Coarctation and related aortic arch anomalies in hypoplastic left heart syndrome

The aortic arches of 34 specimens with hypoplastic left heart syndrome were studied in order to establish the frequency, the nature and the clinical implications of aortic arch anomalies. A localized aortic coarctation was present in 23 specimens. The coarcation was located preductally in 2 and paraductally in 21 cases. The degree of obstruction caused by the coarctation varied considerably. In only 6 cases (1 preductal and 5 paraductal) was the obstruction judged to be severe. One of these cases had an additional aneurysm of the aortic wall proximal to the coarctation. An aberrant relation of the ductus arteriosus and the aortic arch was found in 2 specimens without localized coarctation. In the remaining 9 specimens the aortic arch appeared normal. The aortic arch anomalies were mostly present in specimens with a severely hypoplastic ascending aorta. Clinicians, when preparing infants with hypoplastic left heart syndrome for surgical palliation, should always suspect associated aortic arch anomalies, especially when there is severe hypoplasia of the ascending aorta. Coarctation of the aorta will require additional surgical treatment.     

Clinical considerations regarding infective Libman-Sacks endocarditis

A case of aortic infective endocarditis due to Hemophilus paraphrophilus in a patient with previous Libman-Sacks endocarditis is presented. Suggestions regarding antibiotic prophylaxis are made concerning patients with systemic lupus erythematosus.     

Blunt chest trauma and suspected aortic rupture: reliability of chest radiograph findings

The chest radiographs of 86 patients with suspected aortic rupture from blunt chest trauma were reviewed. Seventy-three patients had no evidence of aortic rupture on aortography or surgical exploration, and 13 patients had surgically confirmed rupture. Sixteen radiographic findings were analyzed for sensitivity and specificity in detecting aortic rupture. The following findings were not statistically significant: hemothorax on either side; rib fractures on either side; pneumothorax on either side; lung contusion; widened left paravertebral stripe; and widening of the mediastinum, along with an increased ratio of mediastinal width to chest width. The most helpful findings leading to suspicion of aortic rupture included nasogastric tube or tracheal deviation to the right at the T4 level; depression of the left mainstem bronchus; and loss of the aortic contour or knob and left apical cap. False positives and false negatives occurred with each radiographic sign, indicating that there is no single finding that is absolutely reliable in predicting or excluding significant injury in every patient with suspected aortic rupture. Analysis of combinations of findings found that when the aortic contour and knob are normal and the nasogastric tube and trachea are not deviated, there was no case of aortic rupture in four consecutive years of experience. These four signs can be used to exclude aortic rupture.     

Prediction of long-term clinical outcome in patients with lumbar spinal stenosis

Purpose

The natural course of lumbar spinal stenosis (LSS) fluctuates and is not necessarily progressive. The aim of this study was to explore the predictors of clinical outcome in patients with LSS that might eventually help to optimise the therapeutic choices.

Methods

A group of 56 patients (27 men, 29 women, median age 55; range 31–72 years) with clinically symptomatic mild-to-moderate LSS were re-examined after a median period of 88 months and their clinical outcomes classified as satisfactory (34 patients, 60.7 % with stable or improved clinical status) or unsatisfactory (22 patients, 39.3 % for whom clinical status deteriorated). A wide range of demographical, clinical, imaging and electrophysiological entry parameters were evaluated as possible predictors of clinical outcome.

Results

Unlike the demographical, clinical and imaging variables, certain electrophysiological parameters were significantly associated with unsatisfactory outcomes. There was a significantly higher prevalence of pluriradicular involvement detected by EMG in patients with unsatisfactory outcome than those with satisfactory outcome (68.2 vs. 32.3 %; p = 0.035). Patients with unsatisfactory outcome had more frequent bilateral abnormalities of the soleus H-reflex (50.0 vs. 14.7 %; p = 0.015) and lower mean H-reflex amplitude. Multivariate logistic regression proposed two variables as mutually independent predictors of unsatisfactory outcome: EMG signs of pluriradicular involvement (OR = 3.72) and averaged soleus H-reflex amplitude ≤2.8 mV (OR = 2.87).

Conclusions

Satisfactory outcomes were disclosed in about 61 % of the patients with mild-to-moderate LSS in a 7-year follow-up. Electrophysiological abnormalities, namely the presence of pluriradicular involvement and abnormalities of the soleus H-reflex, were predictive of deterioration of clinical status in these patients.     

Comparative study of spinopelvic sagittal alignment between patients with and without degenerative spondylolisthesis

Introduction

To date, few studies have focused on spinopelvic sagittal alignment as a predisposing factor for the development of degenerative spondylolisthesis (DS). The objectives of this study were to compare differences in spinopelvic sagittal alignment between patients with or without DS and to elucidate factors related to spinopelvic sagittal alignment.

Materials and methods

A total of 100 patients with or without DS who underwent surgery for lumbar spinal canal stenosis were assessed in this study. Fifty patients with DS (DS group) and 50 age- and gender-matched patients without DS (non-DS group) were enrolled. Spinopelvic parameters including pelvic incidence (PI), sacral slope (SS), pelvic tilt (PT), L4 slope, L5 slope, thoracic kyphosis (TK), lumbar lordosis (LL) and sagittal balance were compared between the two groups. In the DS group, the percentage of vertebral slip (% slip) was also measured.

Results

Several spinopelvic parameters, PI, SS, L4 slope, L5 slope, TK and LL, in the DS group were significantly greater than those in the non-DS group, and PI had positive correlation with % slip (r = 0.35, p < 0.05). Degrees of correlations among spinopelvic parameters differed between the two groups. In the DS group, PI was more strongly correlated with SS (r = 0.82, p < 0.001) than with PT (r = 0.41, p < 0.01). In the non-DS group, PI was more strongly correlated with PT (r = 0.73, p < 0.001) than with SS (r = 0.38, p < 0.01).

Conclusions

Greater PI may lead to the development and the progression of vertebral slip. Different compensatory mechanisms may contribute to the maintenance of spinopelvic sagittal alignment in DS and non-DS patients.     

Glasgow Aneurysm Score in Patients Undergoing Elective Open Repair of Abdominal Aortic Aneurysm: A Finnvasc Study

OBJECTIVE: To use Finnvasc to determine whether the Glasgow Aneurysm Score predicts postoperative outcome after open repair of abdominal aortic aneurysm (AAA). DESIGN: Retrospective study. MATERIAL AND METHODS: The operative risk of 1911 patients undergoing open repair of AAA was retrospectively graded according to the Glasgow Aneurysm Score. RESULTS: At 30 days 100 (5%) patients had died and 21% had developed severe postoperative complications. Receiver operating characteristics (ROCs) curve analysis showed that the Glasgow Aneurysm Score was predictive of postoperative mortality (area under the curve (AUC): 0.668, p<0.0001), severe complications (AUC: 0.654, p<0.0001), cardiac complications (AUC: 0.689, p<0.0001) and intensive care unit stay >5 days (AUC: 0.634, p<0.0001). Patients scoring >76 had significantly higher mortality (9% vs. 3%, p<0.0001), severe (31% vs. 15%, p<0.0001) and cardiac complications (12% vs. 4%, p<0.0001) and intensive care unit stay >5 days (12% vs. 6%, p<0.0001). CONCLUSIONS: The Glasgow Aneurysm Score is a rather good predictor of immediate postoperative mortality and morbidity after elective open repair of AAA.     

Steady-state free-precession (SSFP) cine MRI in distinguishing normal and bicuspid aortic valves

PURPOSE: To assess the diagnostic sensitivity and specificity of double-oblique true fast imaging with steady-state precession (SSFP) cine MRI in distinguishing normal and bicuspid aortic valves. MATERIALS AND METHODS: Echocardiograms on patients referred for MRI of the heart and thoracic aorta over a four-year period were reviewed retrospectively. A total of 17 patients with bicuspid aortic valve were identified and compared to 21 randomly chosen control patients. All patients had double-oblique SSFP (True FISP) cine MRI of the aortic valve independently assessed by two radiologists in a blinded fashion, and graded as bicuspid or normal. Image quality was graded as 1, 2, or 3. Discordance was resolved by consensus. RESULTS: A total of 38 cases were reviewed (27 men, 11 women; age range = 15-67 years, mean = 25.33 years). Interobserver agreement was 0.97 (36/38 cases). One case of normal tricuspid valve was reported as bicuspid by both readers (false-positive). All cases in which disparity arose were rated suboptimal by both readers (grade 2 or 3). Consensus review yielded sensitivity = 100%, specificity = 95.2%, positive predictive value = 94.4%, and negative predictive value = 100%; overall diagnostic accuracy was 97.36%. Interobserver agreement was 0.97. CONCLUSION: Double-oblique True FISP cine MR imaging of the aortic valve is 100% sensitive and 95% specific in distinguishing normal and bicuspid aortic valves.     

In-hospital outcomes after carotid endarterectomy for stroke stratified by modified Rankin scale score and time of intervention

ObjectiveAlthough the benefits of carotid endarterectomy (CEA) for treating symptomatic carotid stenosis are well known, the optimal timing of intervention after acute stroke and whether the optimal timing will vary with preoperative stroke severity has remained unclear. Therefore, we assessed the effect of stroke severity and timing of the intervention on the postoperative outcomes for patients who had undergone CEA for stroke.MethodsWe identified all patients in the Vascular Quality Initiative who had undergone CEA from 2012 to 2020 for prior stroke. The patients were stratified using the preoperative modified Rankin scale score (mRS score, 0-5) and time to CEA after stroke onset (≤2 days, 3-14 days, 15-90 days, 91-180 days). After univariate comparisons, the patients were stratified into the following mRS cohorts for further analysis: 0 to 1, 2, 3 to 4, and 5. The primary outcome was in-hospital stroke/death.ResultsWe identified 15,601 patients, of whom 30% had had an mRS score of 0, 34% an mRS score of 1, 17% an mRS score of 2, 11% an mRS score of 3, 8% an mRS score of 4, and 1% an mRS score of 5. Overall, 9.3% of the patients had undergone CEA within ≤2 days, 46% within 3 to 14 days, 36% in 15 to 90 days, and 8.4% within 90 to 180 days. A decreasing mRS score and an increasing time to CEA were associated with lower rates of perioperative stroke/death (P_trend < .01). After risk adjustment, with CEA at 3 to 14 days as the comparator group, the mRS score 0 to 1 group had had a higher incidence of stroke/death after CEA within ≤2 days (3.6% vs 2.0%; odds ratio [OR], 1.8; 95% confidence interval [CI], 1.2-2.7). The mRS score 2 group had had a similar incidence of stroke/death after CEA within ≤2 days (4.4% vs 3.9%; OR, 1.2; 95% CI, 0.6-2.3) but a lower incidence after CEA at 15 to 90 days (2.1% vs 3.9%; OR 0.5; 95% CI, 0.3-0.96). The mRS score 3 to 4 group had had a higher incidence of stroke/death after CEA within ≤2 days (8.0% vs 3.8%; OR, 2.4; 95% CI, 1.5-3.9) but a similar incidence of stroke/death after CEA at 15 to 90 days (3.0% vs 3.8%; OR, 0.8; 95% CI, 0.5-1.3). For the mRS score 5 group, the stroke/death rates were ≥6.5% across all the time to CEA groups. However, the low sample size limited meaningful comparisons.ConclusionsPatients with minimal disability after stroke (mRS score, 0-1) seemed to benefit from CEA within 3 to 14 days. However, those with severe disability (mRS score 5) have a very high risk from CEA at any time point given the poor outcomes. In contrast to the current guidelines, patients with mild disability (mRS score 2) could benefit from delaying CEA to 15 to 90 days, and those with moderate disability (mRS score 3-4) might benefit from CEA within 3 to 90 days given the acceptable in-hospital outcomes. These data should be considered within the context of the clinical situation in the weeks after index event to determine the net benefit of delayed CEA.