The surgical approach to the management of subclavian artery injuries is usually guided by the location and clinical presentation. With the advent of endovascular surgery, many surgeons are likely to have limited experience with the trap door approach sometimes necessary for control and repair of proximal left subclavian artery (LSA) injuries due to their relative rarity. A 69-year-old male sustained a left lower neck stab wound 3 weeks before his presentation with a pulsatile left supraclavicular swelling, weak radial pulse, and upper extremity weakness. Duplex ultrasound scan revealed a pseudoaneurysm confirmed on computed tomography angiogram and shown to be fed from the LSA. The patient successfully underwent elective open surgical repair of the injury located in the first portion of the subclavian artery through a trap door approach. Although the injury might have been treated minimally invasively with endovascular repair, this technique is currently not available in Nigeria and most Sub-Saharan African countries. Surgery remains the only treatment option for these types of injuries in low-resource countries. Surgeons involved in the management of vascular injuries should, therefore, be conversant with all surgical approaches, including the trap door incision which should be part of their armamentarium.

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Objective: The objective of the study is to determine the utility and practicality of Cheetah noninvasive cardiac output monitoring (NICOM) as a means of hemodynamic monitoring of adult patients after open heart surgery (OHS) in Sub-Saharan Africa (SSA). Materials and Methods: This was a single-institutional prospective study of eight adult patients undergoing OHS with cardiopulmonary bypass between August 2015 and April 2016. Cardiac output (CO) was calculated utilizing three measuring techniques; (1) Cheetah NICOM through skin electrodes, (2) FloTrac Vigileo through an arterial line, and (3) Vigilance through an oximetry Swan Ganz catheter (pulmonary artery catheter). CO readings were grouped into four intervals; precardiopulmonary bypass, postcardiopulmonary bypass, and first 24 h and second 24 h in Intensive Care Unit (ICU). The CO recordings from the three techniques were then compared for correlation between the noninvasive and two invasive techniques. Results: The mean patient age was 46.3 ± 15.7 years and 4 (50.0%) were males. Seven (87.5%) patients had acquired heart disease and 1 (12.5%) congenital heart disease. Three (37.5%) patients had severe pulmonary hypertension and 2 (25.0%) patients required intra-aortic balloon pump postoperatively. Correlation was highest in the ICU after patients were fully warm. Correlation coefficients were r = 0.56, bias 0.39 ± 2.34 between NICOM and Vigileo and r = 0.53, bias 1.43 ± 2.26 between NICOM and Vigilance within the first 24 h in ICU. In subsequent second 24 h in ICU, r = 0.84, bias − 0.16± −1.81 between NICOM and Vigileo and r = 0.29, bias 5.68 ± 1.55 between NICOM and Vigilance were the correlation coefficients. There was either none or poor correlation between NICOM and both the Vigileo or Vigilance pre- and post-cardiopulmonary bypass as most patients were still relatively hypothermic. Conclusion: NICOM reliably calculated CO in normothermic patients after OHS, showing average-to-high positive correlations with the Vigileo and Vigilance. Its easy applicability and cheaper cost make it more readily adaptable in SSA with limited finances and skilled healthcare workforce.

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Background: Traumatic rib fracture (TRF) significantly impacts on patients and predicts mortality. We sought to identify the important causes of morbidity and mortality in patients with TRF in Nigeria. Methods: This study was a prospective observational cohort study of patients with TRF following blunt chest trauma admitted to two hospitals for 4 years. Patients were analyzed according to age, gender, cause of trauma, nature of chest injury, presence of significant subcutaneous emphysema (SE), associated injuries, injury severity scores, and 30-day mortality. Predictors of survival were determined by multiple regression analyses. Results: The 30-day mortality rate was 8.2%. When the relationship between outcome of rib fracture and some study variables were compared; most of the patients who died had SE (P = 0.018), bilateral chest affected (P = 0.002), lung contusion (P = 0.033), and associated injury (P = 0.028). Multiple regression analysis showed some variables as significant contributors of mortality due to rib facture as patients with SE were about 9.5 times more likely to die of rib fracture than those with no SE (odds ratio [OR] = 9.565; 95% confidence interval [CI] for OR = 1.054–86.799; P = 0.045), those with pneumohemothorax were about 5.7 times more likely to die from rib fracture than those with no pneumohemothorax (OR = 5.700; 95% CI for OR = 1.005–32.334; P = 0.049) and likelihood of death from rib fracture was found to be reduced in patients with unilateral chest affected compared with those with bilateral chest affected (OR = 0.088;95% CI for OR = 0.014–0.544; P = 0.009). Conclusion: SE, pneumohemothorax, and involvement of both hemithoraces were identified as predictors of survival following TRF, and thus, there should be the need expeditiously to manage the patients.

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Chemo port is a boon for majority of cancer patients for the comfort it provides for the delivery of chemotherapy. After completion of chemotherapy, it is advisable to remove the chemo port. Removal of chemo port is less morbid procedure and complications occur very rarely. Here by we share our experience of bleeding encounter during chemo port removal and further management. A 36-year-old woman diagnosed with breast cancer underwent breast conservation in 2012. She completed post-operative chemoradiotherapy. 6 years later she presented for follow-up and with no evidence of recurrence, she was advised for chemo port removal. During removal of chemo port, bleeding was encountered from non-visualised source. She was immediately transferred to cardiovascular surgery department. A venogram was performed revealing chemo port in one of the tributaries of subclavian vein and tear in the anterior wall of subclavian vein. Tear was repaired with clips and removal of the chemo port was done ligating the tributary. Chemo port removal is a less morbid procedure and complications are very rare. However, when encountered with complications, one must be learned enough to sought with them. Interdepartmental communication and instant matured decisions will guide in preventing catastrophic events and are lifesaving.

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The principles of airway control, breathing and circulation maintenance provide the starting point of care for patients with thoracic injury. Intravenous access, thoracostomy tube insertion and balanced resuscitation can address most of the issues seen. Endovascular techniques have altered the course of care for patients with blunt aortic injury. Rib plating holds promise regarding enhanced recovery from a flail chest. This article reviews the basic principles and highlights the changing landscape in thoracic trauma.

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Cardiac amyloidosis is an underdiagnosed cause of heart failure. It occurs secondary to the deposition of amyloid protein in the myocardium. The main types of cardiac amyloidosis include light chain cardiac amyloidosis (AL), hereditary (hATTR) amyloidosis, and wild type (wtATTR) amyloidosis. Prognosis is poor when diagnosis is delayed. Early recognition and diagnosis are critical for improved outcomes. Cardiac amyloidosis, previously with limited treatment options, now has multiple pharmaceutical therapeutic options available. Increasing awareness of amyloidosis among patients and clinicians alike may lead to increased screening and diagnosis with institution of medical therapy early in the disease course. Particular attention needs to be focused on high risk populations, the elderly and patients of African ancestry.

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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.

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Obstructive sleep apnea (OSA) is a common and potentially life-threatening breathing disorder that remains significantly under-diagnosed worldwide. This review summarizes recent epidemiological research that sheds light on OSA in the African context for the first time, and describes the pathophysiology, clinical manifestations and treatment options. The author is hopeful that this information will assist clinicians in diagnosing and managing OSA patients, and inspire researchers to develop better diagnostic and treatment modalities.

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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.

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Background: Open heart surgery is nonexistent or undeveloped in many African countries due to the prerequisite for specialized multispecialty teams, expensive equipment, and consumables. This review aims to outline strategies for facilitating local skilled workforce training, improve patients' access, and sustain heart surgery in Africa's most populous nation. Methods: We reviewed the demographic, socioeconomic, and health metrics published by the United Nations, the World Health Organization (WHO), the World Bank, and other relevant sources for the top three African economies – South Africa, Nigeria, and Egypt. Results: South Africa classified as upper-middle-income nation with gross national income [GNI] $12,475–$4126 spends 8.8% of gross domestic product (GDP), while Egypt and Nigeria both classified as lower-middle-income nations GNI $4125–$1046 spends 5.6% and 3.7% of GDP, respectively, on health care. Egypt performed 45%, South Africa 39%, and Nigeria 0.1% of their WHO projected annual heart surgery volume in 2015. These capacities are consistent with the human development index (HDI), thoracic surgeon-to-population ratio, and health insurance coverage ranking of these countries. Conclusion: Although gross income per capita is comparable, the HDI - a better discriminator of development is higher in Egypt with 0.69 against 0.51 in Nigeria, as evidenced by their respective heart surgery capacities. While the WHO projected 72,000 cases/annum for Nigeria is unattainable with the present workforce, the Pan African Society for Cardiothoracic Surgery (PASCATS) 40/1 million population projection of 7200 cases/annum appears a more realistic goal. However achieving even this modest target will require government political willpower and increased budgetary allocation for expanding insurance coverage. PASCATS advocates three mentorship models: resident senior local consultant, mission teams and senior expatriate consultant, with centralization through regional referral centers as viable pathways to develop cardiac surgery in sub Saharan Africa. Regionalization optimizes the scarce workforce and resources and therefore by combining assets can fast track skill acquisition by trainee surgeons.

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The gold medal; recognition as "being first" is an icon of western (Post Hellenic) culture. However just behind the victor are concepts and forces that presaged victory, discovery or complete insight.

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The coronavirus disease also known as COVID-19 was discovered at the end of 2019 following epidemic of acute respiratory syndrome in humans in Wuhan, China. It leads to lung destruction at acute stage of the disease and, possibly, progressive lung destruction from extensive inflammatory process at the ground zero which is the lung. This will eventually lead to a permanent scaring of the lungs with reduction in the oxygenation of the lungs and eventually end-stage lung disease. The use of ventilations and extracorporeal membrane oxygenation does not seem to hold the ace in guaranteeing a long-term relieve, but lung transplant for the condition may be the solution in a long-term basis.

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Neurofibroma and schwannoma are rare benign peripheral nerve sheath tumors and both combined account for the majority of intrathoracic neurogenic tumors seen in adults. They are difficult to distinguish clinically except by immunohistochemistry. A 50-year-old female nonsmoker presented with a 2-year history of right-sided chest pain, cough, and shortness of breath. Chest X-ray showed a large right chest mass confirmed on chest computed tomography scan and measured 14 cm Χ 15 cm Χ 10 cm. The patient subsequently underwent a right posterolateral thoracotomy with complete resection of the tumor, which was diagnosed on immunostains as a neurofibroma. At 1-year follow-up, the patient remains asymptomatic with no evidence of recurrent tumor.

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Objectives: Conservative management of rib fractures has been the standard of care. Recently, surgical fixation with rib plating is emerging as a superior option for flail chest (FC) and multiple rib fractures. This review details our experience with surgical fixation. Materials and Methods: The medical records of 18 patients with severe chest wall injuries referred to the cardiothoracic surgery service at a level 1 trauma center from January 2010 to December 2015 were retrospectively reviewed. 66.7% were male, mean age 58.4 ± 14.5, Glasgow Coma Score 13.3 ± 3.3, and injury severity score 20.4 ± 11.7. 77.8% (14/18) had multiple rib fractures, half with FC, 22.2% (4/18) sternal fractures, and 61.1% of patients were involved in motor vehicle accident. All patients underwent surgical stabilization except three with isolated sternal fractures treated conservatively. Results: 3.4 ± 0.5 ribs were plated in FC versus 2.4 ± 0.5 in non-FC patients. 64.2% had concomitant decortication and 7.1% lung wedge resection. All FC patients had severe lung contusion and respiratory failure requiring preoperative mechanical ventilation mean 10.7 ± 7.9 days. Postoperative ventilatory support was 7.4 ± 4.9 days in FC versus <24 h in non-FC patients. 57.1% of FC patients required tracheostomy for prolonged intubation. Mean interval to surgery, Intensive Care Unit, and hospital length of stay (LOS) was 13.3 ± 5.3, 22.4 ± 14.9, and 29.7 ± 9.2 in FC versus 5.3 ± 3.8, 10.3 ± 10.4, and 14.3 ± 9.3 days, respectively, in non-FC patients. 85.7% received blood transfusion, mean 5.7 ± 3.7 in FC versus 42.8% mean 3.7 ± 0.6 units in non-FC patients. Morbidity in FC patients were pneumonia 42.8%, empyema 14.2%, ARDS 14.2%, and acute kidney injury (AKI) 14.2% compared to non-FC patients AKI 25.0% and empyema 12.5%. There were no deaths. Conclusions: Rib plating of complicated chest wall injuries may reduce morbidity, hospital LOS, chronic disability, and should be considered in FC and multiple rib fractures.

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The field of pharmacy and the role of pharmacists have expanded remarkably within the past thirty years. Clinical pharmacists' postgraduate educational training has prepared them to be competent in patient-centered care and pharmacy operational services that can be applied to any practice setting including specialized fields of clinical pharmacy such as infectious diseases and anticoagulation. Studies have also revealed the impact of clinical pharmacists on medication error reduction within the pediatric and adult critical care units, improved nutritional status in hematopoietic stem cell transplant patients, and reduced readmission rates of patients with heart failure. Highlights of selected literature showcase the role clinical pharmacists' play within the multidisciplinary team and its significant impact on both clinical and economical outcomes.

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A 36-year-old male motorcyclist involved in a motor vehicle accident (MVA) with loss of consciousness and sustained multiple orthopedic injuries and a traumatic ventricular septal defect (VSD) which was hemodynamically stable. He then underwent emergency orthopedic surgery and was discharged after 5 weeks to rehabilitation. Subsequently, 6 months later, he underwent an elective repair of a 1.5 cm apical septal defect with uneventful recovery. A meta-analysis of 61 other reports of traumatic VSD revealed MVA as the most common etiology in 57.8%, predominantly males in 85.5% and younger age group <30 years in 87.5%. The midmuscular septum was involved in 43.6%, and patch closure was used in the majority of patients performed through a right or left ventriculotomy. Operative mortality was zero with elective versus 27.3% for emergency repairs, which also had a 27.3% VSD recurrence. 28.6% of the patients required concomitant cardiac surgical procedures while two patients (4.1%) both with perimembranous VSD required a permanent pacemaker. Less invasive transcatheter closure was successfully deployed in three patients without any complications, and it is an alternative in patients with a suitable anatomy and no associated cardiac injuries requiring surgery. Conservative therapy as a mainstay of treatment should be reserved for asymptomatic small defects with hemodynamically insignificant shunts.

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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.

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Aim: About 90% of kidney cancers are renal cell carcinoma (RCC), and one-third of them are metastatic at the time of diagnosis. Most RCC metastases are to the lung. In this article, we present the results of a series of pulmonary metastasectomies for RCC in our institute. Materials and Methods: Twenty cases who underwent pulmonary metastasectomy for RCC between 2007 and 2017 were retrospectively reviewed. Patients were classified according to the age, sex, smoking history, duration of disease-free survival, number of metastatic lesions, median survival time, survival time after metastasectomy, type of surgery, and whether they received immunotherapy. Results: Fifteen of the patients were male and five were female. The mean age was 60-year-old (range: 28–86-year-old). Nineteen of the 20 patients had a history of nephrectomy. The median disease-free survival time was found to be 16.5 months while the median survival time after nephrectomy was 43.3 months. The number of detected metastatic lesions ranged from one to eight, and the location of the majority of them was intraparenchymal. Survival time after metastasectomy was found to be 20.6 months. Surgical approaches included bilateral metastasectomy through median sternotomy, unilateral wedge resection, and lobectomy through video-assisted thoracoscopic surgery or thoracotomy. Conclusion: The results of a combination of pulmonary metastasectomy and immunotherapy treatment were found to be better than immunotherapy or surgery alone. However, further study is needed with a larger series to support this argument.

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Total blood management during cardiopulmonary bypass requires intentional strategies to be effective. Key areas of impact involve creating a team atmosphere, reducing hemodilution, and optimizing a point of care testing. True team atmospheres realize innovative collaboration by establishing an appropriate discussion platform and maximizing complimentary gender-specific contributions. Technical strategies, from a perfusion standpoint, focus on disposable components, autologous blood management, and cardioplegia modifications. Finally, point of care testing is utilized to justify, improve, and standardize practices. Perfusion's contribution to strategic blood management contributes to improved patient outcomes.

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Objective: Off-pump coronary artery bypass (OPCAB) has been demonstrated to be a safe technique with similar outcomes to on-pump coronary artery bypass (ONCAB) in low-risk patients, while its role and benefits in high-risk patients are the subject of ongoing clinical trials. This review compares our high-risk patients aided by intra-aortic balloon pump (IABP) with low-risk patients undergoing OPCAB to identify any differences in outcomes. Materials and Methods: One hundred and twenty-four patients who underwent OPCAB surgery between January 2004 and December 2013 were retrospectively reviewed. 61.3% were males, 57.3% were African Americans, mean age was 62.7 ± 13.3, and range was 30-90 years. Patients were divided into Group 1, 26 (21.0%) patients with IABP and Group 2, 98 (79.0%) patients without IABP. Group 1 patients had higher risk profile with mean ejection fraction (EF) 26.0 ± 10.8 and EF ≤20 present in 46.1% compared to 45.2 ± 11.9 and 5.1%, respectively, in Group 2 (P < 0.001). Results: 92.35% of Group 1 and 82.7% of Group 2 patients had multivessel disease with a mean number of bypass grafts 2.9 ± 0.97 versus 2.75 ± 0.8, respectively (P < 0.364). Left internal mammary artery (LIMA) to left anterior descending (LAD) was performed in all Group 1 and 97.9% of Group 2 patients, with saphenous vein graft (SVG) to the left circumflex and right coronary arteries in 73.1% versus 62.2% and 57.7% versus 52.0% of Groups 1 and 2, respectively. Complete revascularization occurred in 88.5% and 90.8% of Groups 1 and 2, respectively (P < 0.990). 4.0% were converted to ONCAB for either hemodynamic instability or intramyocardial coronary artery. Major morbidities were re-exploration for bleeding 3.8% versus 1.0%, stroke 3.8% versus 2.0%, acute kidney injury 11.5% versus 0%, and prolonged intubation 15.4% versus 2.0% in Groups 1 and 2, respectively. Euroscore II predicted (P) versus observed (O) mortality was 4.56% versus 4.03%, for Group 1, 7.82% versus 7.69% and Group 2, 3.64% versus 3.06%, and O/P ratios 0.88, 0.98 and 0.84 respectively. Two (2.0%) females in Group 2 with single LIMA to LAD underwent repeat revascularization with SVG to the LAD within 90 days. Conclusion: IABP helps stabilize hemodynamics during OPCAB in high-risk patients with moderate to severe left ventricular dysfunction. Mean number of bypass grafts and predicted versus observed mortality were similar between the low- and high-risk groups.

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Traumatic manubriosternal dislocation is a rare sequel of blunt thoracic trauma. We report a case of 22-year-old man who presented with the history of road traffic accident and sustained manubriosternal dislocation. Initial chest X-ray did not show the lesion; however, a follow-up lateral view revealed the dislocation. In addition, the patient had fracture of the lamina of the C7 vertebra. In view of uncomplicated manubriosternal dislocation and the absence of any major associated injury, the patient was managed conservatively. In the presented case, we discuss the mechanism of injury, type of dislocation.

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