Category: Aortic Dissection Page 2 of 22

More national history data needed for ascending aortic aneurysm

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There was a low growth rate for moderately dilated ascending aorta, according to a systematic review and meta-analysis published in JAMA Network Open.

Ming Hao Guo, MD, of the division of cardiac surgery at University of Ottawa Heart Institute, Canada, and colleagues analyzed data from 8,800 patients (mean age, 58 years; 76% men) from 20 studies from 1946 to May 2017. Studies were included in the meta-analysis if they reported rate of dissection or rupture, growth rate or all-cause mortality in patients with ascending aortic aneurysm.

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Data that were extracted include study design, demographics, follow-up, sample size, initial aneurysm diameter, patient risk factors and comorbidities, incidence of dissection or rupture, aneurysm growth rate during follow-up, incidence of elective ascending aortic surgery, size at dissection or rupture and all-cause mortality. Total follow-up time was 31,823 patient-years.

At enrollment, the mean initial aneurysm size from 13 studies was 42.6 mm.

All studies had a combined effect estimate for annual growth rate of 0.61 mm per year (95% CI, 0.23-0.99; I2 = 92%). During a median follow-up of 4.2 years, the pooled incidence of elective aortic surgery was 13.82% (95% CI, 6.45-21.41; I2 = 56%).

The linearized rate of the composite outcome of aortic dissection, all-cause mortality and aortic rupture was 2.16% per patient-year (95% CI, 0.79-3.55, I2 = 64%). The linearized rate for all-cause mortality was 1.99% per patient-year (95% CI, 0.83-3.15; I2 = 84%).

Researchers did not find a significant relationship between the year of study completion and primary outcomes and initial aneurysm size.

“These results require cautious interpretation as a large number of patients in the studies who met guideline criteria for intervention underwent elective aortic surgery,” Guo and colleagues wrote. “More robust natural history data from prospective studies or randomized clinical trials are necessary to better inform clinical decision-making in patients with ascending aortic disease.”

In a related editorial, Thoralf M. Sundt, MD, chief of the division of cardiac surgery and director of the Corrigan Minehan Heart Center at Massachusetts General Hospital, wrote: “To be sure, for patients, once they have been told they have an aneurysm (read, ‘time bomb in your chest’), it is very hard to turn back the clock and reassure them that the likelihood of a catastrophe is low. I suspect the same is true, to some degree, among caregivers. Who among us wants to sit by watching and hoping that we do not get a phone call that an aorta has dissected? Furthermore, our outcome information is asymmetric. The absence of dissection is a nonevent; we do not see it because there is nothing to see. And, of course, we can never know how many of those aortas we replace would or would not have dissected.” – by Darlene Dobkowski

Disclosures: The authors and Sundt report no relevant financial disclosures.

A major surgery left this woman with one leg and no money. Now her family is asking for your help

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Laurie Gonzales-Lewis of Idaho Falls nearly died during surgery to repair an aortic aneurism. | Courtesy photo
IDAHO FALLS – Members of the community are coming together to help an Idaho Falls woman.

Laurie Gonzales-Lewis recently suffered an aortic aneurism. Brittni Messenger, Lewis’ daugher, tells EastIdahoNews.com the aorta began to expand like a balloon. Fluid began leaking in to Lewis’ heart and started crushing it.

When doctors began surgery to repair the problem, they discovered Lewis had an aortic dissection, which was causing her aorta to unravel from the inside out.

“It was shooting blood clots straight up her brain and down to her leg,” Messenger says.

Gonzales-Lewis’ heart stopped twice during this procedure. She spent the next ten days in sedation. Messenger says her mom was declared brain dead and only given a 15-percent chance of survival.

Then, just two days later, Gonzales-Lewis woke up. For three days, everything seemed normal until doctors noticed something unusual.

“The clots were killing all the tissue. It was causing her excruciating pain until blood flow in the the top half of her right foot stopped,” Messenger says.

Doctors amputated her right leg from the knee down.

Gonzales-Lewis’ condition now requires constant care. Messenger says her step-dad is so busy taking care of her mom that he is unable to work. Disability and insurance benefits don’t kick in until October, leaving them with no means of financial support.

Now Messenger and others are hosting a fundraiser to help with medical costs and a prosthetic leg for Lewis.

The fundraiser kicks off at 5 p.m. Saturday inside York Hall at 954 W. 65th S. Dinner will be served, followed by a raffle around 6:30 p.m.

The cost is $18 for adults, $8 for kids six and up. Kids five and under are free. Each purchase comes with a $5 raffle ticket.

“Anything (people can contribute) is so appreciated right now. It’s been such a hard time for her. It’s completely changed her lifestyle and she’s had to readapt to everything. But it’s amazing that she’s here and we are grateful for the community support,” says Messenger.

York Hall is located in the vicinity of the Budweiser plant.

To learn more about the Benefit dinner and raffle, visit their Facebook page.

Breastfeeding Mom Pumping Hours After Open-Heart Surgery Is the Definition of Badass

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Stephanie Sampson is one incredibly lucky mother and she knows it. Not just because she is a mom of three healthy kiddos but because she is here to see just how amazing they are. That’s because Sampson beat the odds and unknowingly gave birth to her youngest, Eli, with an undiagnosed heart condition that in all likelihood, should’ve killed her — especially during labor. But instead, Sampson not only survived childbirth with an aortic aneurysm, this fierce mom was pumping breast milk immediately following open-heart surgery to repair a chronic aortic dissection that few survive. more………………………

Great and fantastic MIRACLE for sure!

Rock from the Heart for Aortic Health

Brian,

My name is Amy Johnson, and my husband, Pete, and I recently started the Rock from the Heart project. Pete is a musician (drummer) and had surgery last July to repair an ascending aortic aneurysm and replace his aortic valve. We know how fortunate he was that his condition was diagnosed in time to save his life. Before his surgery, Pete said, “if I survive this, I want to do something BIG to help others. I don’t want to just go on with life. I want to make a difference.” So, last December we came up with the Rock from the Heart idea. We reached out to several organizations and ended up partnering with the John Ritter Foundation and are planning the Rock from the Heart concert to raise awareness. Since your organization is also focused on the cause, we wanted to get the information to you.

Here is a link to our website: www.rockfromtheheart.org

The concert (scheduled for Feb 2019) will feature a nationally known music act and held at the Pantages Theater in downtown Minneapolis (seats 1000). Tickets will be $49 for the concert and $200 for a special VIP reception prior to the concert (at which some local and national celebrities will be in attendance.) We plan to announce the event and open ticket sales in mid to late August, but we are starting to pull together our event volunteers and fundraising efforts now. I’m reaching out to other organizations who might be willing to help us in some way, whether it is getting involved in the event planning/ fundraising, attending the event, or simply sharing the event (once the date is closer).

Let me know if you’d like to be involved in some way. Below are links to our Facebook, Twitter and Instagram accounts. Our mission is to raise awareness for aortic health, providing accurate information about bicuspid valve disease and aortic aneurysms by reaching out to the community through music.

Thanks for reading. I’ve visited your website and love how you are sharing valuable information in an easy to use format.

Here is a photo of me, my husband Pete, and Tia and Carin from Aortic Hope – they came out to see Pete drum last night:

Amy Johnson

Event Chair/ Project Director

Rock from the Heart

office@rockfromtheheart.org

www.RockFromTheHeart.org

https://www.facebook.com/pg/RockFromTheHeartMN

https://www.instagram.com/rockfromtheheart/

Brian’s update

Well, I am coming up on 15 years 8/23/2018. My Latest CT/Angio says everything is still stable verified by the U of W team and my buddy at Stanford. But… my valve is still leaking moderately, but…..My left ventricle is getting enlarged somewhat. I am now going to get a second opinion at Swedish Hospital. I am thinking that the suctureless value with the minimally invasive technique where they don’t have to cut your entire sternum would be great. Also, less time on the Heart Lung Machine too and quicker recovery.

——————————————————
Regards,
Enrique Zolezzi, MD
Cardiology Fellow

Transthoracic Echocardiogram 3/15/2018:
CONCLUSIONS:
Bicuspid aortic valve (fusion of right and left coronary cusps) with moderate regurgitation and an antegrade velocity of 1.9 m/s.
Severe left ventricular dilation (EDVI 110 ml/m2, ESVI 40 ml/m2) with normal systolic function, EF 64%.
Dilated aortic sinuses, 4.3 cm diameter. Ascending aortic graft not well seen. Diastolic flow reversal seen in the descending thoracic aorta. The aorta would be better imaged by CT or MRI.
Normal estimated pulmonary systolic pressure, 28 mm Hg.
Normal right ventricular size and systolic function.
Compared to 12/10.2015, aortic regurgitant severity is similar with an increase in LV EDVI from 89 to 110 and ESVI from 34 to 40 ml/m2.
ice of Catherine M Otto, MD
04/05/2018 10:00 AM
PrintPrintDeleteDelete
RE: Latest Echo
Dear Mr. Tinsley,

The echocardiogram shows the degree of aortic valve regurgitation remains the same and is moderate. The size of the aorta is also unchanged. These results are reassuring. We look forward to seeing you in clinic next month.

Enrique Zolezzi, MD
Cardiology Fellow

Predictors of acute aortic dissection diagnosis identified

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Predictors of acute aortic dissection diagnosis identified
Ohle R, et al. Acad Emerg Med. 2018;doi:10.1111/acem.13356.

April 11, 2018
Aortic aneurysm and hypotension were among the clinical features identified as putting patients at high risk for acute aortic dissection in a case-control study.

Robert Ohle, MSc, MA, MB, FRCPC, from the department of emergency medicine, the Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada, and colleagues conducted a historical matched case-control study of adults presenting to two tertiary care EDs or one regional cardiac referral center with possible acute aortic dissection between 2002 and 2014.

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The researchers analyzed 194 patients with nontraumatic acute aortic dissection confirmed by CT or echocardiography and 776 age- and sex-matched controls who had a triage diagnosis of truncal pain but no clear diagnosis upon basic investigation (mean age, 65 years; 67% men).

Ohle and colleagues found that acute aortic dissection could be ruled out by absence of abrupt-onset pain (sensitivity = 95.9%; negative likelihood ratio = 0.07; 95% CI, 0.03-0.14).

They determined the following factors can help rule in a diagnosis of acute aortic dissection:

presence of tearing/ripping pain (specificity = 99.7%; positive likelihood ratio = 42.1; 95% CI, 9.9-177.5);
aortic aneurysm (specificity = 97.8%; positive likelihood ratio = 6.35; 95% CI, 3.54-11.42);
hypotension (specificity = 98.7%; positive likelihood ratio = 17.2; 95% CI, 8.8-33.6);
pulse deficit (specificity = 99.3%; positive likelihood ratio = 31.1; 95% CI, 11.2-86.6);
neurologic deficits (specificity = 96.9%; positive likelihood ratio = 5.26; 95% CI, 2.9-9.3); and
a new murmur (specificity = 97.8%; positive likelihood ratio = 9.4; 95% CI, 5.5-16.2).
“Patients with one or more high-risk feature … should be considered high risk, whereas patients with no high-risk and multiple low-risk features (absence of abrupt-onset pain, history of ischemic heart disease and diabetes) are at low risk for acute aortic dissection,” the researchers wrote.

History of ischemic heart disease decreased the probability of an acute aortic dissection diagnosis, but this was “likely due to it being a risk factor for an alternative diagnosis such as acute coronary dissection,” Ohle and colleagues wrote.

“Ohle [and colleagues] have done a great job at telling us how acute aortic dissection presents to emergency departments,” Lane McNeil Smith, MD, PhD, assistant professor, Lexington Emergency Medicine, Wake Forest Baptist Health, said in a press release. “Are we finally on the verge of a decision rule for this disease that improves our miss rate without ballooning nontherapeutic imaging and costs? This study is a step in the right direction and the authors are in a good position to find the right balance of improved accuracy and increased cost.” – by Erik Swain

Disclosures: The authors and Smith report no relevant financial disclosures.

Aortic Dissection: What’s Next in Endovascular Therapy

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At ISET 2018, Michael Dake summed up the unmet clinical needs for type A and chronic type B dissection, as well as for cases with arch involvement.

OLLYWOOD, FL—Aortic dissection continues to vex clinicians, but creative approaches to treatment are on the horizon, according to one expert in the field.

Michael Dake, MD (Stanford University, CA), who gave a rundown of what’s coming next at the International Symposium on Endovascular Therapy 2018 here, said that while the US Food and Drug Administration broadly approved thoracic endovascular aortic repair (TEVAR) for use in all type B dissections back in 2013, such “‘blanket approval’ comprises a number of different distinct entities associated with type B dissection—complicated, chronic, uncomplicated—all these things.”

Chronic type B dissection “stands out,” Dake said, as a poor fit for TEVAR. Good results are possible but not guaranteed, he continued. There may be continued perfusion and aneurysm degeneration distal to the treated area. Adjunctive false-lumen techniques, from coils to liquid embolics, abound, Dake acknowledged, “but there’s nothing definitive . . . that really can take care of this,” and branched devices involve “long procedures [with] high radiation and still carry significant frequency of endoleaks and complications.”

Instead, converting the type B dissection to aneurysm seems to be the best solution in the near term, Dake said.

Among the type B dissection subsets, “there’s a lot of not-so-subtle differences” that must be considered when thinking about “new horizons,” he observed. Additionally, there are many unanswered questions and unmet clinical needs, Dake said. For instance, he reported, half of attendees polled at last year’s Houston Aortic Symposium said they’d continue medical therapy in a patient with acute uncomplicated type B aortic dissection who was asymptomatic, while 48% chose TEVAR. “That’s a flip of a coin. We have complete equipoise here,” he stressed.

Over the last decade there’s been an attempt to find ways to predict which patients will have disease progression and late aortic events or mortality, in order to “justify a rationale of treating them early” when needed, Dake said. Numerous factors have been identified: aorta and false lumen size, use of calcium channel blockers, gender, age, ulcer-like projections, and the size, location, and number of tears, among other things.

“So, can we predict who is at high risk of expansion or late complications? Yes, we can, but we’re just not very accurate, and there’s a confusing array of too many predictors,” Dake said. Adding a single high-risk factor, specifically aortic diameter > 45 mm, to the scenario posed in the Houston poll tipped the scales, he reported. With that, fully 94% of those present recommended TAVR.

Importantly, though, it’s a question not just of who we should treat but also who we shouldn’t treat, according to Dake. He suggested that medical therapy is the best route for some patients, such as those with chronic type B dissection, connective tissue disease, or a need for chronic anticoagulation, or in cases where there’s unsuitable or unreconstructable access to the aorta. “There are pathology considerations, there are anatomic considerations,” he emphasized.

Who Can We Treat Better?

For dissection with arch involvement, another area in need, one potential solution may be the TAG thoracic branch endoprosthesis (Gore), which Dake and others are currently studying in a pivotal trial. He reported that 58 patients with type B dissection have been treated so far, with two strokes occurring (3.4%), both late.

Lastly, for type A dissection, Gore is conducting an early feasibility study to test a dedicated device, he said.

“A little more on the horizon is this idea of a combined valve conduit including the ascending aorta married to an endovascular valve,” Dake said. Despite proof-of-concept and first-in-human studies, he added, “it’s something that’s not ready for prime time.”

Until these efforts bear fruit, the “current focus of endovascular dissection management is expanding to include not only who we should treat, but who we should treat better,” he concluded. “[For example, the field is moving to increase our prognostic scope beyond how to assess the individual risk to a patient with uncomplicated type B dissection toward how to best predict the risk of disease progression after TEVAR.”

My story: Don’t ignore symptoms of heart attack

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Our family doctor smiled at me sheepishly as he walked into the exam room.

“You’re the last person I would have expected…,” he said trailing off, as I sat there for a check-up two weeks after emergency open heart surgery that saved my life.

Six months earlier, I had passed my annual physical with flying colors.

Years of aerobics, spinning, distance cycling and wrangling a 90 pound Golden Retriever on treks through the woods had left me in good stead. At 62, my heart was strong. My blood pressure was well within the bounds of normal. Everything looked fine.

Then we got to Labor Day.

Around noon, I went to my plot at the community garden about a mile from home to harvest the final fruits of summer for a cookout that evening. When I bent down I felt a sudden excruciating pain shoot through my sternum, up the side of my neck, around my ear and down my jaw.

It lasted maybe five seconds.

I thought about calling for help, but I didn’t collapse. I wasn’t short of breath and my chest didn’t hurt.

So, I gathered my harvest and headed home.

Later that afternoon, I began to feel nauseous. By the time we put the steaks on the grill, I couldn’t stand the smell of food.

My sister, who has been a nurse for years, called to chat and asked about my day.

When I told her what was going on, she was quick to respond.

“You’ve just described the symptoms of a heart attack in a woman. You need to get to the emergency room now,” she said.

When I balked, protesting that the ER would be too busy on a holiday weekend and said I would gladly go in the morning, she doubled down.

“You’ll be dead in the morning,” she said, growing angry at my reticence.

I’ll be wearing red on Friday for Go Red for Women Day, to raise awareness about women’s heart health, and I’m glad I listened to her.

After sitting in the ER for several hours, physicians baffled at my condition ordered a CT scan.

Shortly after the test, a doctor with a horrified look on his face came in and told me I needed to get to Pittsburgh, now.

It wasn’t a heart attack. My heart was fine. But I had suffered a thoracic aortic aneurysm dissection. A weak spot in the biggest artery in my body — the one in which oxygenated blood flows from the heart to nourish the rest of the body — had given out and I was slowly dying.

Within an hour, I was on a helicopter headed for UPMC Shadyside. A surgical team met me in the operating room in the early hours of the morning. They quickly sawed open my chest, stitched a Dacron patch around my aorta and closed me back up.

I’m told the patch should last a lifetime.

We’ve since learned that this condition tends to run in families. Doctors don’t know exactly what gene or genes hold the key to it, but they’ve seen patterns sufficient to raise red flags. In my case, it has emerged over the past 20 years as first my youngest son was diagnosed with an enlarged aorta and more recently as both my mother and her older sister had to have surgery for thoracic aortic aneurysms in their early 80s.

My surgeon assured me my heart was strong and I would recover quickly.

Four days later, I was back home. Within six weeks, I was able to complete a 5K around the track beside the Aerobic Center in Greensburg.

But as I said earlier, I’ll be wearing red this Friday. I’m aware that no one is invincible.

I had a sister who knew how heart issues manifested in women. We all should be so lucky.

Debra Erdley is a Tribune-Review staff writer. Reach her at 412-320-7996, derdley@tribweb.com or via Twitter @deberdley_trib.

After doctors saved Fort Worth woman’s life, she’s opening her heart again… this time it’s to say …

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DALLAS– At the young age of 35 years-old, Mary Worthman is a wife, a mom, and a miracle — because she’s alive.

Click that article source button to watch the video please. 

Surgeons saved Mary’s life of last year. Now, the Fort Worth woman is opening her heart, again. But, this time it’s to say thank you.

Mary had an aortic dissection, basically a tear in her heart. Most people who have one of those don’t ever even make it to the hospital. But, Mary did. And doctors saved her life.

Two open heart surgeries later, she’s meeting the doctors and nurses who saved her life.

“How the heck are you, Doc?” asks Mary’s husband as he grabs Dr. Michael Nazarian’s hand for a firm handshake. “Good to see you; you get a hug.” Dr. Narzarian  tells Mary. “Aww, thanks.” she responds as she hugs him back.

“I try and not to focus on the things I can’t do, just be grateful that I am here and everything.” Mary tells the doctor and nurses.

“It’s always cool,” Dr. Narzarian says. “For me, that’s the fun. like you get to meet people in some very precarious situations, where they are in life-threatening situations, and you help them through it. And when results are good, which they usually are, it’s great.”

This type of celebration seems to be a thing now.

You may recall the teen whose video went viral online. He was looking for the nurse who saved his life during a car crash 17 years ago. A crash that killed his parents.
Caleb and his family Skyped with some caregivers at Medical City McKinney.

I could really use your help please

[dropcap]I[/dropcap] am basically drowning in debt. It’s 100% my fault and my lack of financial stupidity. However, I am also aware this was also tied to my depression and my days of buying and selling tennis racket are over. I finally had a come to Jesus meeting and have adopted the Dave Ramsey plan of getting out of debt. My problem is that I can’t quite start, meaning I am not bringing enough in to cover my bills. Again, my problem not your -my own lack of responsibility. But, I am now 1000% committed to getting myself and family out of dept. It’s been all my fault for my careless spending on crap. I have nothing to really show for it. No fancy house, no fancy cars, absolutely really nothing.

If you are a person that has ever considered about wanting to help out someone who really needs it, then I am that person. I have been running this site for 14 years now and paid for it all by myself. I ONLY would ask if you are that person (s) that feels it in your heart to share some love with a donation, that would be wonderful. Again, don’t feel sorry for me please. I got myself into this, I MUST get myself out of it. 

My address for mailing is:

2921 101st Place SE, Everett, WA 98208

Or I have a GO FUND ME button to click as another option to donate to the site. Again, not mandatory and ONLY, and ONLY if your financial situation permits it. Don’t sacrifice your family’s financial obligations to help me please. Only if you are in a situation where you have the ability to offer a donation. 🙂

In summary, I don’t know who you might be, but if you feel it in your heart and you are not sacrificing anything from your own family, it would be wonderful!

May the GOOD LORD richly bless you! And I hope your AD is doing well. I am due for a CT/Angio on 2/14/18. It will be 15 years on 8/22/18 since my AD Ascending dissection date.

I hope I am still remaining stable. I know my heart valve is at a moderate leak and starting to wonder if the reason I am so tired is perhaps the leaking? I will be getting an echo soon too!

Best!

Brian 🙂

Stroke after emergent surgery for acute type A aortic dissection: Predictors, outcome and neurological recovery

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Dumfarth J, et al. – Researchers aimed at identifying the predictors for stroke after emergent surgery for acute type A aortic dissection. In addition, they analyzed the impact on morbidity, neurological recovery and mid-term survival. Independent preoperative predictors for postoperative stroke were recognized. Despite an association of postoperative stroke with significant morbidity and postoperative complications, data could not confirm a significant impairment in mid-term survival. Data revealed that postoperative stroke was associated with significant morbidity and postoperative complications, however, its association with significant impairment in mid-term survival could not be confirmed.

Methods

  • Three hundred and three (71.9% men, mean age 58.9 ± 13.6 years) patients with acute type A aortic dissection underwent surgical repair from 2000 and 2017.
  • Retrospective evaluation of clinical and imaging data was performed.
  • Depending on the presence of postoperative stroke, patients were divided into 2 groups.
  • Results
  • In 15.8% (n = 48) of the patients, researchers detected postoperative stroke.
  • Among patients with postoperative stroke, higher rates of preoperative cardiopulmonary resuscitation (stroke: 18.8% vs no stroke: 3.5%, P < 0.001) and malperfusion syndrome (stroke: 47.9% vs no stroke: 22.4%, P < 0.001) were evident.
  • As per multivariable analysis, independent predictors for postoperative stroke included the presence of bovine aortic arch [odds ratio (OR) 2.33, 95% confidence interval (CI) 1.086–4.998; P=0.030], preoperative cardiopulmonary resuscitation (OR 6.483, 95% CI 1.522–27.616; P=0.011) and preoperative malperfusion (OR 2.536, 95% CI 1.238–5.194; P=0.011).
  • Postoperative stroke was found to have a strong impact on morbidity and was correlated with greater rates of postoperative complications and a markedly longer hospital stay (stroke: 23 ± 16 days vs no stroke: 17 ± 18 days, P=0.021).
  • No independent association was observed between postoperative stroke and in-hospital mortality (adjusted OR 1.382, 95% CI 0.518–3.687; P=0.518).
  • Patients with stroke and patients without stroke showed no difference in terms of mid-term survival.
 

Biomarker-Assisted Diagnosis of Acute Aortic Dissection

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Articles, see p 250 and p 259

The diagnosis of acute aortic dissection (AD) can be difficult because of its rarity and varied presentation, and this often leads to underdiagnosis. Recent guidelines from both the United States (American Heart Association and American College of Cardiology)1 and Europe (European Society of Cardiology)2 have made recommendations on diagnostic algorithms to improve care.

The American Heart Association/American College of Cardiology guidelines published in 2010 proposed using the Aortic Dissection Detection Risk Score (ADD-RS) as a primary screening tool. The ADD-RS is based on scoring the presence of 3 categorical risks: high-risk conditions (Marfan syndrome, family history of aortic disease, known aortic valve disease, known thoracic aortic aneurysm, or previous aortic manipulation including cardiac surgery), pain features (chest, back, or abdominal pain described as being of abrupt onset, severe intensity, or ripping/tearing), and examination features (evidence of perfusion deficit including pulse deficit, systolic blood pressure difference or focal neurological deficit, or with aortic diastolic murmur and hypotension/shock). The presence of ≥1 markers within each of these categorical features is given a score of 1 with a maximum cumulative score of 3, if all 3 categorical features are present. A score of 0 is considered low risk, a score of 1 is considered intermediate risk, and a score of 2 or 3 is considered to be high risk. The ADD-RS was investigated in the International Registry of Acute Aortic Dissection database in 20113 using the International Registry of Acute Aortic Dissection’s large contemporary repository of AD cases with documentation of clinical presentation and features, management, and outcomes. The study in 2538 cases validated that the ADD-RS has a high sensitivity of 95.7%.

The …

 

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Diagnostic Accuracy of the Aortic Dissection Detection Risk Score Plus D-Dimer for Acute Aortic Syndromes

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The ADvISED Prospective Multicenter Study

Peiman NazerianChristian MuellerAlexandre de Matos SoeiroBernd A. LeidelSibilla Anna Teresa SalvadeoFrancesca GiachinoSimone VanniKarin GrimmMúcio Tavares OliveiraEmanuele PivettaEnrico LupiaStefano GrifoniFulvio Morellofor the ADvISED Investigators
 

Abstract

Background: Acute aortic syndromes (AASs) are rare and severe cardiovascular emergencies with unspecific symptoms. For AASs, both misdiagnosis and overtesting are key concerns, and standardized diagnostic strategies may help physicians to balance these risks. D-dimer (DD) is highly sensitive for AAS but is inadequate as a stand-alone test. Integration of pretest probability assessment with DD testing is feasible, but the safety and efficiency of such a diagnostic strategy are currently unknown.

Methods: In a multicenter prospective observational study involving 6 hospitals in 4 countries from 2014 to 2016, consecutive outpatients were eligible if they had ≥1 of the following: chest/abdominal/back pain, syncope, perfusion deficit, and if AAS was in the differential diagnosis. The tool for pretest probability assessment was the aortic dissection detection risk score (ADD-RS, 0–3) per current guidelines. DD was considered negative (DD−) if <500 ng/mL. Final case adjudication was based on conclusive diagnostic imaging, autopsy, surgery, or 14-day follow-up. Outcomes were the failure rate and efficiency of a diagnostic strategy for ruling out AAS in patients with ADD-RS=0/DD− or ADD-RS ≤1/DD−.

Results: A total of 1850 patients were analyzed. Of these, 438 patients (24%) had ADD-RS=0, 1071 patients (58%) had ADD-RS=1, and 341 patients (18%) had ADD-RS >1. Two hundred forty-one patients (13%) had AAS: 125 had type A aortic dissection, 53 had type B aortic dissection, 35 had intramural aortic hematoma, 18 had aortic rupture, and 10 had penetrating aortic ulcer. A positive DD test result had an overall sensitivity of 96.7% (95% confidence interval [CI], 93.6–98.6) and a specificity of 64% (95% CI, 61.6–66.4) for the diagnosis of AAS; 8 patients with AAS had DD−. In 294 patients with ADD-RS=0/DD−, 1 case of AAS was observed. This yielded a failure rate of 0.3% (95% CI, 0.1–1.9) and an efficiency of 15.9% (95% CI, 14.3–17.6) for the ADD-RS=0/DD− strategy. In 924 patients with ADD-RS ≤1/DD−, 3 cases of AAS were observed. This yielded a failure rate of 0.3% (95% CI, 0.1–1) and an efficiency of 49.9% (95% CI, 47.7–52.2) for the ADD-RS ≤1/DD− strategy.

Conclusions: Integration of ADD-RS (either ADD-RS=0 or ADD-RS ≤1) with DD may be considered to standardize diagnostic rule out of AAS.

Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT02086136.

Cocaine-induced Type-A Aortic Dissection Extending to the Common Iliac Arteries

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Abstract

Aortic dissection is a rare and fatal complication of cocaine-induced hypertension. The injury mechanism is through shear stress that penetrates the intimal vessel layer, allowing blood flow to separate intimal and medial layers. Due to its scarcity and the paucity of related literature, our knowledge of this condition is limited. We present a rare case of a cocaine-induced aortic dissection, which extended continuously from the aortic root to the common iliacs, along with a literature review of similar cases.

A 48-year-old male with recent cocaine use presented with left-sided chest-pain, which radiated to the back with nausea, diaphoresis, and shortness of breath. The patient was hypotensive. The initial radiographs and computed tomography were negative. The cardiac enzymes were elevated and the patient was admitted to rule out acute coronary syndrome. Next day echocardiogram and computed tomography revealed a Type-A aortic dissection continuously extending from the aortic root to the left common iliac artery. The patient was immediately transferred for surgery. Postoperatively, he developed acute kidney injury and shock liver. The patient status continued to deteriorate and he expired on postoperative day four.

This case demonstrates the importance of prompt and thorough diagnostic evaluation, despite subjective history and initially negative imaging that might point towards other conditions. Unlike the previous cases, our case failed to identify the positive history of cocaine until nearly 24 hours into the patient’s hospital course, suggesting a need for close monitoring in these patients and a possible need for repeat imaging.​​​​​​​

Kinking of an open stent graft after total arch replacement with the frozen elephant technique for acute Type A aortic dissection

article source:

Interactive CardioVascular and Thoracic Surgery, ivx387,https://doi.org/10.1093/icvts/ivx387
Published:

 

10 January 2018

 

Article history
 Abstract
Recently, in Japan, the J Graft Open Stent Graft (JOSG) was commercialized for surgical repair of an aortic aneurysm and aortic dissection and the frozen elephant trunk technique was applied. Kinking of the JOSG is a rare adverse event that requires additional intervention. We experienced 2 patients who developed kinking of a JOSG after translocated total arch replacement with the frozen elephant trunk technique for acute Type A aortic dissection. Both patients had intermittent claudication with a decreased ankle–brachial pressure index after the operation. Computed tomography angiography showed kinking between the non-stent and stent parts of the JOSG. Therefore, we performed endovascular repair. A severely angulated arch preserved by a translocated technique may lead to kinking of a JOSG. This suggests that the removed non-stent part should be as short as possible to prevent kinking of the JOSG.

INTRODUCTION

The J Graft Open Stent Graft (JOSG) (Japan Lifeline Inc., Tokyo, Japan) (Fig. 1) was commercialized in 2014 in Japan [1] and is applied using the frozen elephant trunk (FET) technique for extensive aortic arch aneurysm and aortic dissection. In aortic dissection, the FET is used for closing the entry of the descending aorta, securing flow of the true lumen and decreasing the pressure of the false lumen, which may promote thrombosis of the false lumen. The E-vita OPEN PLUS (Jotec Inc., Hechingen, Germany) and Thoraflex Hybrid (VASCUTEK Ltd., Scotland, UK) have been used in Western countries with good results [23]. Similarly, although the JOSG has different characteristics compared with other open stent grafts, good early outcomes after total arch replacement (TAR) with the FET using the JOSG for acute Type A aortic dissection have been reported [4]. However, some adverse events are associated with this procedure, requiring additional interventions [1–4]. Kinking of the JOSG is rare [1]. We describe 2 patients who developed kinking of JOSGs after TAR with the FET for acute Type A aortic dissection.

Figure 1:

The J Graft Open Stent Graft. (A) Stent part. (B) Non-stent part.

CASE REPORT

Case 1 was a 44-year-old man, who was transferred to our hospital because of chest pain. Computed tomography (CT) angiography showed acute Type A aortic dissection that consisted of entry of the ascending aorta and large re-entry of the descending aorta with compression of the true lumen by a patent false lumen. Therefore, he underwent translocated TAR with the FET emergently. After TAR, transoesophageal echocardiography detected kinking of the JOSG. We then performed a remodelling root procedure because of aortic root rupture near the left coronary artery ostia and aorto-left femoral artery bypass to maintain blood flow of the lower body. After the operation, our patient developed intermittent claudication. CT angiography showed kinking between the non-stent and stent parts of the JOSG due to a severely angulated arch (Fig. 2A). This required additional endovascular repair. After endovascular repair, CT angiography showed an expanded lumen of the JOSG (Fig. 2B).

Figure 2:

(A and C) Computed tomography angiography after the operation in Cases 1 and 2, respectively. The black arrow shows kinking of the J Graft Open Stent Graft. (B and D) Computed tomography angiography after endovascular repair in Cases 1 and 2, respectively.

Case 2 was a 30-year-old man, who had annuloaortic ectasia and moderate aortic valve regurgitation with Marfan syndrome. CT angiography showed acute Type A aortic dissection from the aortic root to the thoraco-abdominal aorta with entry of the ascending aorta and a patent false lumen. Therefore, we performed a reimplantation root procedure and translocated TAR with the FET emergently. After the operation, he had decreased blood pressure in the lower body and intermittent claudication. CT angiography showed kinking between the non-stent and stent parts of the JOSG caused by a severely angulated arch (Fig. 2C). We then performed additional endovascular repair, which improved kinking of the JOSG (Fig. 2D).

DISCUSSION

Coarctation or kinking of an open stent graft after TAR with the FET is a rare adverse event. Uchida et al. [1] reported kinking between the non-stent and stent parts of the JOSG for a sharply bending aorta. We also experienced 2 patients who developed kinking of the JOSG between the non-stent and stent parts after TAR with the FET for acute Type A aortic dissection. A risk of kinking may be a severely angulated arch in acute aortic dissection, which is associated with a relatively young age. Moreover, translocated TAR may aggravate this adverse event due to preservation of the curve of the aortic arch, instead of achieving haemostasis. Uchida et al. [1] recommended that the stent part should sufficiently cover the aortic arch, and the non-stent part should be kept as short as possible to protect the stent graft from kinking. E-vita OPEN PLUS and Thoraflex may prevent kinking of open stent grafts in severely angulated arches because these open stent grafts have no non-stent parts between the distal anastomosis site and the stent [23]. However, the JOSG has an inner stent made of nitinol wire with a soft woven graft, which reduces injury to the intima. This is different from other commercialized open stent grafts, such as E-vita OPEN PLUS, which consists of an outer stent. The inner stent end boundary between the non-stent soft woven graft and the stent may easily lead to kinking by an angulated arch compared with other open stent grafts. Therefore, in translocated TAR with the FET for acute aortic dissection, the removed non-stent part of the JOSG should be as short as possible to prevent kinking of the JOSG.

ACKNOWLEDGEMENTS

We thank Ellen Knapp from Edanz Group (www.edanzediting.com/ac) for editing the draft of this article.

Conflict of interest: none declared.

REFERENCES

 
 

Low Rate of Bailout Emergency Surgery During TAVR, but Caution Still Needed

article source:

TAVR is not PCI, say experts. While complications needing bailout are rare with TAVR, when they occur they tend to be deadly.

Low Rate of Bailout Emergency Surgery During TAVR, but Caution Still Needed

The need for emergent cardiac surgery resulting from complications during transcatheter aortic valve replacement is a “rare event” but “highly consequential” when it is required, according to a large analysis of patients treated at European centers.

Emergent surgery for complications such as left ventricle guidewire perforation, annular rupture, valve embolization/migration, and aortic dissection was required in just 0.76% of TAVR-treated patients. Of these, more than one-third died within 72 hours and 46% died in-hospital.

“Although half of the patients with such complications proceeding to [emergent cardiac surgery] were salvaged acutely, mid-term outcomes were bleak,” Holger Eggebrecht, MD (Cardiovascular Center Bethanien, Frankfurt, Germany), and colleagues report in their study published online recently in the European Heart Journal. Prevention of complications needing emergent surgery remains the most important strategy for improving clinical outcomes of TAVR patients, they add.

Speaking with TCTMD, Tamim Nazif, MD (Columbia University Medical Center, New York, NY), said the study is a reminder that while TAVR is a less invasive procedure than surgery and is increasingly performed via a minimalist approach to expedite recovery and discharge, it does carry risk. “People tend to lose sight of that with the evolution in the field, but this is a sobering reminder that it’s a major cardiac procedure that comes with some degree of risk,” he commented.

That said, Nazif also found the results reassuring, particularly since they are in line with what has been observed in randomized clinical trials, such as PARTNER 2Aand the SAPIEN 3 registry. “It’s comforting that the real-world experience seems to be mimicking the trial experience,” he said.

Rodrigo Bagur, MD, PhD (Western University, London, Canada), who also was not involved in the study, pointed out that while the overall rate of emergency cardiac surgery is “quite low,” an additional 60 patients were considered for emergency surgery but did not undergo any procedure. The outcome of these patients is unknown, but “likely may have been fatal,” said Bagur.  

“The bottom line is that even though TAVI teams and operators became more and more proficient in different aspects of the procedure, there are still procedural-related complications that can occur and perhaps might not be absolutely predictable and/or avoidable,” he said.

Large Registry of European Centers

The new analysis from the European Registry on Emergent Cardiac Surgery During TAVI (EuRECS-TAVI) is based on 27,760 patients undergoing transfemoral interventions at 79 centers between 2013 and 2016. The mean age of TAVR patients was 82.4 years, and the mean logistic EuroSCORE was 17.1% (mean STS risk score was 5.8%). Less than one-quarter of patients were considered to be at high risk for surgery.

In total, 212 patients required emergency surgery for complications, the most frequent being left ventricular guidewire perforation (28.3%) and annular rupture (21.2%). More than 90% of the complications manifested acutely during the TAVR procedure, report investigators. Cardiac surgery was performed most frequently on the TAVR table in a hybrid catheterization lab (61.1%), while the remainder were transferred to the operating room.

Overall, 24.2% of those requiring emergency surgery died the day of the operation and 34.6% died within 72 hours. The in-hospital and 1-year mortality rate was 46.0% and 78.2%, respectively. In-hospital mortality was highest for patients needing surgery for annular rupture (62.2%), coronary obstruction (54.5%), aortic dissection (52.0%), and left ventricle guidewire perforation (50.8%).

Bagur pointed out that the rate of emergency surgery declined over time, which might be related to more systematic use of preprocedural CT planning. This allows physicians to select an appropriate valve type and choose how aggressive to be with pre- and postdilatation. He said the rate of left ventricle perforations seems high and deserves attention to reduce the risk, such as being more careful in shaping the wire or using preshaped guidewires.

The EuRECS data showed no significant difference between low- and high-volume hospitals with respect to the incidence of emergency surgery during TAVR and in-hospital mortality following the operation. Nazif said he was surprised by those findings, noting that a previous analysis of the Society of Thoracic Surgeons/American College of Cardiology TVT Registry did show that higher-volume centers had better clinical outcomes than low-volume institutions, including lower in-hospital mortality.

Is Surgical Backup Necessary? Yes, Say Experts

In an editorial, Craig Smith, MD (Columbia University Medical Center), writes that these latest results raise the question of whether TAVR should be restricted to centers that have on-site cardiac surgery. For Smith, a cardiac surgeon, it is “grossly obvious” that only centers with surgical backup perform TAVR, but he acknowledges that restricting the procedure to such centers is subject to intense debate.

“Opponents of restriction rely on two primary arguments—access and an analogy to PCI. The problem with ‘access’ is that it can have many different meanings,” writes Smith. “It becomes synonymous with ‘convenience’ when argued to be a patient’s ‘right’ to a TAVI program in every local hospital. The results from EuRECS suggest that patients under that scenario would be acquiring, along with convenience, access to unjustifiable risk.”

In the United States, the Centers for Medicare & Medicaid Services (CMS) has placed conditions on reimbursement, stating TAVR should take place in a facility using a heart team approach, which includes interventionalists and surgeons experienced in both procedures. CMS also requires that TAVR be performed at a hospital with on-site surgical backup. In Europe, there are centers where TAVR is performed without the surgical safety net.

For Nazif, the EuRECS analysis reinforces the need for a surgical presence at TAVR centers, particularly as physicians move into treating intermediate- and low-risk patients where a preventable mortality risk is not acceptable.

To TCTMD, Bagur pointed out that TAVR requires a team approach. Even if transfemoral TAVR is performed by interventional cardiologists, “it is important to rely on the rapid availability of our cardiac surgeons that were part of the clinical decision-making process.” He noted that performing TAVR in centers without surgical backup seems quite courageous but may result in some centers, including low-volume centers and/or those with insufficient training, “being unable to properly handle critical complications, such as saving 40% to 50% of lives as shown in the paper.”

In his editorial, Smith stresses that TAVR is not PCI, a procedure that has been shown to be acceptably safe in centers without surgical backup. Although the frequency of emergent surgery during PCI is in the range of 0.2% to 0.6%, complications are less lethal than in TAVR, where structural heart device complications are so challenging, writes Smith.

Nazif agreed. “These are very severe complications that carry very severe mortality rates,” he said. “We need to take TAVI seriously—it’s not the same as PCI. It should be done at experienced centers with surgical backup.”

Sources
  • Eggebrecht H, Vaquerizo B, Moris C, et al. Incidence and outcomes of emergent cardiac surgery during transfemoral transcatheter aortic valve implantation (TAVI): insights from the European Registry on Emergent Cardiac Surgery during TAVI (EuRECS-TAVI). Eur Heart J. 2017;Epub ahead of print.
  • Smith CR. Emergent cardiac surgery following TAVI: implications for the future. Eur Heart J. 2018;Epub ahead of print.
Disclosures
  • Eggebrecht, Smith, Nazif, and Bagur report having no relevant conflicts of interest.

How Marfan Syndrome Can Impact Your Heart Health

5 common questions answered by a heart surgeon

article source:

[dropcap]A[/dropcap]bout 90 percent of people with Marfan syndrome will develop changes in their heart and blood vessels.

If you have Marfan syndrome, you have abnormal connective tissue that can cause your blood vessel walls to weaken and stretch. This damage often affects the aorta, the main artery that carries blood from your heart to the rest of your body.

When the walls of your aorta stretch, you have a higher risk of:

  • Aortic aneurysm (bulging)
  • Dissection (tearing)
  • Rupture (bursting)

These can lead to a life-threatening medical emergency.

In this Q&A, Lars Svensson, MD, PhD, Chairman of Cleveland Clinic’s Sydell and Arnold Miller Family Heart & Vascular Institute, answers five of the most common questions he hears from patients with Marfan syndrome.

Q.: When does an aortic aneurysm require surgery?

A.: The larger the aneurysm, the higher the risk of dissection or rupture — and need for emergency surgery. Preventive, repair surgery is an elective, non-emergency procedure that has much better outcomes. Futhermore, long term survival is then similar to age and gender matched survival for the United States.

For the way Cleveland Clinic performs the modified reimplantation operation, now exceeding 700 patients, for elective surgery a mortality risk of less than 0.5 percent can be expected and a 95 percent or better likelihood of the repair working beyond 10 years after surgery.

Typically, we recommend repair surgery when aneurysms become 5.5 cm or larger. However, we may recommend it sooner if you have:

  • Marfan syndrome
  • Loeys-Dietz syndrome
  • Shorter, smaller stature
  • Family history of aortic dissection
  • An aneurysm that is growing quickly (5 mm or more per year)

Q.: Can I stop my aortic aneurysm from growing?

A.: Aneurysms can grow quickly or not at all, depending on the underlying disease. That’s why we monitor them with regular echocardiograms, or cardiac MRI or CT scans, if needed. Blood pressure control is important.

For patients with Marfan syndrome, the best ways to try to limit the growth of an aortic aneurysm is to:

  • Keep blood pressure below 130/80 mm Hg. Often, we will prescribe beta blockers, ACE inhibitors or other medications to help
  • Maintain healthy cholesterol levels
  • Keep resting heart rate below 70 beats per minute
  • Eat a plant-based diet
  • Exercise moderately
  • Avoid smoking

Q.: What does an aortic aneurysm feel like? How do I know if I have one or if it’s getting worse?

A.: Most of the time, you can’t feel an aneurysm. The only way to detect one or see if it’s changing is through imaging scans.

However, if an aneurysm is quite large, you may have:

  • Pain in the jaw, neck, upper back or chest
  • Coughing, hoarseness or difficulty breathing
  • Pain in the lower back, abdomen or groin not relieved by body movement or taking pain medication

If your aorta has started to tear, you may feel severe pain in your chest or back or both. Some people also report pain in the abdomen or stroke symptoms, including sudden weakness, numbness or loss of balance.

Call 911 if you have any of these symptoms.

Q.: Should I be careful about exercising if I have an aortic aneurysm?

A.: In general, people with aortic aneurysms can still do aerobic exercise, while carefully monitoring their heart rate. Sometimes a stress test will help us assess the heart and determine appropriate heart rate limits.

We typically advise patients to avoid heavy isometric exercise and to not lift more than half of their body weight. Doing multiple repetitions with lighter weights is OK.

There are no limits on physical exercise or exertion after you’ve had (and recovered from) surgery to repair an aortic aneurysm. Cleveland Clinic has cared for professional athletes who’ve returned to active competition.

Q.: Should I be careful about doing other recreational activities if I have an aortic aneurysm?

A.: Flying in an airplane, sitting in a hot tub and jumping on a trampoline are typically safe for people who have an aortic aneurysm. There is no scientific evidence indicating otherwise.

Riding roller coasters or other thrill rides may be best to avoid, however. They can cause blood pressure to swing rapidly.

 

James Brown-62

Name: James Brown
Email: sirjab@live.com
Age at time of Dissection: 62
Type of Dissection: Ascending
Date of Aortic Dissection:  7 September 2016
Tell Us Your Story:

[dropcap]T[/dropcap]he day started out as any other day I was feeling good and about 3:00 PM I started making dinner I needed to make a run to the store my wife and I went and on the way back we stopped at the mailbox’s to check for mail, I got out of the truck and all of a sudden felt this pressure in my chest and back, it was as if I was being pushed to the ground.

We went straight back to the house where I tried to lay down but the pain was excruciating, so I laid down on the floor the wife called 911 and paramedics came. I don’t remember a whole lot after that. I was rushed to the er where they treated me for heart attack and sent me to St. Peter’s later that night.

The admitting doctor Jimmy Swan did not believe I had heart attack so he ran a catheter up my arm and discovered the tear. I was immediately prepped for surgery. Doctor Santemerino performed the surgery which took 11 hours, He nearly lost me on the table.

I spent 17 days in I.C.U and a total of 30 days in the hospital with one week spent in a nursing home. My recovery has been slow, I haven’t felt good since the dissection. I found out just a few weeks ago that my aorta has increased from 4,4 to 6 cm with the dissection continuing into the abdomen.

I was told by a cardiologist that there was no need to see a vascular surgeon because there was nothing that could be be done for me and if I did see the surgeon he just tell me the same thing. Now I am scheduled to see the vascular surgeon this week and discuss my next steps.

It may well be that they can’t repair the dissection because of where it is and the risk involved the cardiologist said if they did operate it could leave me brain dead or paralyzed. I will leave my fate in the Hands of God and the vascular surgeon.

I survived this life threatening ordeal once hopefully I will survive this also and be around to complete my story and this journey.

Tom Tolbert on life after heart surgery: New perspective, same old humor

article source:

[dropcap]T[/dropcap]here’s a vine that needs trimming on Tom Tolbert’s roof. It’s an assignment he savors, tricky and satisfying as he saves himself a few bucks, but Tolbert’s roof-climbing days are over.

 

It’s just that Tolbert, 52, walks a fine line in his recovery from his surgery, a thoracic aortic dissection. The odds were heavily against him surviving the initial operation to repair a tear in body’s largest artery, and he required three subsequent procedures to ward off the complications.

There were times this fall when the former NBA player was unable to walk more than a few steps before retreating in exhaustion. “It’s all about my blood pressure now,” he said. “Maintain that at a proper level, they tell me. Be kind to the aorta.”


Tolbert was at home watching a Giants baseball game at around 9 p.m. on the evening of Aug. 29 when he suddenly felt pain in both of his temples.

“I’m thinking, what the hell is that?” he recalled. “Then both of my shoulder blades started hurting, and then my chest and throat were throbbing. I thought I was having a heart attack, so I got on the computer and Googled the symptoms. They weren’t associated with a heart attack, but I knew something was wrong.”

Shivering cold but drenched in sweat, he went upstairs to climb in bed with his wife, Lorrie, who had turned in early that night.

“I heard this faint voice…‘Sugar’… That’s what we call each other. ‘I don’t feel very good.’ Tom has an unbelievably high threshhold for pain, so I knew it was bad. We got down to Alameda Hospital in a hurry. They ran a series of tests, and when the doctor came in, he said, ‘It’s your aorta. You’re going to need surgery. Immediately. Tonight.’”

That ambulance ride said a great deal about Tolbert and his demeanor. He could be quite the boastful boor at this stage of his life, having been a high-profile star at the University of Arizona and a seven-year veteran of the NBA, including three memorable seasons as a 6-foot-7 power forward under Warriors coach Don Nelson in the early 1990s.

He’s a rare and endearing brand of talk-show host, combining the authoritative voice of an ex-athlete with a fan’s ceaseless devotion. But there isn’t a trace of cockiness or self-obsession in his manner, on or off the air — and his first reaction, to just about anything, is humor.

“So we’re buzzing down to Stanford, and I noticed that they’d handcuffed my gurney to the side of the ambulance. So I had ‘em take a picture with me giving the thumbs-up: ‘They finally got me,’” he laughed. When Tolbert got to the surgery room, being introduced to all sorts of people, he borrowed a line from the movie “Animal House” to greet them all: “Tom Tolbert, rush chairman, damn glad to meet you.”

“I just think there are only so many things you can control in your life,” Tolbert said. “There’s nothing I can do about surgery, so I might as well be as loose as I can, have some fun with it. I’ve always had that ability when something’s out of my hands. Here we’ve got this team of surgeons, and they’re the best. I just kept thinking, ‘They’re gonna get this done.’”

Afterward, Tolbert got the grim news that “there were a number of ways it could have gone worse than it did. My doctor said if the dissection had gone upward, toward the heart, instead of downward, I would have died. And he said, ‘If I didn’t already have you opened up when the dissection happened, you’re probably done.’”

About a week after returning home, Tolbert taped an upbeat message for his KNBR listeners to hear. He was back in the studio on Oct. 9, and for the last two months, he’s been able to drive himself to his workplace of 21 years. He felt about the same during those first few shows, but he didn’t look it, having lost nearly 40 pounds (down to 255) through the ordeal.

“That’s the first thing that jumped out, like, whoa!” Lund said, recalling the sight of a slimmed-down Tolbert. “A few things were different. We had to make sure he had a convenient parking place, and sometimes he has to get up during the show to keep the blood circulating. But basically, it’s like he never left. We’ve quit asking about his energy, because it’s always high. That great sense of humor never left him.

Warriors coach Steve Kerr, a longtime friend dating back to their playing days at Arizona, recalled their first conversation after the surgery: “He said, ‘Yeah, I was looking for ways to lose weight. I thought about diet. I thought about exercise. Then I just settled on heart surgery. It’s worked out really well.’ Typical Tom. Incredible outlook. Most of his life is based on sports and humor and people and friends. He’s just a beautiful human being.”


Lorrie recognized that great quality in her husband, but she was deeply shaken by his post-surgical condition. “From the perspective of seeing Tom as this big, solid, brawny guy, it was pretty dramatic and emotional for me,” she said, right about the time Tom pulled up his shirt to reveal a foot-long, vertical scar running down his abdomen. “I’m still feeling the effects of what happened. It’s incredibly stressful. You don’t feel it for the first few weeks, and then your world kind of falls apart a little bit.”

Nobody was quite prepared for the debilitating condition of his legs — not even his doctors, because the chance of surviving his initial operation was so low. “They’ve had to get creative,” said Lorrie. “After three more operations (all at Stanford), you wonder if he’ll ever be able to walk normally again.”

Tolbert recalled “just trying to walk around the kitchen, into the dining room and do a full circle, maybe four times. Then I had to rest for three or four minutes and do it again, just to keep my muscles intact.” After the last procedure — his fourth in seven weeks — he actually felt worse, he said. “I could barely make it from the street to the house. My quads were killing me; I just felt done.”

When he woke the following morning, though, there was only a bit of pain. He was able to walk around the kitchen 10 times, he said. “It was like a miracle to me. It was such a breakthrough, I started crying.

“And I remember needing to get out and walk outside. It was right around the time of the Santa Rosa fires, so the air was filled with soot and smoke, but I got out there, walked about 100 yards down the street and was so happy. That’s all I wanted.”

Tolbert said he walks up to five miles at a stretch now, four or five times a week, and hopes he might return to playing golf at some point.

To maintain the proper level of blood flow, doctors inserted several stents in his coronary arteries to keep them open; they are likely to remain in place for the rest of his life. Because his condition can only be monitored, not healed, and the high risk of aneurysm, his life centers around a proper diet and maintaining low blood pressure.

As such, Tolbert has been forced to abandon a life of heavy weightlifting, Friday night pizza dinners and the joy of consuming whatever he wanted.

“Sodium is the big thing I have to avoid, and I’m at the store reading every label now,” he said. “And beer is OK, thank God. In fact, my doctor told me, ‘Make sure you have your 7-10 beers a week, it’s actually good for you.’ And I was like, ‘Can I have seven this Saturday?’ Uh, no, that’s not how it works.”


When an inevitable question arose — what brought this on? — Tolbert didn’t need much thought.

“Basically, I’ve turned into my dad,” he said.

According to Lorrie, 78-year-old Tom Tolbert Sr. has had 22 procedures over the years, all related to the aorta.

“You think Tom’s scar is nasty; his dad’s runs completely top to bottom. So we’re in the middle of genetic testing right now, to find out for sure if all our kids need to be monitored,” she said. “We learned there’s a mutated genetic gene that causes dissection, and we’re trying to find out everything we can.”

As Tolbert sat talking about his future, he dropped his carefree facade.

“I’m so grateful to have my kids, my friends and my wife taking care of every little thing,” he said. “I really believe it helps the healing process when you have those types of vibes coursing through your body. I mean, I don’t get through any of this without Lorrie. She’s the best. I just love her to death.”

Lorrie, seated nearby, walked over and planted a big kiss on her man.

Bruce Jenkins is a San Francisco Chronicle columnist. Email: bjenkins@sfchronicle.com Twitter: @Bruce_Jenkins1

Bruce Jenkins

Bruce Jenkins

Sports Columnist

Viewpoint: Ask Patients Flat-Out Do You Have a Problem with Pain Meds?

article source:

Roberts, Martha ACNP, PNP

doi: 10.1097/01.EEM.0000529885.73957.75
Viewpoint
 
 
pain medication

pain medication

[dropcap]Y[/dropcap]our next patient is a 32-year-old woman complaining of a headache. You check her vitals: a heart rate of 101 bpm, blood pressure of 150/90 mm Hg, sat of 100%, respirations of 22 bpm, and a 10/10 on the pain scale. You talk to her about her complaint of headache. She says she is allergic to Tylenol.

The patient is calm, healthy-looking, and in no distress. You do your usual head-to-toe review, and ask your typical history and physical questions. Her neurological exam is negative. She is positive for a wide range of complaints—body aches, crampy back pain, runny nose, slight abdominal pain, maybe some diarrhea, and of course, the headache. You spend minimal time on the other systems, and inquire about her main complaint. Because this patient has a plethora of issues and is of child-bearing age, you check her CBC, BMP, ECG, flu, UA, and hCG. You know they are going to come back negative. You consider a D-dimer because she is on birth control and might be PERC-positive, but you’re not convinced this is PE-related.

What if we start the conversation differently? What if we did an HPI with specific questions? She has been to the ED before, and doesn’t have a primary care physician. Nothing stands out as an emergency. You wonder if a workup is necessary, but don’t want to miss any zebras. A few clues suggest this could be something nefarious, but the opioid epidemic should tell us otherwise.

The bottom line is patients want pain medications. We have to figure out if a patient is drug-seeking or has a valid complaint. The problem is we cannot predict what she has based on a limited history and physical. The answer to this case lies in our bedside manner, approach, and honesty. Opioid abuse, misuse, withdrawal, and addiction are not diagnoses of exclusion; none of us wants all those tests done.

ED visits and overdose deaths involving opioid analgesics and benzodiazepines increased from 0.6 to 1.7 per 100,000 between 2004 and 2011. (Am J Prev Med 2015;49[4]:493.) The number of deaths per year attributed to prescription opioid medications reached 16,651 in 2010. (MMWR 2013;62[12]:234; http://bit.ly/2yM9QfS.)

We don’t ignore the one or two percent risk of certain diagnoses like PE, MI, and aortic dissection, so why ignore the signs of drug-seeking? The abuse of and addiction to opioids is a serious global problem that affects the health, social, and economic welfare of all societies. (National Institutes of Health, 2014; http://bit.ly/2yPhFUg.) Just like we would not forget to ask about smoking or cholesterol levels in a patient with chest pain, we cannot forget to ask about pain medication use.

It is estimated that between 26.4 and 36 million people abuse opioids worldwide. (United Nations Office on Drugs and Crime, 2012; http://bit.ly/2yQcYJU.) An estimated 2.1 million Americans suffered from substance abuse disorders related to prescription opioid pain relievers in 2012, and 467,000 people are addicted to heroin. (Substance Abuse and Mental Health Services Administration, 2013; http://bit.ly/2yRKaAw.) Surely, the smaller percentage of those with PE, MI, or dissection is outweighed by a diagnosis of opioid abuse or withdrawal.

A study in the Western Journal of Emergency Medicine looked at 178 patients from the case management program who made 2,486 visits in one year. (2012;13[5]:416.) Headache accounted for 21.7 percent and back pain 20.8 percent, while requesting a refill took up seven percent, lost or stolen medication 0.6 percent, 10/10 pain 29.1 percent, greater than 10/10 pain 1.8 percent, and out of medication 9.5 percent. Not every headache is going to be a stroke.

Just as we take measures to rule out PE, dissection, and MI by risk-stratifying patients, we should consider an individual’s risk for abuse before prescribing opioids. (Ann Emerg Med 2016;68[4]:S81.) We are behind the times if we do not risk-stratify patients for potential abuse or misuse. Narcotics-seeking is often hidden among the initial investigation. It may even get lost in a triage provider’s initial questions and three to four hours of unnecessary tests. Neither the provider nor the patient really wants to talk about narcotic abuse, but we should be asking our patients flat-out: Do you have a problem with narcotic pain medication use?

Addiction has a strong, visceral hold on our patients, and we are ignoring the easy stuff. Questioning our patients directly about it should not be a game. When all the information is gathered in the initial interview without bias or judgment, patients are more likely to get the treatment they need. This may stop us all from doing unnecessary workups and costly imaging.

Next time we interview a patient, we should ask if he has tried anything for pain and list multiple medications: acetaminophen, ibuprofen, tramadol, morphine, or methadone. Patients may not be upfront about these medications if they have true addiction issues. They are fearful we will not prescribe pain medications or treat their acute pain. When we set the standard of care in the beginning, however, we can avoid drama and overtesting.

We should ask every patient of every age and walk of life about his personal experience with pain and then consider how to address it. This starts with being upfront in a nonjudgmental way and using a team approach to their care. It may prevent thousands of deaths and save hospitals millions of dollars. It will also get patients the help they actually need. The nature of their complaint doesn’t even matter, but our practices can change because of it.

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