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We present a successful use of biventricular pneumatic assistance during seven days allowing the recovery from a severe primary graft failure that occurred in the operating room. Suboptimal donors are associated with higher rates of immediate graft failure; however proper use of mechanical assistance can help to recover graft function.
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BACKGROUND: Management of postcardiotomy cardiogenic shock with a ventricular assist device (VAD) is a common and accepted therapeutic option. However, VAD use in patients with mechanical heart valves (MHVs) is thought to carry an increased risk of thromboembolus. We report a series of 7 patients with combined VAD-MHV and review the literature. METHODS: A retrospective review was performed on all patients who were supported with a ventricular assist device with a mechanical heart valve in place. A literature review was also performed from 1966 to 2000. RESULTS: Seven patients were identified from April 1988 to June 2000 as having VAD support with a MHV. One thromboembolic event was documented in the 7 patients (14%). Five of the 7 patients (71%) underwent VAD explantation. Overall survival rate was 3 of 7 (43%). Causes of death included heart failure, renal failure, multisystem organ failure, adult respiratory distress syndrome, and cerebral hypoxia. All patients who died had support withdrawn at the request of the family. All patients discharged are currently alive with length of survival of 3, 26, and 84 months. CONCLUSIONS: This study suggests that this population's rate of survival to discharge and risk of thromboembolus compare favorably to that of the general VAD population. We believe that anticoagulation can be managed as with any MHV patient and that flow rates can be kept slightly lower, which may encourage valve washing.
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We retrospectively analyzed 1334 patients who were implanted standard gamma interlocking nails (SGN) to stabilize trochanteric femoral fractures over the years 1992-1998. Reoperation to remove the nails was performed in 37 patients, in 9 of them purely because of pain. Three out of these 9 patients with removed SGN suffered femoral neck fractures in the early postoperative course after having been mobilized to full weight-bearing capacity. This complication was not observed with other implant systems and, considering the notoriously high complication rate of femoral neck fractures, severely reduces the value of the SGN concept per se. These findings in combination with other known shortcomings of SGNs prompted us to conduct an experimental study on the fracture force of excavated femurs addressing the hypothesis that the specific design of the SGN is responsible for the occurrence of fatigue fractures of the femoral neck. Eighteen matched pairs of fresh human cadaveric proximal femurs, which were treated by insertion and removal of (i) SGNs or (ii) dynamic hip screws (DHS) or (iii) by excavation in the absence of an implant, were subjected to incremental loading cycles and compared to the untreated contralateral femurs. Overall, the fracture force was found to be significantly lower among the treated than among the untreated bones. However, the fracture force required after removal of the DHS system was still significantly higher than for SGN or excavation alone. In this way, our findings demonstrate that removing relatively big implants such as SGN can cause serious complications such as femoral neck fractures. We therefore recommend to leave this type of device in place even after fracture healing except in cases of deep and chronic infection.
The solid plastic carrier in the Thermafil obturation system must be removed to facilitate retreatment. The purpose of this study was to compare the efficacy and time required to retreat canals obturated with Thermafil with plastic carriers using a new technique based on the System B HeatSource or a solvent. Fifty-two extracted human mandibular premolars with single canals were instrumented and then obturated with Thermafil with plastic carriers. After 2 wk storage at 22 degrees C and 100% humidity, they were randomly divided into 2 groups of 26 teeth each. Group 1 teeth were retreated using chloroform and hand files, whereas teeth in group 2 were retreated with a new technique using the System B HeatSource. The end point of retreatment was defined as complete removal of the plastic carrier. The time required for retreatment was recorded. Then, the apical 5 mm segment of each root was sectioned horizontally at 1 mm intervals and each section digitally imaged. The total area of the canal and the area of the canal occupied by gutta-percha and sealer were measured using NIH image software. Data were analyzed using an unpaired t test. The mean time for retrieval of the plastic carrier was significantly less for the System B technique (1.8 min) than for the solvent technique (3.6 min) (p < 0.001). The difference between the two groups in the amount of filling material (carrier, gutta-percha, and sealer) removed was not significant (p > 0.05).
Expandable metal biliary stents are reserved for patients with unresectable malignant biliary obstruction. Occasionally, these stents may cause complications necessitating removal. We describe successful endoscopic removal of a biliary Wallstent one year after insertion in a patient who initially underwent placement of an expandable metal biliary stent for presumed biliary malignancy. The stent was removed after a stent related bleeding duodenal ulcer formed.
BACKGROUND: During the exchange of a defect Provox-I voice prosthesis followed by an insertion of a Provox-II voice prosthesis the esophageal part of the prosthesis often is pushed into the esophagus, as the enteral passage of the prosthesis was thought to be less traumatic for the voice shunt in comparison to a complete extraction of the stiff esophageal flange through the tracheostoma. This procedure is also recommended in the users video of the ATOS company. CASE: A laryngectomized patient, in whom the change of the voice prosthesis was carried out pushing the esophageal flange of the prosthesis into the esophagus, developed a mechanical ileus, as the voice prosthesis got stuck in Bauhin's valve. This resulted in the necessity of a laparatomy for removal of the voice prosthesis. CONCLUSION: During the replacement of the Provox voice prosthesis it is necessary in all cases that the esophageal remnant of the voice prosthesis either is pulled out of the tracheoesophageal shunt via the tracheostoma or removed with a guide-wire transorally.
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PURPOSE OF REVIEW: To examine the current literature regarding retrievable inferior vena cava filters and to discuss the appropriate indications for their clinical use. RECENT FINDINGS: Permanent filters have been shown to be effective, but have a number of long-term complications such as filter thrombosis or migration. Indications for their placement should be accurately evaluated, especially in patients with a long life expectancy, or in whom the period of contraindication to anticoagulation is short. On the other hand, temporary filters are difficult to manage and their maximum implantation time is often insufficient to solve the clinical problem leading to their placement. Four different retrievable filters recently received approval for temporary insertion. Recent data suggest that the use of these filters may be related to a low rate of pulmonary embolism and insertion complications. Nevertheless, no randomized clinical trials have been performed, and the only available data refer to retrospective or prospective studies. SUMMARY: Retrievable filters are a new generation of filter that offers the attractive possibility of being left in place permanently or being removed after quite a long period when they become unnecessary.
This report describes a 67-year-old trauma victim in whom a retrievable Günther Tulip (Cook, Bloomington, IN) inferior vena cava filter was placed. The filter migrated to the right atrium immediately after placement. Initial attempts to retrieve the filter with Amplatz Goose Neck snares (Microvena, White Bear Lake, MN) were unsuccessful. A second attempt performed a week later with the addition of the new EnSnare (MDTech, Gainesville, FL) was successful. Possible causes of the migration are discussed and the difficulties encountered while removing this retrievable filter are described.
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Intracoronary thrombi are commonly found in patients with acute coronary syndromes. A large thrombus burden or a platelet-rich thrombus frequently resists pharmacologic therapy ("thrombolytic ceiling"). In such cases restoration of adequate antegrade coronary flow necessitates application of a mechanical force. Power thrombectomy is a revascularization strategy incorporating a mechanical device for removal of occlusive coronary thrombi in conjunction with or following administration of either platelet glycoprotein IIb/IIIa receptor inhibitors or thrombolytic agents, or both. Mechanical devices for power thrombectomy include ultrasound sonication, rheolytic thrombectomy (Angiojet), laser, transluminal extraction catheter, aspiration catheter, and to a limited extent, balloon angioplasty. In acute coronary syndromes the strategy of power thrombectomy aims to achieve the clinical advantages of more nearly complete vessel patency, improved antegrade flow, and enhanced preservation of myocardial tissue.
In 1979 Singer and Blom described an endoscopic technique of vocal rehabilitation of the total laryngectomy patient. We have used this technique in 26 patients. Fluent speech developed in 24 patients. Four patients inadvertently had the devices used in this technique fall out of the fistula with subsequent closure. They will need repuncture. Two patients who had excellent speech voluntarily removed their devices. One transient case of aspiration responded to silver nitrate cautery of the fistula and placement of a new device. We believe that at the present time this is the surgical procedure of choice to vocally rehabilitate the total laryngectomy patient.
Indwelling urinary catheters are inserted to drain the bladder for a variety of reasons, but are an intervention of last resort. Unless contraindicated, patients with an indwelling catheter should therefore have at least one trial without catheter to assess if they can pass urine without having a catheter in situ. The commonest method in undertaking trial without catheter is to remove a indwelling urethral catheter and monitor urinary output over a period of time. Another method is when the catheter is not removed in patients who have a suprapubic catheter. Instead the catheter is clamped, and urethral urine output monitored. This is followed by immediately measuring any residue of urine drained via the supra-pubic catheter. This article looks at undertaking a 'trial without catheter' using both methods and examines the arguments concerning when to remove catheters, midnight or early in the morning.
PURPOSE: The effectiveness of treating patients with an infected penile implant by removing the device, cleansing the wound with a series of antiseptic solutions and placing a new device at the same procedure was assessed. MATERIALS AND METHODS: A total of 65 patients were included in the study. All foreign material was removed from the infected wound followed by copious wound irrigations with a protocol of 7 antibacterial solutions. A new prosthesis was inserted and the patient was placed on antibiotics. RESULTS: Followup ranged from 6 to 93 months. Recent status was determined in 85% of cases (55 of 65). Of the 55 patients 45 (82%) showed no sign of infection. In 5 patients recurrent infection was documented and in 5 others erosion of parts to the exterior possibly related to infection was noted. CONCLUSIONS: Salvage of an infected penile implant has been successful and is gaining in popularity among urologists to reduce morbidity associated with infection.