition, the neurological performance and histologic studies showed recovery after this type of injury using NPCs, and it might be due to inflammation modulatory effects on neural stem cells.Conclusion:NPCs therapy for SCI in both two-time points (before and after SCI) could be beneficial and make a neurological recovery. In other words, NPCs therapy could be considered as a therapeutic and also preventive approach for SCI.

Risk Prediction Model for Major Adverse Outcome in Proximal Thoracic Aortic Surgery

Proximal thoracic aortic surgery utilizing hypothermic circulatory arrest carries risks of mortality and major morbidity; however, these risks are not the same for every patient. The goal of the current study was to establish a risk prediction model for risk-stratifying patients undergoing proximal thoracic aortic surgery with hypothermic circulatory arrest for degenerative pathology, to facilitate preoperative physician-patient counseling. A retrospective analysis was conducted on 489 patients who underwent proximal thoracic aortic surgery with hypothermic circulatory arrest for degenerative pathology between July 2005 and August 2014 at a single referral institution; patients with acute dissection (n= 139) were excluded. Multivariable logistic regression was used to build a risk prediction model and identify preoperative predictors of major adverse outcome-the composite endpoint of 30-day/inhospital mortality, stroke, acute renal failure, prolonged ventilation, or discharge to a location other than home. The results were validated using an independent cohort of 120patients operated on from September 2014 to September2016. Multivariable analysis identified age (p= 0.0002, odds ratio [OR] 2.01), total arch replacement (p≤0.0001, OR 6.75), and procedure status (p= 0.0028; OR 2.73 for urgent, OR 43.58 for emergent) as independent predictors associated with major adverse outcome. The calibration curve for probability of major adverse outcome showed excellent agreement between the model and observations. The concordance index was 0.93 in external validation. The current study identified risk factors for major adverse outcome after proximal thoracic aortic surgery with hypothermic circulatory arrest for degenerative pathology. The proposed simple, accurate model can quantify risk and facilitate physician-patient counseling before possible surgical intervention.

Total aortic arch replacement using elephant trunk or frozen elephant trunk technique: a case-control matching study.

Surgical management of aortic arch diseases is one of the most challenging issues in cardiovascular surgery. The aim of this study was to compare the outcome after frozen elephant trunk (FET) with conventional elephant trunk (ET) technique. Out of a total of 551 patients after thoracic aortic surgery, we analyzed 70 consecutive patients, who underwent aortic arch replacement with ET or FET technique between 2001 and 2017 in our institution. The patients were case-control matched in regard to such variables as age, sex, presence of an acute aortic dissection and necessity for concomitant procedures. The analysis included 25 patient pairs. Among the 25 FET patients, eleven patients were female, the median age was 69, 15 (60%) patients had an aortic dissection and thirteen needed various concomitant procedures. In the second group, treated with conventional ET technique, 10 (40%) patients were female, the median age was 66 years, thirteen presented with an aortic dissection and 16 (64%) underwent concomitant procedures. These and other characteristics did not differ significantly between the groups. In-hospital mortality was statistically similar: 5 (20%) in the FET group vs. 8 (32%) for ET group (P=0.52). The incidence of stroke, acute renal failure and postoperative bleeding was comparable. The length of stay in the intensive care unit did not differ between the cohorts (P=0.258). Predictors of in-hospital mortality were length of the operation, bleeding postoperatively, and acute renal failure. The one-year survival rates were higher in the FET cohort compared to the conventional approach (60% vs. 38%), however without statistical significance. In regard to the short- and mid-term outcome, there were only slight differences between both techniques. In patients with extensive aneurysmal aortic disease, conventional ET and FET procedures seem to be associated with acceptable satisfactory mid-term outcome.

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

Editor's Choice – Current Options and Recommendations for the Treatment of Thoracic Aortic Pathologies Involving the Aortic Arch: An Expert Consensus Document of the European Association for Cardio-Thoracic Surgery (EACTS) & the European Society for Vascular Surgery (ESVS)

Derivation and Validation of Machine Learning Approaches to Predict Acute Kidney Injury after Cardiac Surgery.

Machine learning approaches were introduced for better or comparable predictive ability than statistical analysis to predict postoperative outcomes. We sought to compare the performance of machine learning approaches with that of logistic regression analysis to predict acute kidney injury after cardiac surgery. We retrospectively reviewed 2010 patients who underwent open heart surgery and thoracic aortic surgery. Baseline medical condition, intraoperative anesthesia, and surgery-related data were obtained. The primary outcome was postoperative acute kidney injury (AKI) defined according to the Kidney Disease Improving Global Outcomes criteria. The following machine learning techniques were used: decision tree, random forest, extreme gradient boosting, support vector machine, neural network classifier, and deep learning. The performance of these techniques was compared with that of logistic regression analysis regarding the area under the receiver-operating characteristic curve (AUC). During the first postoperative week, AKI occurred in 770 patients (38.3%). The best performance regarding AUC was achieved by the gradient boosting machine to predict the AKI of all stages (0.78, 95% confidence interval (CI) 0.75–0.80) or stage 2 or 3 AKI. The AUC of logistic regression analysis was 0.69 (95% CI 0.66–0.72). Decision tree, random forest, and support vector machine showed similar performance to logistic regression. In our comprehensive comparison of machine learning approaches with logistic regression analysis, gradient boosting technique showed the best performance with the highest AUC and lower error rate. We developed an Internet–based risk estimator which could be used for real-time processing of patient data to estimate the risk of AKI at the end of surgery.

Innovations in Thoracic Aortic Aneurysm Surgery

This Special issue guest edited jointly by Dr. Mohamad Bashir and Dr. Joseph E. Bavaria aims to highlight clinical controversies and uncertainties regarding thoracic aortic aneurysm, its surgical treatment and innovations. The issue cross fertilised topics from a pool of international repute and brought them to clinical, scientific and academic platform to portray their Viewpoints, results and experiences. The emphasis of current aortic practice is centred around multi-disciplinary approach and linkage of thoughts, research and experiences. The issue dwelled on all concepts above reflecting on the future trends and projections in aortic surgery. We understand the ongoing need for new treatment options to provide effective and corrective surgery and such needs to be centred on foundations and pillars of extensive research and clinical expertise.

Assessment of the EuroSCORE II in a New Zealand Tertiary Centre

The updated European System for Cardiac Operative Risk Evaluation (EuroSCORE II) is a well-established cardiac surgery risk scoring tool for estimating operative mortality. This risk stratification system was derived from a predominantly European patient cohort. No validation analysis of this risk model has been undertaken for the New Zealand population across all major cardiac surgery procedures. We aim to assess the efficacy (discrimination and calibration) of the EuroSCORE II for predicting mortality in cardiac surgical patients at a large New Zealand tertiary centre. Data was prospectively collected on patients undergoing cardiac surgery from September 2014 to September 2017 at Waikato Hospital, New Zealand. Patient demographic information, preoperative clinical risk factors and outcome data were entered into a national database. Included patients received either isolated coronary artery bypass grafting (CABG), isolated valve surgery, isolated thoracic aortic surgery, or a combination of these procedures. The primary outcome was the discrimination and calibration of predicted EuroSCORE II risk scores compared with observed 30-day mortality events. 1,666 cardiac surgery patients were included during the study period, with an average EuroSCORE II of 2.97% (95% confidence interval (CI): 2.76-3.18). Nine hundred thirty-three (933) patients underwent isolated CABG, 384 underwent isolated valve surgery, 48 received isolated thoracic aortic surgery and 301 received combination procedures. Thirty-day (30-day) mortality events in each of these groups was 7, 4, 2 and 13 deaths respectively. There were 26 deaths across the total cohort at 30-days (observed mortality rate 1.56%). Discrimination analysis using receiver operating characteristic curves demonstrated the area under the curve (AUC) of the EuroSCORE II in each of these groups as 93.4% (95% CI: 91.6-94.9, p<0.0001), 66.3% (95% CI: 61.3-71.0, p=0.37), 37.0% (95% CI: 15.7-58.2, p=0.23) and 74.8% (95% CI: 69.5-79.6, p<0.0001) respectively. The total cohort AUC was 83.1% (95% CI: 81.2-84.9, p<0.0001). Calibration analysis using Hosmer-Lemeshow tests for the subgroups revealed p-values of 0.848, 0.114, 0.638 and 0.2 respectively. The total cohort Hosmer-Lemeshow p-value was 0.317. EuroSCORE II showed a strong discriminative ability for isolated CABG 30-day mortality in a New Zealand patient cohort. However, the scoring system discriminated poorly across valvular, thoracic aortic or complex combination cardiac surgical procedures. Good calibration of the EuroSCORE II was achieved across both the total cohort and subgroups. It is important to consider the performance of other cardiac surgery risk stratification models for the New Zealand population.

PS01.085: TREATMENT STRATEGY FOR AORTO-ESOPHAGEAL FISTULA

Abstract Background Aorto-esophageal fistula (AEF) is relatively rare, but life-threatening condition. AEF is usually caused in the patients with thoracic aortic diseases, such as aneurysms, or after thoracic aortic surgery. We present our surgical strategy for AEF. Methods From May 2004 to November 2017, 12 patients with AEF were treated at our hospital. The age ranges from 44 to 83 years, and the number of male/female was 9/3. Five patients had previous thoracic endovascular aortic repair (TEVER) in the descending aorta, four patients had descending or total arch replacement. Two patients caused by rupture of thoracic aortic aneurysm, and one patient had penetration of esophagus caused by aspiration of Press Through Package. As the first procedures for surgical treatment, we perform TEVAR in order to prevent the fatal hemorrhage from aortic pseudoaneurysm. At the same day, removal of esophagus with debridement of adjacent infected tissues is performed by open thoracic procedure. After a few days, excision of the infected graft or the aorta followed by new graft replacement with omental flap installation is performed. Four patients used homograft and four patients used rifampicin-soaked graft. After the patient's general condition improve, we plan to perform open surgery for reconstruction of esophagus. Results A 3-year survival rate was 50%, and perioperative mortality was 25%. Hospital mortality was noted in 3 patients due to sepsis, brainstem infarction and pulmonary hemorrhage (6–117 days after the first surgery). Late death occurred in 4 patients (n = 2: ileus, n = 1: carcinoma, n = 1: pneumonia). Eight patients could undergo esophagus reconstruction, by colon graft in 4 patients, a pedicled jejunum and a gastric tube in 2 patients, respectively. The duration from esophageal resection to reconstruction was 1–11 months. Conclusion Because AEF usually accompanied with hemodynamic instability, immediate surgical intervention is regarded as the only effective treatment. Corporation between gastrointestinal surgeons and cardiovascular surgeons is necessary to achieve this treatment. We share our experiences of AEF treatment and discuss surgical strategy. Disclosure All authors have declared no conflicts of interest.

Direct Innominate Artery Cannulation as a Sole Systemic and Cerebral Perfusion Technique in Aortic Surgery

Arterial cannulation is often challenging in thoracic aortic surgery due to the location of the surgery and need for cerebral protection during periods of circulatory arrest. Cannulation sites including the ascending and descending aorta, axillary, carotid and femoral arteries have limitations and are associated with complications due to their proximity to surrounding structures. Therefore, the innominate artery can be used by either direct cannulation or indirect cannulation via a graft as an alternative site. We present a technique of sole direct innominate artery cannulation that is able to provide both systemic and selective antegrade cerebral perfusion during aortic surgery.

Urine neutrophil gelatinase\u2013associated lipocalin predicts outcome and renal failure in open and endovascular thoracic abdominal aortic aneurysm surgery

Urine neutrophil gelatinase–associated lipocalin (uNGAL) has been evaluated as a biomarker for AKI detection and adverse outcome in open and endovascular thoracoabdominal aortic aneurysm surgery. This observational, retrospective study included 52 patients. UNGAL was measured peri-operatively (48 h) and correlated with AKI requiring dialysis, tracheotomy and adverse outcome. Mean patients’ age was 64.5 years. A total of 26.9% (n = 14) developed AKI, and 21.1% (n = 11) required dialysis, tracheotomy rate was 19.2% (n = 10) and in-hospital mortality rate was 7.6% (n = 4). uNGAL levels were related to AKI requiring dialysis at ICU (p = 0.0002), need for tracheotomy at baseline and admission on ICU (p = 0.0222, p = 0.0028, respectively), as well as adverse discharge modality (p = 0.0051, p = 0.0048, respectively). Diagnostic quality was good for uNGAL levels at admission to ICU regarding AKI requiring dialysis (sensitivity: 81.8% [48.2–97.7]; specificity: 87.8% [73.8–95.9]; area under the curve (AUC): 0.874 [0.752–0.949]). The diagnostic quality of uNGAL was favorable for the prediction of tracheotomy (sensitivity: 70.0% [34.8–93.3]; specificity: 83.3% [68.6–93.0]; AUC: 0.807 [0.674–0.903]) and adverse discharge (sensitivity: 77.8% [40.0–97.2]; specificity: 83.7% [69.3–93.2]; AUC: 0.817 [0.685–0.910]). uNGAL may be valuable as an post-operative predictor of AKI and adverse outcome after open and endovascular TAAA repair.

Reflection of pioneers: redo thoracoabdominal aortic aneurysm repair controversies in thoracic aortic aneurysm surgery.

Reoperative thoracoabdominal aortic aneurysm repair is frequently necessary and brings with it a unique set of challenges. Typically, most reoperative repairs are necessitated by aortic disease progressing into previously healthy aortic tissue from a replaced section of the aorta (an extension of the previous repair) or, to a lesser degree, because of a late complication of prior distal aortic repair (an open or endovascular repair failure). Characterizing the reason for the reoperation as well as the location of prior repair is the first step towards anticipating major outcomes following such repair. Since the introduction of endovascular repair for aortic aneurysms, indications for open repair have become more specific and limited; many centers have justified using endovascular approaches in patients with prior open aortic repair by deeming these patients "high risk" because of their previous incision. Our analysis found that reoperative repairs were not typically subject to worse early outcomes than patients without prior distal aortic repair, except for the more complicated types of reoperation, which involve infection.

Perioperative Risk Profiles and Volume-Outcome Relationships in Proximal Thoracic Aortic Surgery

Using the national Society of Thoracic Surgeons Adult Cardiac Surgery Database data for thoracic aortic surgical procedures for aortic aneurysm, this study aimed to (1) characterize patients' risk profiles and outcomes, (2) evaluate center volume-outcome relationships across US centers, and (3) identify risk factors for operative mortality. Between 2011 and 2016, 53,559 operations for ascending aortic aneurysm performed across 1,045 centers in the United States were identified. Logistic regression related baseline characteristics and comorbidities to operative mortality. Ten-fold cross-validation was performed to estimate sensitivity and specificity across a range of the discrimination threshold. Centers were stratified into five strata by average annual case volume. Predicted probability of operative mortality was calculated from the model and was used to evaluate patients' risk profiles across the volume strata. Operative mortality occurred in 3.2% of all cases and in 2.2% of elective cases. Only 24 (2.3%) centers performed ≥50 cases annually, whereas 609 (58.3%) centers performed fewer than five cases annually. Multiple logistic regression, of which the c-index was 0.80, revealed that compared with centers with ≥50 cases, centers with fewer than five cases had an increased risk of mortality (odds ratio, 2.50; 95% confidence interval, 2.08 to 3.01; p < 0.0001). The predicted probability of operative mortality was similar across the volume strata, but the observed mortality rate varied significantly, with lower volume yielding higher operative mortality. Proximal thoracic aortic surgical procedures for aortic aneurysms in the United States are associated with a low operative mortality rate of 2.2% for elective cases. Risk of operative death decreases significantly at an annual center volume of more than 20 to 25 cases per year.

Innominate vs Axillary artery cannulation in thoracic aortic surgery: A systematic review and meta-analysis

Innominate vs Axillary artery cannulation in thoracic aortic surgery: A systematic review and meta-analysis

Providing Culturally Competent Acute Care Physical Therapy for a Complex Medical Patient of Amish Heritage

Background and Purpose: Health care providers, including physical therapists, should identify and incorporate sociocultural, educational, and environmental factors in their clinical decisions for patients of various cultural backgrounds—specifically Amish heritage as illustrated in this case report. The purpose of this case report is to describe how cultural beliefs affected acute care physical therapy (PT) and discharge planning for an older adult of Amish heritage. Case Description: The patient was a 65-year-old woman of Amish heritage 2 days post thoracic aortic aneurysm dissection surgery with an unexpected subsequent stroke. Due to their Amish beliefs, the patient and the family declined the physical therapist's initial postacute care discharge recommendation to an off-site skilled nursing facility. Significant discussion with multiple family members throughout the entire therapy process emphasized continued skilled services in accord with Amish cultural beliefs to promote safe reintegration into the Amish community. PT interventions primarily focused on culturally sensitive patient and family education and functional mobility to encourage safe patient resumption of activities of daily living and role in society. Outcomes: By the end of 2 weeks of PT (1 initial examination and 8 intervention sessions), the patient demonstrated improvements in all aspects of functional mobility and total Functional Independence Measure scores (21/126 to 86/126). On postoperative day 14, the patient transitioned to an on-site inpatient rehabilitation facility. After completing only 4 days in the inpatient rehabilitation facility, the family firmly advocated that the patient be discharged home with assistance from the family and Amish community. Discussion: Physical therapists may be unfamiliar with patients of Amish heritage due to the infrequency of PT services used by these individuals. This case report demonstrates a physical therapist's sensitivity to and acceptance of the Amish cultural beliefs, which ensured appropriate clinical decisions and positive patient- and family-centered outcomes. Engaging the patient's family in dialogue about realistic discharge options early in the acute care stay allowed the family time to understand the complexity of the patient's diagnoses and challenges of the health care environment as well as align decisions with their cultural beliefs.

Safety of Fibrinogen Concentrate and Cryoprecipitate in Cardiovascular Surgery: Multicenter Database Study

To investigate whether administering fibrinogen concentrate or cryoprecipitate is associated with increased postoperative thromboembolic events and improved mortality in patients undergoing thoracic aortic surgery. Multicenter retrospective cohort study using propensity-score analyses and multivariate logistic regression analysis to control for confounders. Four hospitals (1 national cardiovascular center and 3 university hospitals). Patients undergoing thoracic aortic surgery with cardiopulmonary bypass between January 2010 and October 2012 (n = 1,047). Outcomes in patients treated with fibrinogen concentrate or cryoprecipitate (fibrinogen group) were compared with those who did not receive these products (no fibrinogen group) based on propensity-score matching. Multivariate logistic regression analysis then was performed to confirm the results. Among 1,047 patients enrolled in this study, 247 patients received fibrinogen concentrate or cryoprecipitate. The median amount of administered fibrinogen was 3 g (interquartile range 2-4 g). Eighty-seven patients were excluded from the propensity-score matching because of missing data. Propensity-score-matched analysis showed no significant difference in the incidence of thromboembolic events or 30-day mortality rate between the groups. Multivariate analysis revealed that the fibrinogen group showed no significant difference in thromboembolic events (odds ratio 1.22; 95% confidence interval 0.76-1.95; p = 0.408) or mortality rate (odds ratio 0.44; 95% confidence interval 0.18-1.12; p = 0.081) compared with those in the no fibrinogen group. Administering fibrinogen concentrate or cryoprecipitate was associated with neither thromboembolic events nor 30-day mortality in patients undergoing thoracic aortic surgery. Administering fibrinogen concentrate or cryoprecipitate is safe and does not appear to increase thromboembolic events and mortality in thoracic aortic surgery patients.

Redo proximal thoracic aortic surgery: challenges and controversies.

Reoperations on the proximal thoracic aorta represent a challenge. The mortality rate is at least three times higher than it is for the initial surgery and the complications after such procedures occur with disappointingly high frequency, leading to substantial morbidity and delayed recovery. This article aims to present the early and the late outcomes of these kinds of operations, to identify the causes for failure of the primary surgery, to underline the critical points during the perioperative management of those patients and finally to emphasize on the rapid evolution and advent of techniques over the last few years.