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Whether to repair nonsevere tricuspid regurgitation (TR) during surgery for ischemic mitral valve regurgitation (IMR) remains uncertain.The goal of this study was to investigate the incidence, predictors, and clinical significance of TR progression and presence of ≥moderate TR after IMR surgery.Patients (n = 492) with untreated nonsevere TR within 2 prospectively randomized IMR trials were included. Key outcomes were TR progression (either progression by ≥2 grades, surgery for TR, or severe TR at 2 years) and presence of ≥moderate TR at 2 years.Patients' mean age was 66 ± 10 years (67% male), and TR distribution was 60% ≤trace, 31% mild, and 9% moderate. Among 2-year survivors, TR progression occurred in 20 (6%) of 325 patients. Baseline tricuspid annular diameter (TAD) was not predictive of TR progression. At 2 years, 37 (11%) of 323 patients had ≥moderate TR. Baseline TR grade, indexed TAD, and surgical ablation for atrial fibrillation were independent predictors of ≥moderate TR. However, TAD alone had poor discrimination (area under the curve, ≤0.65). Presence of ≥moderate TR at 2 years was higher in patients with MR recurrence (20% vs. 9%; p = 0.02) and a permanent pacemaker/defibrillator (19% vs. 9%; p = 0.01). Clinical event rates (composite of ≥1 New York Heart Association functional class increase, heart failure hospitalization, mitral valve surgery, and stroke) were higher in patients with TR progression (55% vs. 23%; p = 0.003) and ≥moderate TR at 2 years (38% vs. 22%; p = 0.04).After IMR surgery, progression of unrepaired nonsevere TR is uncommon. Baseline TAD is not predictive of TR progression and is poorly discriminative of ≥moderate TR at 2 years. TR progression and presence of ≥moderate TR are associated with clinical events. (Comparing the Effectiveness of a Mitral Valve Repair Procedure in Combination With Coronary Artery Bypass Grafting [CABG] Versus CABG Alone in People With Moderate Ischemic Mitral Regurgitation, NCT00806988; Comparing the Effectiveness of Repairing Versus Replacing the Heart's Mitral Valve in People With Severe Chronic Ischemic Mitral Regurgitation, NCT00807040).

Objectives The aim of this study was to report the 2-year results of the SURTAVI (Surgical Replacement and Transcatheter Aortic Valve Implantation) trial and confirm the interim Bayesian analysis. Background Transcatheter aortic valve replacement (TAVR) with a self-expanding valve was noninferior to surgery in patients with severe aortic stenosis and intermediate operative risk using Bayesian statistical methods. Novel Bayesian designs have been used to shorten the time to primary endpoint analysis in randomized clinical trials, although the predictive value of Bayesian analysis compared with frequentist approaches remains debated. Methods The SURTAVI trial randomized 1,660 patients. An interim analysis was performed 1 year after the 1,400th patient was treated to estimate the primary 2-year endpoint of all-cause mortality or disabling strokes for all patients. Results The Kaplan-Meier rate for the complete 2-year primary endpoint was 12.7% in the TAVR group and 12.6% in the surgery group (0.0% difference; 95% confidence interval: −3.4% to 3.5%), compared with 12.6% with TAVR and 14.0% with surgery (−1.4% difference; Bayesian credible interval: −5.2% to 2.3%) in the interim Bayesian analysis. A comparison of individual clinical, hemodynamic, and quality-of-life endpoints using Bayesian and frequentist methods found no significant differences. Conclusions The complete analysis of all patients with aortic stenosis at intermediate risk for surgery in the SURTAVI trial confirmed the noninferiority, with respect to the frequency of all-cause mortality or disabling stroke, of TAVR to surgery, as determined in the interim Bayesian analysis. Follow-up will extend out to 10 years.

To determine the frequency and risk factors for non-home discharge (NHD) and its association with clinical outcomes and quality of life (QOL) at 1 year following cardiac surgery in patients with ischemic mitral regurgitation (IMR).Discharge disposition was evaluated in 552 patients enrolled in trials of severe or moderate IMR. Patient and in-hospital factors associated with NHD were identified using logistic regression. Subsequently, association of NHD with 1-year mortality, serious adverse events (SAEs), and QOL was assessed.NHD was observed in 30% (154/522) with 25% (n = 71/289) in moderate and 36% (n = 83/233) in patients with severe IMR (unadjusted P = .006), a difference not significant after including age (5-year change: adjusted odds ratio [adjOR], 1.52; 95% confidence interval [CI], 1.35-1.72; P .001), diabetes (adjOR, 1.94; 95% CI, 1.27-2.94; P = .002), and previous heart failure (adjOR, 1.64; 95% CI, 1.06-2.52; P = .03). Odds of NHD were increased for patients with postoperative SAEs (adjOR, 1.85; 95% CI, 1.19-2.86; P = .01) but not based on type of cardiac surgery. Greater rates of death and SAEs were observed in NHD patients at 1 year: adjusted hazard ratio, 4.29 (95% CI, 2.14-8.59; P .001) and adjusted rate ratio, 1.45 (95% CI, 1.03-2.02; P = .03), respectively. QOL did not differ significantly between groups.NHD is common following surgery for IMR, influenced by older age, diabetes, previous heart failure, and postoperative SAEs. These patients may be at greater risk of death and subsequent SAEs after discharge. Discussion of NHD with patients may have important implications for decision-making and guiding expectations following cardiac surgery.

Socioeconomics only account for 18% of all healthcare disparities. Healthcare disparities in the intensive care unit (ICU) have been well documented and persist in spite of previous government and medical interventions.

Presently, the prevalence of congestive heart failure in the United States is 6.5 million people. We report two cases of severe congestive heart failure patients with a very poor prognosis

Background: It has been estimated that over 400,000 patients die each year from medical errors in the United States.

In our series of unsung or forgotten medical heroes, we first published a manuscript on Alvin Blunt, Jr, M.D. who was the first African American MASH physician in the Korean War. Dr. Kenneth L. Wilson’s manuscript changed United States military history. Our second manuscript in our series, Medical Miracle in Indianola, Mississippi: The Untold Story of Dr. Clinton Battle and the Indianola Conjoined Siamese Twins, introduces the world to a 29-year-old physician who vaginally delivered the first set of conjoined twins to be successfully separated and both survived the operation. This great feat was done at Rev. John and Missouri Matthews’ home without anesthetics or ultrasound. Dr. Battle died dejected because he never received any credit for this magnificent accomplishment in medical history. In this manuscript, we present the compelling story of Dr. Colonel Vance Marchbanks, who monitored astronaut John Glen during his historic space flight. Dr. Marchbanks was a pioneer Flight Surgeon who developed an oxygen delivery system that enabled flight crews to fly at higher altitudes.

Objective The Cardiothoracic Surgical Trials Network reported that left ventricular reverse remodeling at 2 years did not differ between patients with moderate ischemic mitral regurgitation randomized to coronary artery bypass grafting plus mitral valve repair (n = 150) or coronary artery bypass grafting alone (n = 151). To address health resource use implications, we compared costs and quality-adjusted survival. Methods We used individual patient data from the Cardiothoracic Surgical Trials Network trial on survival, hospitalizations, quality of life, and US hospitalization costs to estimate cumulative costs and quality-adjusted life years. A microsimulation model was developed to extrapolate to 10 years. Bootstrap and deterministic sensitivity analyses were performed to address uncertainty. Results In-hospital costs were $59,745 for coronary artery bypass grafting plus mitral valve repair versus $51,326 for coronary artery bypass grafting alone (difference $8419; 95% uncertainty interval, 2259-18,757). Two-year costs were $81,263 versus $67,341 (difference 13,922 [2370 to 28,888]), and quality-adjusted life years were 1.35 versus 1.30 (difference 0.05; −0.04 to 0.14), resulting in an incremental cost-effectiveness ratio of $308,343/quality-adjusted life year for coronary artery bypass grafting plus mitral valve repair. At 10 years, its costs remained higher ($107,733 vs $88,583, difference 19,150 [−3866 to 56,826]) and quality-adjusted life years showed no difference (−0.92 to 0.87), with 5.08 versus 5.08. The likelihood that coronary artery bypass grafting plus mitral valve repair would be considered cost-effective at 10 years based on a cost-effectiveness threshold of $100K/quality-adjusted life year did not exceed 37%. Only when this procedure reduces the death rate by a relative 5% will the incremental cost-effectiveness ratio fall below $100K/quality-adjusted life year. Conclusions: The addition of mitral valve repair to coronary artery bypass grafting for patients with moderate ischemic mitral regurgitation is unlikely to be cost-effective. Only if late mortality benefits can be demonstrated will it meet commonly used cost-effectiveness criteria.

Severe coronary artery calcification is a challenge for percutaneous coronary intervention (PCI), particularly in left main coronary artery disease (LM-CAD). Rotational atherectomy (RA) is a useful tool for modification of calcified plaque prior to PCI. We report our experience with RA for severely calcified LM-CAD.From January 2008 to January 2017, all patients who underwent RA-assisted LM-PCI were evaluated. The study population included both protected and unprotected LM-CAD patients. Clinical characteristics and in-hospital outcomes were collected retrospectively. In-hospital outcomes included post-PCI myocardial infarction, stroke, death, emergency coronary artery bypass graft surgery, and urgent repeat PCI. Angiographic success was defined by residual stenosis20% and presence of TIMI 3 flow.Fifty-five consecutive patients who underwent RA-assisted PCI of LM-CAD were identified (mean age, 73.0 ± 10 years; 64% male). Mean left ventricular ejection fraction was 37.5 ± 15.7%. Fifty-one patients (93%) had multivessel disease and 39 patients (71%) underwent RA-assisted LM-PCI with use of a mechanical support device. The median largest burr size used was 1.5 mm. The mean number of LM stents implanted was 0.95 ± 0.3. The mean LM stent diameter and length were 3.7 ± 0.3 mm and 15.8 ± 7.5 mm, respectively. Intravascular ultrasound was used to assess vessel size and stent apposition in 20 patients (36.0%). Angiographic success was obtained in all patients (100%).Despite technical challenges, RA of the LM coronary artery can be performed safely and is associated with a high rate of angiographic success.

In our series of unsung or forgotten medical heroes, we first published a manuscript on Alvin Blunt, Jr, M.D. who was the first African American MASH physician in the Korean War. Dr. Kenneth L. Wilson’s manuscript changed United States military history. Our second manuscript in our series, Medical Miracle in Indianola, Mississippi: The Untold Story of Dr. Clinton Battle and the Indianola Conjoined Siamese Twins, introduces the world to a 29-year-old physician who vaginally delivered the first set of conjoined twins to be successfully separated and both survived the operation. This great feat was done at Rev. John and Missouri Matthews’ home without anesthetics or ultrasound. Dr. Battle died dejected because he never received any credit for this magnificent accomplishment in medical history. In this manuscript, we present the compelling story of Dr. Colonel Vance Marchbanks, who monitored astronaut John Glen during his historic space flight. Dr. Marchbanks was a pioneer Flight Surgeon who developed an oxygen delivery system that enabled flight crews to fly at higher altitudes.

Conjoined twins are very rare. The overall survival rate has been estimated to be approximately 25% to 50%. We report a case of conjoined twins delivered in Indianola, Mississippi in 1955 who made medical history. The Matthews’ conjoined twins were the first in history to be separated and both survive.

The simultaneous commencement of operative interventions by two or more surgical teams in the multiply injured patient is gaining more acceptance. We describe a rare case of concomitant penetrating injuries to the brain, chest and abdomen that required an orchestrated immediate approach and resulted in a good outcome. Both injuries were life threatening. A coordinated effort between Trauma Surgery and Neurosurgery working simultaneously produced an excellent outcome for this patient.

Background: Socioeconomics only account for 18% of all healthcare disparities. Healthcare disparities in the intensive care unit (ICU) have been well documented and persist in spite of previous government and medical interventions. Vitamin D deficiency is the most common nutritional deficiency in the United States and the world. This deficiency has been largely overlooked in the debate on healthcare disparities.

Conjoined twins are very rare. The overall survival rate has been estimated to be approximately 25% to 50%. We report a case of conjoined twins delivered in Indianola, Mississippi in 1955 who made medical history. The Matthews’ conjoined twins were the first in history to be separated and both survive. They were delivered in rural Mississippi at home by vaginal delivery by Dr. Clinton Battle, a 29-year-old Meharry School of Medicine graduate. The Matthews twins are now 61 years old (retired school teachers) and their 92-year-old mother, Missouri Matthews, are alive and well living in Mississippi.

Background— The risk for stroke after transcatheter aortic valve replacement (TAVR) is an important concern. Identification of predictors for stroke is likely to be a critical factor aiding patient selection and management as TAVR use becomes widespread. Methods and Results— Patients enrolled in the CoreValve US Extreme Risk and High Risk Pivotal Trials or Continued Access Study treated with the self-expanding CoreValve bioprosthesis were included in this analysis. The 1-year stroke rate after TAVR was 8.4%. Analysis of the stroke hazard rate identified an early phase (0–10 days; 4.1% of strokes) and a late phase (11–365 days; 4.3% of strokes). Baseline predictors of early stroke included National Institutes of Health stroke scale score >0, prior stroke, prior transient ischemic attack, peripheral vascular disease, absence of prior coronary artery bypass surgery, angina, low body mass index (2 ), and falls within the past 6 months. Significant procedural predictors were total time in the catheterization laboratory or operating room, delivery catheter in the body time, rapid pacing used during valvuloplasty, and repositioning of the prosthesis. Predictors of stroke between 11 and 365 days were small body surface area, severe aortic calcification, and falls within the past 6 months. There were no significant imaging predictors of early or late stroke. Conclusions— Predictors of early stroke after TAVR included clinical and procedural factors; predictors of later stroke were limited to patient but not anatomic characteristics. These findings indicate that further refinement of imaging to identify anatomic factors predisposing to embolization may help improve stroke prediction in patients undergoing TAVR. Clinical Trial Registrations— URL: http://www.clinicaltrials.gov . Unique identifiers: NCT01240902, NCT01531374.

The simultaneous commencement of operative interventions by two or more surgical teams in the multiply injured patient is gaining more acceptance.

Introduction. Klebsiella pneumoniae is a well-known cause of liver abscess. Higher rates of liver abscess associated with Klebsiella pneumoniae are seen in Taiwan. Metastatic endophthalmitis is a common complication associated with a poor prognosis despite aggressive therapy. Case Report. We report a case of a 67-year-old Korean female with Klebsiella pneumoniae liver abscess. The patient developed metastatic endophthalmitis and ultimately succumbed to her disease despite aggressive medical and surgical treatment. Conclusion. Dissemination of Klebsiella pneumoniae is associated with significant morbidity and mortality. Liver abscesses preferably should be treated with percutaneous drainage, but surgical treatment is needed in some cases. Metastatic spread to the eye is a common complication that must be treated aggressively with intravenous antibiotics and surgical intervention if necessary.

To assess trainee physicians' ability to puncture at the femoral head and complication rates when obtaining access to the common femoral artery using fluoroscopy.The common femoral artery is the most common artery accessed during cardiac catheterization. Fluoroscopy can be used to visualize the femoral head and estimate the common femoral artery location. Puncture superior or inferior to the femoral head is associated with increased rates of retroperitoneal bleeding or thrombosis, respectively. Adequate training in groin puncture technique is essential in minimizing complications and upholding patient safety.Two consecutive samples of patients were retrospectively analyzed - one from Keck Medical Center (Keck) (n = 45), and one from Los Angeles County-University of Southern California (LAC-USC) (n = 100). An attending interventional cardiologist performed all groin punctures at Keck, and a trainee performed groin puncture at LAC-USC after detailed faculty instruction. A single reviewer retrospectively analyzed all angiograms. Puncture was recorded as occurring above, below, or at the femoral head.Percentage of punctures at the femoral head between LAC-USC vs Keck was not significantly different (93.0% vs 95.6%; P=.26). There was no significant difference in percentage of punctures below and above the femoral head between both groups, and no difference in complications.Femoral artery puncture at the femoral head is associated with improved outcomes. Our data show no significant difference between attending physicians' and trainees' ability to puncture at the level of the femoral head. Groin puncture using fluoroscopy can be taught to a high proficiency level with appropriate instruction.

Nonlethal myocardial ischemia produces profound and long-lasting effects on regional ventricular function and metabolism (myocardial stunning) and protects against myocardial infarction from subsequent prolonged ischemia (ischemic preconditioning). Two-dimensional echocardiography (2DE) is an essential tool for quantitative analysis of regional and global left ventricular (LV) function during myocardial ischemia and reperfusion and the study of these phenomena. However, the inability to perform 2DE in the open-chest rat heart has seriously limited the use of this model. To investigate the effect of transient coronary occlusion on segmental wall motion and LV geometry, we employed a 20 MHz intravascular ultrasound catheter placed on the epicardial surface of the rat heart ( n =15) to yield 2DE images suitable for quantitative analysis. Three 2-minute left coronary occlusions were made, separated by 5 minutes of reperfusion, with imaging during occlusion and at 5 and 60 minutes of reperfusion. Ischemic and nonischemic wall thicknesses, LV cross-sectional area, estimated LV volume, and the fractional changes of these parameters were measured. In eight animals these values were also compared with necropsy measurements of wall thickness, LV cross-sectional area, and volume. LV and right ventricular structures were well visualized in short-axis cross-sectional images in all animals, and images suitable for quantitative analysis were obtained in 92% of the periods. Coronary occlusion caused immediate, marked LV cavitary expansion, which rapidly returned to normal by 5 minutes of reperfusion. Active systolic thickening of the anterior wall at baseline (47%±3%) became passive thinning during occlusion (−6%±2%) and recovered partially, to 30%±3% at 5 minutes of reperfusion and 42%±4% at 60 minutes ( p p not significant at 60 minutes). Recovery of thickening after 5 minutes of reperfusion was not different after the first versus third occlusion (23%±4% vs 30%±3%; p =0.19). Measurements made by 2DE correlated well with those made by necropsy, although wall thickness was slightly thicker by 2DE. We conclude that epicardial echocardiography with an intravascular ultrasound catheter provides quantifiable 2DE images in this model and yields accurate information on segmental wall thickening and ventricular geometry not available by other techniques. Left coronary occlusion in the rat is associated with marked global and segmental LV expansion, which rapidly reverses with reperfusion. Postischemic regional wall motion abnormalities are present after coronary occlusion as brief as 2 minutes and can be measured accurately. The effect of multiple brief occlusions is not cumulative. This technique expands the utility of the rat model for studies of global and regional LV function, wall thickening and geometry, and the study of acute myocardial infarction, stunning, and preconditioning.

Blunt injuries to the innominate artery in the civilian setting are relatively rare. The majority of patients who sustain this injury will die at the scene. Those that survive transport to the hospital present difficult challenges for trauma surgeons with mortality rates that range from 10 to 25 per cent. The proximal innominate artery is more commonly injured by blunt trauma mechanisms. On the other hand, penetrating trauma more commonly involves the distal innominate artery. A 23-year-old male presented to our trauma service after a motor vehicle collision. He was an unrestrained passenger partially ejected from the vehicle. The patient was hemodynamically stable on arrival to the emergency department. He was noted to have tenderness of the neck and chest wall. On initial evaluation the patient had no signs of neurologic injury. The chest radiograph revealed a left-sided pneumothorax and a widened mediastinum. A CT scan of the chest (Fig. 1) demonstrated a mediastinal hematoma, acute extravasation of contrast adjacent to the superior vena cava, proximal filling defect of the brachiocephalic vessels, and three left rib fractures. This prompted a formal thoracic aortogram (Fig. 2) that showed an injury consistent with a pseudoaneurysm anterior to the origin of the in-nominate artery with a short segment occlusion likely due to an intimal flap distal to the pseudoaneurysm. Fig. 1 CT scan of chest showing abrupt narrowing of the innominate artery. Fig. 2 Formal aortogram showing short segment occlusion/intimal flap cistal to pseudoanuerysm. Our patient was taken to the operative room where a median sternotomy was performed and was found to have a midinnominate artery transection. He underwent an aorto-innominate artery bypass with Dacron graft and the injured proximal innominate was oversewn. The patient tolerated the procedure well and made a good recovery and was discharged from hospital after 2 weeks on aspirin. At a subsequent follow-up visit, he was well and had returned to moderate activities. Less than 5 per cent of patients who sustain blunt trauma to the ascending aorta survive transportation to the hospital. These injuries present difficult challenges to trauma surgeons with in-hospital mortality rates that range from 10 to 25 per cent.1 The proximal innominate artery is more commonly injured by blunt trauma; however, the distal innominate artery is usually injured by penetrating trauma. Multiple mechanisms of injury have been attributed to causing innominate artery injury. Vertical deceleration, as in a fall from heights (> 15 ft), as well as posterior displacement of the sternum that occurs in horizontal displacement injuries have been described.2, 3 What is common between these mechanisms is shear and stretching forces between the immobile ascending aorta and the fairly mobile proximal innominate artery. An additional mechanism includes sudden compression of the artery between the sternum and the vertebrae, accompanied by hyperextension of the neck place. Diagnosing innominate artery injuries requires a high index suspicion. Often, the clues to this injury are a combination of the mechanism, chest pain, and radiologic findings of widened mediastinum. A sudden deceleration mechanism should also raise suspicion of these types of injuries. In the case of the innominate artery, the most frequent location of injury is at the origin from the aortic arch.4 In blunt chest trauma, the innominate artery is the most common aortic branch injured.4 The pathologic finding is an intimal tear with variable size hematoma and thrombus within the media and adventitia. A small intimal defect can eventually lead to thrombus formation and occlusion. Commonly, the patient's complaint of anterior chest wall pain is nonspecific. Chest radiographs will often reveal a widened mediastinum. In a series reported by Weiman et al., five out of five patients with blunt injury to the innominate artery had a widened mediastinum on chest radiograph. If radiologic evaluation of a patient suggests a major vascular injury, an arteriogram is indicated to delineate the injury. CT angiography or formal arch aortographies are the mainstay of diagnosis in the hemodynamically stable patient. Repair of innominate artery injuries involves basic principles of thoracic vascular injury. Median sternotomy is used and can be combined with a cervical extension for more distal vascular control, if needed. Primary repair of the vessel is the preferred choice if technically feasible. In patients with partial tears, primary repair with 4-0 polypropylene suture is often possible. In the majority of cases, innominate artery injuries are best managed by the bypass exclusion technique. This approach allows management without the use of systemic herparinization, cardiopulmonary bypass, or hypothermic circulatory arrest. Angioplasty and interposition grafting have been reported, both with and without use of cardiopulmonary bypass or intra-arterial shunting. Endovascular stent grafts were initially reported for the treatment of abdominal aortic aneurysms. Studies have shown that these stent grafts are beginning to play a larger role in traumatic aortic injuries. The advantages include minimal physiologic insult and no need for heparinization allows treatment of even the most critically injured or frail patients. Disadvantages include device failure, particularly with finding an adequate length and landing zone for proximal innominate artery injuries. Home-made devices have been used with success, but multi-institutional trials with more flexible grafts are still needed. Traumatic injury to the innominate artery are rare, however, surgeons providing care for the surviving patients should have a high index of suspicion with sudden deceleration mechanisms and chest pain. In unstable patients with presumed undiagnosed thoracic vascular injury, the appropriate incision is a left anterolateral thoracotomy. In the hemodynamically stable patient, median sternotomy with or without cervical extension is the preferred exposure. The bypass exclusion technique allows for repair without the sequelae and risks from systemic heparinization and cardiopulmonary bypass.

A recent article by Dr. Haider et al1, “Association between Hospitals Caring for a Disproportionately High Percentage of Minority Trauma Patients and Increased Mortality: A Nationwide Analysis of 434 Hospitals,” raised the question of whether there was an increased mortality risk among trauma patients treated at hospitals with higher proportions of minority patients (i.e., black and Hispanic patients combined). They categorized 434 hospitals included in the National Trauma Data Bank between 2007 and 2008 on the basis of the percentage of minority patients admitted and treated due to acute traumatic injury. In their analysis they compared the adjusted odds of in-hospital mortality between hospitals with less than 25% of patients who were minorities as the reference group (majority) versus hospitals with 25% to 50% of patients who were minorities (mixed) and hospitals with more than 50% of patients who were minorities.1

Background >Vitamin D deficiency is the most common nutritional deficiency in the United States. It is seldom measured or recognized, and rarely is treated, particularly in critically ill patients. The purpose of this study was to investigate the prevalence and impact of vitamin D deficiency in surgical intensive care unit patients. We hypothesized that severe vitamin D deficiency increases the length of stay, mortality rate, and cost in critically ill patients admitted to surgical intensive care units. Methods We performed a prospective observational study of vitamin D status on 258 consecutive patients admitted to the Surgical Intensive Care Unit at Grady Memorial Hospital between August 2009 and January 2010. Vitamin D levels (25 [OH]2 vitamin-D3) were measured by high-pressure liquid chromatography and tandem mass spectrometry. Vitamin D deficiency was defined as follows: severe deficiency was categorized as less than 13 ng/mL; moderate deficiency was categorized as 14 to 26 ng/mL; mild deficiency was categorized as 27 to 39 ng/mL; and normal levels were categorized as greater than 40 ng/mL. Results Of the 258 patients evaluated, 70.2% (181) were men, and 29.8% (77) were women; 57.6% (148) were African American and 32.4% (109) were Caucasian. A total of 138 (53.5%) patients had severe vitamin D deficiency, 96 (37.2%) had moderate deficiency, 18 (7.0%) had mild deficiency, and 3 (1.2%) of the patients had normal vitamin D levels. The mean length of stay in the Surgical Intensive Care Unit for the severe vitamin D–deficient group was 13.33 ± 19.5 days versus 7.29 ± 15.3 days and 5.17 ± 6.5 days for the moderate and mild vitamin D-deficient groups, respectively, which was clinically significant ( P = .002). The mean treatment cost during the patient stay in the surgical intensive care unit was $51,413.33 ± $75,123.00 for the severe vitamin D–deficient group, $28,123.65 ± $59,752.00 for the moderate group, and $20,414.11 ± $25,714.30 for the mild vitamin D–deficient group, which also was clinically significant ( P = .027). More importantly, the mortality rate for the severe vitamin D–deficient group was 17 (12.3%) versus 11 (11.5%) in the moderate group ( P = .125). Because no deaths occurred in the mildly or normal vitamin D–deficient groups, we compared the mortality rate between severe/moderate and mild/normal vitamin D groups ( P = .047). Conclusions In univariate analysis, severe and moderate vitamin D deficiency was related inversely to the length of stay in the surgical intensive care unit (r = .194; P = .001), related inversely to surgical intensive care unit treatment cost (r = .194; P = .001) and mortality (r = .125; P = .023), compared with the mild vitamin D–deficient group, after adjusting for age, sex, race, and comorbidities (myocardial infarctions, acute renal failure, and pneumonia); the length of stay, surgical intensive care unit cost, and mortality remained significantly associated with vitamin D deficiency.

The objectives of this study were: 1) to delineate the temporal course of histopathologic healing as the left atrial appendage (LAA) is obliterated by a mechanical device; and 2) to compare this process with other intravascular and intracardiac implanted technologies.Intracardiac device healing is incompletely understood. We thus studied the histopathology of device-based LAA obliteration.Nine dog hearts were examined over time after LAA device placement and results were compared with human hearts with prior LAA obliteration using the same device.At 3 days in dogs, atrial surfaces were covered by fibrin, which sealed gaps between the LA wall and the device and filled the LA appendage cavity. At 45 days, endothelial cells covered the endocardial surface with underlying smooth muscle cells that sealed the device-LA interface. Regions with prior thrombus were replaced by endocardium surrounding the device membrane. Disorganized thrombus remained in the LAA body and at the periphery near the appendage walls. Mild inflammation was observed as thrombus resorbed. By 90 days, a complete endocardial lining covered the former LAA ostium. Organizing thrombus had become connective tissue, with no residual inflammation. The human necropsy hearts had similar findings. In these 4 hearts (139, 200, 480, and 852 days after implant), the ostial fabric membrane was covered with endocardium. The appendage surface contained organizing thrombus with minimal inflammation. Organizing fibrous tissue was inside the LAA cavity, prominent near the atrial wall. The LAA interior contained organizing thrombus.This intracardiac device integration study delineated healing stages of early thrombus deposition, thrombus organization, inflammation and granulation tissue, final healing by connective tissue, and endocardialization without inflammation. These observations may yield insight into cellular healing processes in other cardiac devices.

The development of drug-eluting stents (DES) is one of the critical milestones in the advances of interventional cardiology. However, clinical stent thrombosis still poses a serious potential complication. In acute ST-segment elevation myocardial infarction (STEMI), acute total vessel occlusion has a larger thrombus burden, and the use of DES in this particular setting raises safety concerns. Published data from randomized, controlled studies, observational studies and recently published meta-analyses mostly support the safety of DES use in acute STEMI. However, these studies have limited study populations and follow-up periods, so the long-term safety of DES in the setting of STEMI is still unclear, and careful consideration should be given in clinical decision-making. In this article we reviewed the findings of randomized and nonrandomized trials on the use of drugeluting versus bare-metal stents in the setting of acute STEMI.

A newly designed flow support catheter with a supporting wire mesh cage which can be expanded into a tubular configuration and then readily reduced was evaluated in mongrel dogs. Regional myocardial blood flow (RMBF) was measured using the radioactive microsphere technique in the area of both balloon-denuded instrumented and control non-instrumented coronary arteries following placement of either a fixed-wire or a higher profile rapid exchange flow support catheter. At 5, 20, and 180 min following delivery and expansion of either device, RMBF was not significantly different in left ventricular subepicardium and subendocardium perfused by the instrumented vs. the control coronary arteries. Angiography demonstrated widely patent instrumented arteries in 15/18 dogs; in no dog was side branch occlusion observed. Significant cage thrombus deposition was seen angiographically in 3 animals causing temporary total coronary occlusion in 1. Following reduction and removal of the flow support catheter, vessel patency was present in all dogs. The flow support catheter is an effective endovascular stenting device capable of providing structural arterial support, while simultaneously maintaining distal coronary blood flow. It is envisioned that the primary application of this catheter will be to enable primary salvage of vessels acutely injured during coronary angioplasty, by "tacking up" intimal flaps for an extended period. It may also provide a bridge to emergency surgical revascularization.

The ever increasing operator demands and objectives to mill fast and efficient windows has led to the development of innovative milling technology. New lead mill profiles and cutting structures have replaced old crushed carbide technology.The new design utilizes inserts brazed into pockets machined in the mill head. Mills dressed with the new cutting structure are able to effectively mill a casing window and drill formation rat hole in less time than it took with the welded-on crushed carbide technology. With this new design, operators are now afforded an option. In medium to hard formations, the new cutting structure can be used to mill the window and drill rat hole in one trip. While sidetracking in formations with high compressive strengths, Polycrystalline Diamond Compact (PDC) inserts can be utilized. The use of the new cutting structure in a one trip sidetrack system can result in substantial cost savings, improved milling reliability and a higher quality window. The combination of new cutting elements and mill profile has proved to be economically sound allowing for consistency of product manufacturing and has eliminated the potential variances inherent in the welding processes. The system design and cutting structure reduces torsional resistance providing for smoother in-gauged milled windows in one trip. This paper updates an earlier paper with the concepts of using the new cutting structure and presents the new technology and recent case histories of four sidetrack operations.

Introduction: Although intussusception is a rare cause of mechanical bowel obstruction in adults, traumatic intussusception is exceedingly rare. In adults, intussusception contributes

Introduction: Although splenic injury is the most frequent abdominal injury resulting from blunt trauma, delayed splenic rupture is a rare event. Traumatic rupture of the spleen has been well described in medical literature and is found in approximately 30% of patients undergoing surgery for blunt abdominal injury. Computed tomography negative delayed rupture of the spleen is a very rare clinical entity. This is in spite of computed tomography having a sensitivity and specificity for detection of splenic injuries as high as 96% and 100%, respectively. When a patient presents after blunt abdominal trauma, awareness of the problem of delayed splenic rupture, a high index of clinical suspicion and rapid diagnostic approach may help reducing the morbidity and mortality associated with unrecognized splenic injury and/or hemorrhage. Case Report: We present a case report of a 61­year­old male restrained driver, involved in a motor vehicle crash, who presented with a normal spleen on initial computed tomography scan. Conclusion: Computed tomography ­ negative delayed rupture of the spleen is a very rare clinical entity.

Introduction: A novel approach for the management of severe traumatic brain injury is to perform a decompressive laparotomy when controlling intracranial hypertension (ICH) appears futile. Bladder pressures measured above 20 mmHg are used to signify the presence of an abdominal compartment syndrome and indicate the need for a decompressive laparotomy. Case Report: We are presenting a case study of a 16­year­old male who sustained a gunshot wound to the head that resulted in a severe traumatic brain injury and incessantly elevated intracranial pressures (IVP). The patient did not demonstrate a sustained and significant reduction in his ICH following a decompressive craniectomy. We performed a decompressive laparotomy successfully reducing the patient’s ICP below 20 mmHg. The patient survived to discharge and was neurologically improved at follow­up. Conclusion: This case highlights the importance of regarding the body a continuous compartment allowing a reduction in intracranial pressure by decompressing the abdomen even in the absence of an abdominal

Introduction: Physicians who care for trauma patients should be aware of the possibility of a pulmonary embolism presenting immediately after traumatic injury. Case Report: We report a case of a 30­year­old female restrained driver who developed a pulmonary embolism within two hours of a motor vehicle accident. Conclusion: We conclude that trauma can produce a hypercoagulable state that can occur immediately after a traumatic event and result in a pulmonary embolism.

Introduction: Symptomatic gallstone disease is the second most common abdominal emergency in pregnant women after acute appendicitis. Extrahepatic biliary obstruction by gallstones during pregnancy remains one of the most challenging management problems in the field of surgery. Although there have been many advancements in the surgical and endoscopic management of gallstone disease, the risks of these interventions and anesthesia to the developing fetus still prevents their routine application during the gestational period. Traditionally, these types of disorders during pregnancy are managed conservatively or via appropriately timed cholecystectomy. However, when the late­term pregnant patient presents acutely with evidence of biliary tract obstruction and sepsis, it represents a medical or surgical emergency. Case report: We present the case management of a 25­year­old late term pregnant female with an impacted www.ijcasereportsandimages.com common bile duct stone and impending biliary sepsis as a result of failed postpartum endoscopic stone extraction. Conclusion: Due to the risk of potential harm to the fetus, this patient subset must be managed in clinically sound and technically proficient manner, which does not allow time for conservative management. Consequently, appropriate management algorithms for conservative therapy versus endoscopic or surgical interventions need to be clearly outlined and defined.

A 24-year-old male seat-belted driver involved in a high-speed motor vehicle crash was taken to the operating room for repair of a partial aortic transection. After resolution of the right hemopneumothorax, an elevated right hemidiaphragm was seen on a chest radiograph.

A 39-year-old woman presented with complaints of shortness of breath on exertion and was found to have fixed splitting of the second heart sound and a systolic murmur. Electron beam angiography was performed prior to (Fig. 1A) and following (Fig. 1B) percutaneous closure. Balloon sizing (Amplatzer®‚ sizing balloon, AGA Medical Corp., Golden Valley, Minn., USA) showed a stretched diameter of 31 mm (Fig. 2C). Transesophageal echocardiography (Fig. 2A) showed an atrial septal defect 26 mm in size with adequate (>5 mm) rims in all quadrants except at the base of the aorta. A 34-mm Amplatzer Septal Occluder Device® (AGA Medical Corp.) was placed. Electron beam angiography provided an accurate assessment of defect size and excellent visualization of adjacent cardiac structures including the aortic valve and pulmonary veins. FIG. 2 (A) Transesophageal echocardiography (TEE) showing ASD 26 mm in size with absent anterior rim (arrow). (B) TEE following device placement. (C) Stretched defect of 31 mm using Amplatzer sizing balloon. (D) 34-mm Amplatzer Septal Occluder deployed across the ASD. FIG. 1 (A) Pre-closure axial electron beam angiography (EBA) image showing a large ostium secundum atrial septal defect (ASD) with absent anterior rim (arrowhead) and defect size of 30.45 mm. (B) Post-closure axial EBA showing 34 mm Amplatzer Septal Occluder Device. RA = right atrium, LA = left atrium, Ao = aorta, RV = right ventricle. (A)