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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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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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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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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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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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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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 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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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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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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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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Objective: Some earlier studies have suggested that cocaine use in African-Americans (AAs) results in higher defibrillation thresholds. We are therefore reviewing our own experience with this racial group for comparison. Materials and Methods: We retrospectively reviewed the medical records of AA patients who had placement by a single operator of implantable cardioverter defibrillator (ICD) at an inner city hospital from January 2006 to December 2015. Results: Seventy-four patients, mean age 59.2 ± 12.9 years, comprising 37 (50.0%) males, underwent ICD implantation of which 67.6% were single chamber and 32.4% dual chamber devices. Diagnosis was nonischemic cardiomyopathy in 68.9% and indication for device therapy was primary prevention in 87.8%. Sixty-six (89.2%) patients were noncocaine users, whereas 8 (10.8%) were cocaine abusers. The mean age, ejection fraction, and defibrillation threshold between the noncocaine and cocaine users were 60.2 ± 12.8 versus 51.3 ± 12.4 (P = 0.642), 21.6 ± 8.3 versus 16.1 ± 4.6 (P = 0.0704), and 23.5 ± 5.0 versus 25.0 ± 8.4 (P = 0.447), respectively. Biotronik device patients had complete follow-up and they had an all-cause mortality of 28.8% (15/52), while 27.0% (10/37) of the survivors had at least one or more antitachycardia pacing or high voltage shock therapies. Conclusion: There was no statistically significant difference in defibrillation threshold testing observed in AA patients in our series between noncocaine and cocaine users as previously seen in some earlier small reviews. Larger studies or meta-analysis of several studies to accumulate a substantial number of AAs using cocaine may be required for a definitive answer to the question.

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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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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 rhythm after valve surgery has been shown to impact on long-term outcome with increased thromboembolic risk in patients with persistent atrial fibrillation (AF) despite anticoagulation. Concomitant Cox maze IV (CMPIV) or pulmonary vein isolation using bipolar radiofrequency ablation has been demonstrated to reduce stroke risk when successful in restoring stable sinus rhythm. We report the case of a 27-year-old male with rheumatic mitral stenosis, persistent AF, and left atrial thrombus who underwent concomitant CMPIV radiofrequency ablation during mechanical mitral valve replacement and has subsequently remained in sinus rhythm and free from thromboembolism 10 years postoperatively. Strategies aimed at addressing AF and the left atrial appendage at the time of valve surgery may be beneficial in reducing embolic stroke and should be part of the contemporary surgeons armamentarium. Concomitant ablation when the capacity and expertise is locally available should therefore be considered in low-risk patients without severe left ventricular dysfunction or severe pulmonary hypertension during valve surgery in patients with persistent AF. When ablation is not feasible or equipment unavailable, consideration should then be given at a minimum to excision or exclusion of the left atrial appendage which is the most common source of emboli in AF as an alternative stroke reduction strategy.

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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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A case of penetrating chest trauma due to stab injury is described. At presentation to the emergency department (ED), he was hemodynamically unstable and only a small sutured left parasternal wound was noted. Extended focused assessment sonography in trauma revealed pericardial tamponade and left-sided hemothorax. He was shifted to the operating room immediately and rent in the anterior wall of the main pulmonary artery was closed. Timely diagnosis and the management strategy in ED resulted in successful outcome.

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Objective: There are conflicting data on the influence of race and gender on the outcome of patients undergoing coronary artery bypass graft surgery (CABG), with blacks and females showing higher operative mortality (OM) in some series and not others. Materials and Methods: The medical records of 176 black patients undergoing isolated CABG by a single surgeon from 2000 to 2014 were retrospectively reviewed. The mean age was 61.9 ± 11.2 years and majority 93 (52.8%) were males. Identified risk profiles were peripheral vascular disease 53 (30.1%) patients, insulin-dependent diabetes mellitus 49 (27.8%), end-stage renal disease (ESRD) 27 (15.3%), chronic obstructive pulmonary disease 27 (15.3%), cerebrovascular disease 24 (13.6%), and HIV/AIDS 5 (2.8%). One hundred and forty (79.5%) had severe triple vessel disease, 30 (17.0%) left main disease, and ejection fraction mean 43.0 ± 14.3. Results: One hundred and twenty-eight patients (72.7%) underwent on-pump and 48 patients (27.3%) off-pump coronary artery bypass graft (OPCAB), with 150 (85.2%) urgent surgeries. EuroSCORE-II (ES-II) score was 3.86 ± 3.18 while observed OM was 6.81% (12/176). There was no difference in OM between males and females 6.45% versus 7.22% (P = 0.924) and on-pump and OPCAB 7.81% versus 4.16% (P = 0.604). Univariate analysis identified ESRD and ES as predictors but on multivariate analysis only ESRD with odds ratio 4.630 (95% CI: 1.321-16.229, P = 0.017). The society of thoracic surgeons (STS) quality measurement task force major complications were acute kidney injury 6.81%, prolonged ventilation 6.81%, stroke 3.40%, deep sternal wound infection 2.27%, and reoperation 1.70%. Overall 1 and 5 years survival was 90.0% and 73.9%, respectively, with no significant difference between males and females 92.4% and 75.0% versus 86.4% and 70.9%, respectively, when P = 0.764. Conclusion: The observed/expected 1.76 ratio may partly be due to higher number of urgent and ESRD patients of 85.2% and 15.3% compared to 27.9% and 2.36-7.90%, respectively, in the STS database. Our ESRD patients had 4΍ times odds of death than non-ESRD. Despite males having slightly higher risk profiles, long-term survival was similar with females and overall 1 and 5 years survival comparable to blacks in other series.

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Seven percent of mediastinal tumors are of thyroidal origin. The incidence of mediastinal/substernal thyroid masses ranges from 2.6% to 21% of patients undergoing thyroidectomy. The wide range in reported incidence is largely due to variation in the definition of substernal thyroid masses. They can be defined as a thyroid gland with cervical extension that descended below the thoracic inlet. The purpose of this report is to discuss an 84-year-old male with shortness of breath, pain radiating to the chest, dysphagia, and odynophagia. The patient was admitted to the hospital for retrosternal chest pain and pneumonia. A computerized axial tomography scan of the chest revealed a mediastinal mass compressing the trachea. The patient underwent neck and mediastinal exploration, with complete excision of the mediastinal thyroid. We were able to deliver the mass into the neck from the mediastinum avoiding the need for sternotomy or thoracotomy.

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