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Rationale: Usual interstitial pneumonia (UIP) is the defining morphology of idiopathic pulmonary fibrosis (IPF). Guidelines for IPF diagnosis conditionally recommend surgical lung biopsy for histopathology diagnosis of UIP when radiology and clinical context are not definitive. A "molecular diagnosis of UIP" in transbronchial lung biopsy, the Envisia Genomic Classifier, accurately predicted histopathologic UIP.Objectives: We evaluated the combined accuracy of the Envisia Genomic Classifier and local radiology in the detection of UIP pattern.Methods: Ninety-six patients who had diagnostic lung pathology as well as a transbronchial lung biopsy for molecular testing with Envisia Genomic Classifier were included in this analysis. The classifier results were scored against reference pathology. UIP identified on high-resolution computed tomography (HRCT) as documented by features in local radiologists' reports was compared with histopathology.Measurements and Main Results: In 96 patients, the Envisia Classifier achieved a specificity of 92.1% (confidence interval [CI],78.6-98.3%) and a sensitivity of 60.3% (CI, 46.6-73.0%) for histology-proven UIP pattern. Local radiologists identified UIP in 18 of 53 patients with UIP histopathology, with a sensitivity of 34.0% (CI, 21.5-48.3%) and a specificity of 96.9% (CI, 83.8-100%). In conjunction with HRCT patterns of UIP, the Envisia Classifier results identified 24 additional patients with UIP (sensitivity 79.2%; specificity 90.6%).Conclusions: In 96 patients with suspected interstitial lung disease, the Envisia Genomic Classifier identified UIP regardless of HRCT pattern. These results suggest that recognition of a UIP pattern by the Envisia Genomic Classifier combined with HRCT and clinical factors in a multidisciplinary discussion may assist clinicians in making an interstitial lung disease (especially IPF) diagnosis without the need for a surgical lung biopsy.

Vascular access for large endovascular devices has evolved as patients have become more complicated and device indications have expanded. As the benefits of catheter-based treatments for aortic aneurysm repair and aortic valve replacement become mainstream, there is a need to address difficult vascular access by developing not only smaller-diameter devices but also creative options for vascular access. We describe direct descending thoracic aortic access during endovascular aneurysm repair, transcatheter aortic valve replacement, and redo mesenteric revascularization in three patients who did not have traditional access options.

Objective Complications with opioid-based postoperative pain management have led to guideline recommendations for a multimodal analgesia strategy incorporating nonopioid agents. We evaluated the opioid-sparing effect of intravenous acetaminophen in patients undergoing transapical transcatheter aortic valve replacement. Methods A multimodal pain management strategy that incorporated intravenous acetaminophen was retrospectively evaluated in 43 patients undergoing transapical transcatheter aortic valve replacement between November 2012 and March 2014. Before intravenous acetaminophen formulary availability, 23 patients received standard postoperative pain management interventions including intravenous narcotics and oral narcotics/acetaminophen. After intravenous acetaminophen availability, 20 patients received intravenous acetaminophen (4 g/d, ≥4 doses) and supplemental intravenous and nonacetaminophen oral narcotics. Daily narcotic dose (standardized to morphine equivalents), drug cost, and hospital length of stay were compared between groups. Results Baseline characteristics were similar between intravenous acetaminophen (n = 20) and nonintravenous acetaminophen (n = 23) patients including the Society of Thoracic Surgery mortality risk (10.5% vs 9.0%, P = 0.3). The median number of intravenous acetaminophen doses was 6.5 (interquartile range = 4.0–18.5), with a median cost per patient of US $221 (interquartile range = $136–$629). Patients who received intravenous acetaminophen used significantly fewer morphine equivalents on postoperative day 0 compared with patients not receiving intravenous acetaminophen (22.5 vs 45.0 morphine equivalents, P = 0.03) and had a shorter median length of stay (5.0 vs 7.0 days, P = 0.007). After adjusting for the Society of Thoracic Surgery risk, intravenous acetaminophen continued to be associated with a reduction in median postoperative length of stay [−1.9 days (95% confidence interval = −0.9 to −8.2 days), P = 0.049]. Conclusions In patients undergoing transapical transcatheter aortic valve replacement, a multimodal pain management strategy incorporating intravenous acetaminophen was associated with reductions in narcotic use on the day of surgery and overall length of stay.

Thoracic endovascular aortic repair (TEVAR) of acute ascending aortic pathology is feasible; however, the unique features of this aortic segment in addition to access challenges restricts its use to a select, high-risk subset of patients. With the advent of TAVR, large device delivery using transapical access has become a well-defined technique. We report a patient with critical aortic stenosis and an acute ascending aortic penetrating ulcer with tamponade managed successfully utilizing transapical TAVR and TEVAR. To our knowledge, this is the first reported case of a hybrid single-stage TAVR and ascending aortic TEVAR using transapical access. © 2015 Wiley Periodicals, Inc.

Background Valve-in-valve transcatheter aortic valve replacement is less effective in small surgical bioprostheses. We evaluated the feasibility of bioprosthetic valve fracture with a high-pressure balloon to facilitate valve-in-valve transcatheter aortic valve replacement. Methods In vitro bench testing on aortic tissue valves was performed on 19-mm and 21-mm Mitroflow (Sorin, Milan, Italy), Magna and Magna Ease (Edwards Lifesciences, Irvine, CA), Trifecta and Biocor Epic (St. Jude Medical, Minneapolis, MN), and Hancock II and Mosaic (Medtronic, Minneapolis, MN). High-pressure balloons Tru Dilation, Atlas Gold, and Dorado (C.R. Bard, Murray Hill, NJ) were used to determine which valves could be fractured and at what pressure fracture occurred. Results Mitroflow, Magna, Magna Ease, Mosaic, and Biocor Epic surgical valves were successfully fractured using high-pressures balloon 1 mm larger than the labeled valve size whereas Trifecta and Hancock II surgical valves could not be fractured. Only the internal valve frame was fractured, and the sewing cuff was never disrupted. Manufacturer's rated burst pressures for balloons were exceeded, with fracture pressures ranging from 8 to 24 atmospheres depending on the surgical valve. Testing further demonstrated that fracture facilitated the expansion of previously constrained, underexpanded transcatheter valves (both balloon and self-expanding) to the manufacturer's recommended size. Conclusions Bench testing demonstrates that the frame of most, but not all, bioprosthetic surgical aortic valves can be fractured using high-pressure balloons. The safety of bioprosthetic valve fracture to optimize valve-in-valve transcatheter aortic valve replacement in small surgical valves requires further clinical investigation.

Valve-in-valve transcatheter aortic valve replacement (VIV TAVR) can result in high residual gradients that are associated with increased mortality. Bioprosthetic valve fracture (BVF) has been shown to improve residual gradients following VIV TAVR; however, factors influencing the results of BVF have not been studied.BVF was performed in 75 patients at 21 centers. Hierarchical multiple linear regression was performed to identify variables that were associated with lower final transvalvular gradient.Surgical valves with a median true internal diameter of 18.5 mm (interquartile range, 17.0-20.5 mm) were treated with VIV TAVR in conjunction with BVF using balloon-expandable (n = 43) or self-expanding (n = 32) transcatheter heart valves with a median size of 23 mm (interquartile range, 23-23 mm). There were no aortic root disruptions, coronary occlusions, or new pacemakers; in-hospital or 30-day mortality was 2.6% (2 out of 75). Final mean transvalvular gradient was 9.2 ± 6.3 mm Hg, but was significantly lower when BVF was performed after VIV TAVR compared with BVF first (8.1 ± 4.8 mm Hg vs 16.9 ± 10.1 mm Hg; P .001). After adjusting for timing of BVF (ie, before or after VIV TAVR), transcatheter heart valve size/type, surgical valve mode of failure, true internal diameter, and baseline gradient and BVF balloon size, performing BVF after VIV TAVR (P .001) and using a larger BVF balloon (P = .038) were the only independent predictors of lower final mean gradient.BVF can be performed safely and results in reduced residual transvalvular gradients. Performing BVF after VIV TAVR and using larger balloon appears to achieve the best hemodynamic results.

Primary cardiac tumors are extremely rare. Although complete surgical resection of malignant primary cardiac tumors results in an improved survival compared with no intervention, the overall prognosis is generally poor, with treatable recurrent primary cardiac sarcomas being extremely rare. We report a patient with a recurrent primary cardiac sarcoma obstructing the left atrium managed with radical cardiac resection, including right pneumonectomy, with 21-month postprocedural survival.

8529 Background: Large cell neuroendocrine carcinoma (LCNEC) is characterized by aggressive behavior and poor outcomes compared with other non-small cell lung cancers (ONSCLC). Methods: The National Cancer Database (NCDB) was used to identify patients diagnosed with early stage NSCLC (pathologic stage I, II, IIIA) from 2004-2012 who underwent surgical resection. Patients were divided into two groups: LCNEC and ONSCLC. One-way ANOVA was used to compare continuous variables, and chi-squared testing was used to compare categorical variables. Multivariate logistic regression analyses were used to obtain hazard ratios. Results: We identified 1672 patients with resected LCNEC and 134139 with resected ONSCLC. A higher proportion of patients with ONSCLC had a Charlson-Deyo co-morbidity score of 0 compared to LCNEC patients (50.6% vs. 43.8%; p < 0.001). No other significant differences in clinical and demographic characteristics were identified. Overall survival was lower for LCNEC patients across all stages when compared to patients with resected ONSCLC (46 months versus 74 months; 5-year survival 45% versus 57%; p

8563 Background: Effective treatment of stage I SCLC requires both surgical resection and chemotherapy. We analyzed the National Cancer Database (NCDB) for the treatment patterns and disparities in the management of stage I SCLC. Methods: We identified patients with clinical stage I SCLC from the NCDB. Median and 5-year survival were calculated using Kaplan Meier analysis. Multivariable logistic regression model was used to determine the factors that can predict surgical resection. Results: We identified 4,849 patients with clinical stage I SCLC diagnosed between 2004 and 2012. We divided them into 4 treatment groups; surgical resection with chemotherapy (n = 774, 15.9%), surgical resection without chemotherapy (n = 423, 8.7%), non-surgical treatment (n = 2,978, 61.4%) and no treatment (n = 674, 13.9%). 5-year survival for each group was 47%, 36%, 22% and 11% respectively, ( p-value < 0.001). Among patients who underwent surgical resection, lobectomy (67.1%) was the most common procedure followed by sub-lobar resection (28.8%) and pneumonectomy (2.8%) with 5-year survival of 48%, 34% and 33% respectively, ( p-value < 0.001). Multivariate analysis identified that elderly (age ≥ 70) patients, African-Americans, patients with low income and Medicaid are less likely to undergo surgery, ( p-value < 0.001). Patients receiving treatment at academic cancer centers, right sided tumors and Charlson score ≥ 1 are more likely to receive surgery, ( p-value < 0.001). Conclusions: Despite better outcomes only 25% of patients undergo surgery for stage I SCLC. Over the years there has been only a modest increase in the proportion of patients undergoing resection. We have identified significant disparities in the treatment of patients with stage I SCLC. Our data clearly show the need to educate physicians on appropriate delivery of care for patients with stage I SCLC.

Thoracic endovascular aortic repair (TEVAR) of acute ascending aortic pathology is feasible; however, the unique features of this aortic segment in addition to access challenges restricts its use to a select, high-risk subset of patients. With the advent of TAVR, large device delivery using transapical access has become a well-defined technique. We report a patient with critical aortic stenosis and an acute ascending aortic penetrating ulcer with tamponade managed successfully utilizing transapical TAVR and TEVAR. To our knowledge, this is the first reported case of a hybrid single-stage TAVR and ascending aortic TEVAR using transapical access.

Radial artery pseudoaneurysms occur infrequently and are most commonly associated with medical interventions such as arterial lines or cardiac catheterization procedures. Animal bites, particularly cat bites, as a cause for radial artery pseudoaneurysms are extremely rare with only 1 previously reported case in the literature. A unique case of digital micro emboli from a radial artery pseudoaneurysm caused by a cat bite to the wrist is presented.

Vascular complications remain an important consideration when selecting access for delivery of large endovascular devices. With the advent of transcatheter aortic valve replacement, transapical access has become an acceptable technique when transfemoral or direct transaortic access is contraindicated. We report the use of the transapical approach during thoracic aortic endovascular repair in 2 patients, one of which included concomitant delivery of a transcatheter aortic valve replacement device. To our knowledge, this is the first reported case of a hybrid single-stage transcatheter aortic valve replacement and thoracic aortic endovascular repair using transapical access.

Our objective was to determine the impact of abdominal ultrasound (US) on 1) the use of diagnostic peritoneal lavage (DPL) and abdominal computed tomography (ACT) for diagnosing blunt abdominal trauma (BAT) and on 2) surgical resident training. The study design was a retrospective chart review. Patients sustaining BAT who had ACT or DPL done during the 1-year period before the introduction of US (pre-US) were compared with those from a 1-year period beginning 6 months after US (post-US). Data collected included diagnostic modality, demographic data, mortality, associated injuries, length of stay, mechanism of injury, and number of exploratory laparotomies. Of 128 patients in the pre-US group, 35 patients (27%; P < 0.001) underwent DPL, 0 patients (0%; P < 0.001) received US, and 92 patients (72%) received ACT, with positive results for 31 patients (34%). Exploratory laparotomy was performed on 35 patients (27%) in the pre-US group. Of 140 patients in the post-US group, 8 patients (6%; P < 0.001) underwent DPL, 120 patients (85%; P < 0.001) received US, and 108 patients (77%) received ACT, with positive results for 44 patients (42%). Exploratory laparotomy was performed on 22 patients (15%; P < 0.001) in the post-US group. Resident experience with DPL before and after the introduction of US and availability of US for graduated residents was documented. Chi-square and Fisher's exact test were used for statistical analysis. Resident experience changed from 22 to 3 DPLs per year in the pre- and post-US groups, respectively. Ten per cent of graduating residents had US available for use after leaving this institution. US replaced DPL and resulted in slightly more positive ACT scans in assessing BAT at our institution. Paradoxically, only 10 per cent of graduating residents had US available after leaving this institution. Until the use of US for diagnosing BAT has widespread use in the community, we must question our adequacy of resident preparation for diagnosing BAT.

A 30-year-old female with Ehlers–Danlos syndrome and prior right iliac dissection treated with covered stent placement in 2005 presented with acute severe left leg pain. It began with arising from bed and was exacerbated by left hip flexion. Initial evaluation with arterial Duplex imaging revealed evidence of dissection extending from the proximal left common iliac artery to the proximal left superficial femoral artery. Computed tomographic (CT) angiography was performed and confirmed dissection with aneurysmal dilatation of the left common iliac artery to 2.0 × 1.7 cm (Panel A). The patient required intravenous narcotics and was admitted for pain control. A repeat CT angiogram four days later revealed further dilation of the left common iliac artery to 2.4 × 2.0 cm and new aneurysmal dilatation of the proximal left superficial femoral artery (Panel B). Owing to the growth of the aneurysm a third CT angiogram was obtained two days later. This revealed rapid expansion of the common iliac artery aneurysm to 3.3 × 2.7 cm as well as expansion of the proximal superficial femoral artery aneurysm (Panel C).

Pork ribs with intact muscle tissue were used in an experimental attempt to identify bullet wipe on bone at distances from 1 to 6 feet with 0.45 caliber, full metal jacket ammunition. This resulted in the unexpected finding of primer-derived gunshot residue (GSR) deep within the wound tract. Of significance is the fact that the GSR was deposited on the bone, under the periosteum, after the bullet passed through a Ziploc((R)) bag and c. 1 inch of muscle tissue. It is also important to note that the GSR persisted on the bone after the periosteum was forcibly removed. The presence of primer-derived GSR on bone provides the potential to differentiate gunshot trauma from blunt trauma when the bone presents an atypical gunshot wound. In this study, the presence of gunshot primer residue at a distance of 6 feet demonstrates the potential for establishing maximum gun-to-target distance for remote shootings. Language: en