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Early Outcomes of Deliberate Nonoperative Management for Blunt Thoracic Aortic Injury in Trauma
242
Abstracts
, EARLY OUTCOMES OF DELIBERATE NONOPERATIVE MANAGEMENT FOR BLUNT THORACIC AORTIC INJURY IN TRAUMA. Caffarelli AD, Mallidi HR, Maggio PM, et al. J Thoracic Cardiovasc Surg 2010;140:598–605. Traditionally, blunt aortic injury (BAI) in trauma patients has been managed as a surgical emergency, with non-operative management being reserved for patients who have contraindications to surgery. This retrospective chart review of a cohort of trauma patients presenting or referred to Stanford University School of Medicine Emergency Department from January 2001 to May 2008 sought to analyze the early outcomes of planned nonoperative management of trauma patients with BAI. A total of 53 patients with BAI were identified; 29 of whom were followed with non-operative management and 24 who underwent operative management (9 open and 15 stent-graft repairs). Nonoperative management consisted of admission to intensive care units, invasive cardiovascular monitoring, aggressive negative inotropy for goal systolic blood pressure of 100–120, and serial helical computed tomography (CT) angiography at arrival, 24 h, and every 48–72 h until aortic injury was unchanged for 7 days. Mean age in both cohorts was 45 years, and the majority was male. There were two in-hospital mortalities; autopsies found non-aortic causes of death. Of the 27 non-operative survivors, a range of aortic injury morphology was identified, with the majority suffering pseudoaneurysms of less than one-half of aortic circumference (18/27), 6/27 suffering intraluminal thrombus or intimal injury, 2/27 had mural hematoma, and 1/27 had a pseudoaneurysm of more than one-half the aortic circumference. No statistical difference was found between operative and nonoperative cohort demographics or in-hospital survival (though no p-value was given for survival analysis). Follow-up with serial CT scans was limited to non-operative cohort, and ranged from 1 to 641 days, with a median of 31 days post-injury. Of these nonoperative patients, follow-up showed 17/27 patients (67%) were confirmed alive as of April 1, 2009, 1 patient with a stable pseudoaneurysm died of a non-aortic cause, and 8 patients were lost in follow-up but were presumed alive given that all had social security numbers and no deaths reported by the social security death index, resulting in a possible 97% survival at a median of 1.8 years post-injury. The authors concluded that non-operative management is a reasonable alternative in select trauma patients with BAI. They argued that trauma patients tend to be younger and without underlying abnormalities of the layers of the aortic wall (as compared to patients with aortic aneurysms from degenerative or connective tissue disorders who are at elevated risk of acute rupture and require surgical intervention). Limitations noted by authors included limited follow-up, small and underpowered cohort, and retrospective analysis. [Kirsten Liu, MD Denver Health Medical Center, Denver, CO] Comment: This was a very small study with important shortcomings in the statistical methodology and incomplete followup. Although the groups may not have been statistically different in terms of their demographics at baseline, very few demographics were actually considered. Furthermore, an important confounder not commented on in the manuscript would be related to why those patients not undergoing surgery were selected for non-operative
intervention in the first place. Still, despite all of this, the results are intriguing and should lead to further research. If non-operative management is a valid strategy in certain patients, this could change how these patients are managed in an important way. , INITIAL CLINICAL RESULTS USING INTRACARDIAC ELECTROGRAM MONITORING TO DETECT AND ALERT PATIENTS DURING CORONARY PLAQUE RUPTURE AND ISCHEMIA. Fischell T, Fischell DR, Avezum A. J Am Coll Cardiol 2010;56:1089–98. This study, funded by the device manufacturer, is the first clinical study to evaluate intracardiac ST monitoring for ST-segment shifts associated with thrombotic occlusion with the ultimate goal of improving patient clinical outcome by decreasing symptom onset to treatment time in patients with acute coronary syndrome. To assess device safety and accuracy, 20 patients from the Cardiosaver phase-one clinical study, and 17 patients from the DETECT phase-one clinical study were evaluated. An AngelMed Guardian (Angel Medical Systems, Shrewsbury, NJ) implantable ischemia detection system was implanted to continuously monitor ST-segment variation. Two alarm types were established to alert patients, an ‘‘emergency’’ setting for ST-segment shift over 90 s with a normal heart rate alerted patients to seek emergent help. A second ‘‘see doctor’’ alarm was activated by ST-segment shift associated with an elevated heart rate. The 37 patients with implantable ischemia detection systems were monitored for a total of 58.2 patient-years. During that time, 4 patients had ST-segment shifts accompanied with elevated heart rate, 3 patients had false-positive alarms secondary to ventricular dysrhythmia, and 4 patients had ST-segment shifts with a normal heart rate concerning for coronary thrombosis. All 4 patients with concern for coronary thrombosis presented to a hospital and found to have thrombotic coronary occlusion or a ruptured plaque confirmed with angiogram or intravascular ultrasonography. Alert to hospital evaluation time was an average of 26.5 min (6, 18, 21, and 60 min for each case). This is a great improvement from the current 144-min average symptom-to-door time. [Anna Engeln, MD Denver Health Medical Center, Denver, CO] Comments: This study must be taken in the context of being funded by the device manufacturer. Another important consideration is the rationale behind implanting such devices in the first place. How patients were selected for this is not addressed in the manuscript. Lastly, it is important to note that of 37 patients, there were almost two false positives for each of the true positives seen. Furthermore, although there was a reduction in the time to medical evaluation from symptom onset, it is not possible to know if that had any appreciable effect on morbidity or mortality. Nonetheless, this may be an important technology for a subset of patients at risk for cardiac events in the future. , EPIDEMIOLOGY OF POSTCONCUSSION SYNDROME IN PEDIATRIC MILD TRAUMATIC BRAIN INJURY. Barlow KM, Crawford S, Stevenson A, et al. Pediatrics 2010;126:e374–81. The incidence of mild traumatic brain injury (mTBI) is very high in the pediatric population, occurring in 692 of 100,000
Abstracts
, EARLY OUTCOMES OF DELIBERATE NONOPERATIVE MANAGEMENT FOR BLUNT THORACIC AORTIC INJURY IN TRAUMA. Caffarelli AD, Mallidi HR, Maggio PM, et al. J Thoracic Cardiovasc Surg 2010;140:598–605. Traditionally, blunt aortic injury (BAI) in trauma patients has been managed as a surgical emergency, with non-operative management being reserved for patients who have contraindications to surgery. This retrospective chart review of a cohort of trauma patients presenting or referred to Stanford University School of Medicine Emergency Department from January 2001 to May 2008 sought to analyze the early outcomes of planned nonoperative management of trauma patients with BAI. A total of 53 patients with BAI were identified; 29 of whom were followed with non-operative management and 24 who underwent operative management (9 open and 15 stent-graft repairs). Nonoperative management consisted of admission to intensive care units, invasive cardiovascular monitoring, aggressive negative inotropy for goal systolic blood pressure of 100–120, and serial helical computed tomography (CT) angiography at arrival, 24 h, and every 48–72 h until aortic injury was unchanged for 7 days. Mean age in both cohorts was 45 years, and the majority was male. There were two in-hospital mortalities; autopsies found non-aortic causes of death. Of the 27 non-operative survivors, a range of aortic injury morphology was identified, with the majority suffering pseudoaneurysms of less than one-half of aortic circumference (18/27), 6/27 suffering intraluminal thrombus or intimal injury, 2/27 had mural hematoma, and 1/27 had a pseudoaneurysm of more than one-half the aortic circumference. No statistical difference was found between operative and nonoperative cohort demographics or in-hospital survival (though no p-value was given for survival analysis). Follow-up with serial CT scans was limited to non-operative cohort, and ranged from 1 to 641 days, with a median of 31 days post-injury. Of these nonoperative patients, follow-up showed 17/27 patients (67%) were confirmed alive as of April 1, 2009, 1 patient with a stable pseudoaneurysm died of a non-aortic cause, and 8 patients were lost in follow-up but were presumed alive given that all had social security numbers and no deaths reported by the social security death index, resulting in a possible 97% survival at a median of 1.8 years post-injury. The authors concluded that non-operative management is a reasonable alternative in select trauma patients with BAI. They argued that trauma patients tend to be younger and without underlying abnormalities of the layers of the aortic wall (as compared to patients with aortic aneurysms from degenerative or connective tissue disorders who are at elevated risk of acute rupture and require surgical intervention). Limitations noted by authors included limited follow-up, small and underpowered cohort, and retrospective analysis. [Kirsten Liu, MD Denver Health Medical Center, Denver, CO] Comment: This was a very small study with important shortcomings in the statistical methodology and incomplete followup. Although the groups may not have been statistically different in terms of their demographics at baseline, very few demographics were actually considered. Furthermore, an important confounder not commented on in the manuscript would be related to why those patients not undergoing surgery were selected for non-operative
intervention in the first place. Still, despite all of this, the results are intriguing and should lead to further research. If non-operative management is a valid strategy in certain patients, this could change how these patients are managed in an important way. , INITIAL CLINICAL RESULTS USING INTRACARDIAC ELECTROGRAM MONITORING TO DETECT AND ALERT PATIENTS DURING CORONARY PLAQUE RUPTURE AND ISCHEMIA. Fischell T, Fischell DR, Avezum A. J Am Coll Cardiol 2010;56:1089–98. This study, funded by the device manufacturer, is the first clinical study to evaluate intracardiac ST monitoring for ST-segment shifts associated with thrombotic occlusion with the ultimate goal of improving patient clinical outcome by decreasing symptom onset to treatment time in patients with acute coronary syndrome. To assess device safety and accuracy, 20 patients from the Cardiosaver phase-one clinical study, and 17 patients from the DETECT phase-one clinical study were evaluated. An AngelMed Guardian (Angel Medical Systems, Shrewsbury, NJ) implantable ischemia detection system was implanted to continuously monitor ST-segment variation. Two alarm types were established to alert patients, an ‘‘emergency’’ setting for ST-segment shift over 90 s with a normal heart rate alerted patients to seek emergent help. A second ‘‘see doctor’’ alarm was activated by ST-segment shift associated with an elevated heart rate. The 37 patients with implantable ischemia detection systems were monitored for a total of 58.2 patient-years. During that time, 4 patients had ST-segment shifts accompanied with elevated heart rate, 3 patients had false-positive alarms secondary to ventricular dysrhythmia, and 4 patients had ST-segment shifts with a normal heart rate concerning for coronary thrombosis. All 4 patients with concern for coronary thrombosis presented to a hospital and found to have thrombotic coronary occlusion or a ruptured plaque confirmed with angiogram or intravascular ultrasonography. Alert to hospital evaluation time was an average of 26.5 min (6, 18, 21, and 60 min for each case). This is a great improvement from the current 144-min average symptom-to-door time. [Anna Engeln, MD Denver Health Medical Center, Denver, CO] Comments: This study must be taken in the context of being funded by the device manufacturer. Another important consideration is the rationale behind implanting such devices in the first place. How patients were selected for this is not addressed in the manuscript. Lastly, it is important to note that of 37 patients, there were almost two false positives for each of the true positives seen. Furthermore, although there was a reduction in the time to medical evaluation from symptom onset, it is not possible to know if that had any appreciable effect on morbidity or mortality. Nonetheless, this may be an important technology for a subset of patients at risk for cardiac events in the future. , EPIDEMIOLOGY OF POSTCONCUSSION SYNDROME IN PEDIATRIC MILD TRAUMATIC BRAIN INJURY. Barlow KM, Crawford S, Stevenson A, et al. Pediatrics 2010;126:e374–81. The incidence of mild traumatic brain injury (mTBI) is very high in the pediatric population, occurring in 692 of 100,000