In spite of recent advances in the techniques of cardiopulmonary bypass (CPB), both incidence and mortality rates associated with acute kidney injury (AKI) post CPB remain high. Perioperative risk factors for the AKI include advanced age, diabetes mellitus, underlying kidney disease, and poor cardiac function. Attempts should be made to avoid or modify risk factors such as anemia, preoperative contrast exposure, and excessive hemodilution. The benefits of off-pump coronary artery bypass graft (CABG) surgery on AKI remain equivocal. Well-controlled randomized studies are needed to further clarify the role of various pharmacologic agents such as atrial natriuretic peptides and fenoldopam on the prevention of AKI post-CABG. Continuous renal replacement therapy is preferable to intermittent hemodialysis in patients needing dialysis.

Chronic obstructive pulmonary diseases (COPDs) are a group of continuously deteriorative diseases that may require more than one form of therapy. Although pharmaceutical management is always more tolerable for patients, many do not respond adequately on this medical regimen. These subgroups of patients may therefore require more aggressive and effective treatment, to improve their symptoms and quality of life. Lung volume reduction surgery (LVRS) is a procedure that provides the opportunity for a better quality of life in these patients with advanced COPD and is the aim of this review. LVRS can be performed through a unilateral or bilateral surgical approach, depending on the sites and the extent of the disease, as well as on the patients' inclusion criteria. Patients who do not meet the standards for open LVRS may however still benefit from video-assisted LVRS (video-assisted thoracic surgery) or bronchoscopic lung reduction surgery. The improvement after these procedures is seen in clinical symptomatology, quality of life, and overall survival, and these are accomplished with low-operative mortality rates. Complications though common do not have a significant impact on the final outcome. Therefore, these various interventions can be beneficial to patients with advanced COPD that is unresponsive to standard medical therapy.

Background: Spontaneous pneumomediastinum (SPM) because of its relative rarity frequently causes apprehension when encountered in the emergency department (ED) leading often to unnecessary investigative workups. Methods: The medical records of patients admitted at a level 1 trauma center ED from January 2012 to June 2017 with SPM were retrospectively reviewed. Results: There were 8 patients with 50.0% females, mean age 26.7 ± 11.5 years and body mass index 22.8 ± 3.6. Chest pain (87.5%), shortness of breath (62.5%), and neck pain (50.0%) were the most common symptoms. Known predisposing or precipitating factors were present in 50.0% and leukocytosis in 75.0%. Although chest X-ray was diagnostic, all patients also had electrocardiogram, chest computed tomography scan, and contrast esophagram. In addition, 3 (37.5%) patients with pneumopericardium associated with tachyarrhythmia had transthoracic echocardiogram, while 1 (12.5%) presenting with persistent vomiting had esophagogastroscopy. There were no significant abnormalities found in these additional studies. All patients were treated conservatively without any complications, and mean hospital length of stay was 1.7 ± 0.8 days. Conclusion: SPM is a benign condition rarely requiring any surgical intervention. Chest X-ray is usually diagnostic, and additional investigations are therefore seldom necessary unless the diagnosis is questionable or there is a high index of suspicion for esophageal injury. Discharge from the ED or 23 h observation disposition should be sufficient for most patients.

Acute Stanford Type A aortic dissection (ATAAD) has a high mortality rate, particularly with delayed diagnosis and treatment. A 30-year-old male Marfan patient presented to the emergency department with acute abdominal pain and underwent laparoscopic appendectomy for acute appendicitis about 15 h later. Postoperatively, the patient developed acute pulmonary edema and respiratory failure. Transthoracic echocardiogram revealed severe aortic insufficiency, 7.5 cm root aneurysm, severe left ventricular dysfunction, and probable ATAAD. Following computed tomography angiogram confirmation of ATAAD, he underwent emergency root and ascending aortic replacement with a composite mechanical valve graft 48 h after hospitalization. The patient had Escherichia coli pericarditis at time of sternotomy likely hematogenous from appendicitis and later also developed postoperative pneumonia. At 2 years follow-up, he was doing well without any evidence of prosthetic valve conduit infection. The simultaneous presentation of two unrelated pathologies with acute abdominal pain led to the initial missed diagnosis of ATAAD, which delayed treatment and increased risks for morbidity and mortality. Therefore, Marfan syndrome patients presenting with acute abdomen should be ruled out for acute aortic dissection despite any other obvious concomitant pathology, especially in younger patients.

Chronic pericarditis (CP) with bony encasement of the heart resulting in constrictive pathophysiology is relatively rare. We report a 43-year-old female with CP and long-standing right heart failure in New York Heart Association (NYHA) Class IV while on medical management, who was subsequently referred for surgery. Patient had porcelain bony encasement of the heart which was safely resected with the aid of cardiopulmonary bypass (CPB). There was a dramatic reduction in the central venous pressure and subsequent improvement in functional status to NYHA Class I–II postoperatively. While pericardiectomy is generally performed without CPB, it may be a useful adjunct in patients with heavily calcified porcelain pericardium. CPB facilitates more complete pericardial resection leading to lower incidence of residual constrictive symptoms postoperatively in patients with porcelain CP. Although there was no histologic or bacteriologic evidence of tuberculosis (TB), the presumptive etiology was TB given its prevalence in our environment.