A rare etiology of frequent ventricular ectopy: Embolic complication of a venous iliac stent to the right ventricle.

Peripheral venous stent migration is an exceedingly rare complication of endovascular stenting. In this clinical vignette, we present a case of a 74-year-old male with a history of endo-venous laser ablation therapy of the right greater saphenous vein complicated with an occlusion requiring a left iliac vein stent. The patient presented to the clinic months after the procedure with complaints of palpitations.

Leveraging a Learning Collaborative Model to Develop and Pilot Quality Measures to Improve Opioid Prescribing in the Emergency Department.

The American College of Emergency Physicians (ACEP) Emergency Medicine Quality Network (E-QUAL) Opioid Initiative was launched in 2018 to advance the dissemination of evidence-based resources to promote the care of emergency department (ED) patients with opioid use disorder. This virtual platform-based national learning collaborative includes a low-burden, structured quality improvement project, data benchmarking, tailored educational content, and resources designed to support a nationwide network of EDs with limited administrative and research infrastructure. As a part of this collaboration, we convened a group of experts to identify and design a set of measures to improve opioid prescribing practices to provide safe analgesia while reducing opioid-related harms.

Effect of Alternatives to Opiates Program on Discharge Opioid Prescribing in Trauma Patients.

Opioid overdose deaths have increased over the last two decades, despite efforts to reduce prescribing. This study aimed to determine if a hospital-wide Alternatives to Opiates (ALTO) program reduced opioid prescribing in hospital and upon discharge after trauma. The primary outcome was incidence of opioid prescribing at hospital discharge Pre- and Post-ALTO.

Ultrasound-Guided Nerve Blocks: Suggested Procedural Guidelines for Emergency Physicians.

Acute pain is one of the most frequent, and yet one of the most challenging, complaints physicians encounter in the emergency department (ED). Currently, opioids are one of several pain medications given for acute pain, but given the long-term side effects and potential for abuse, alternative pain regimens are sought. Ultrasound-guided nerve blocks (UGNB) can provide quick and sufficient pain control and therefore can be considered a component of a physician's multimodal pain plan in the ED.

Pain management in the emergency department: a clinical review.

Pain is one of the most common reasons for patients to visit the emergency department. The ever-growing research on emergency department analgesia has challenged the current practices with respect to the optimal analgesic regimen for acute musculoskeletal pain, safe and judicious opioid prescribing, appropriate utilization of non-opioid therapeutics, and non-pharmacological treatment modalities. This clinical review is set to provide evidence-based answers to these challenging questions.

Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department.

The treatment of opioid use disorder with buprenorphine and methadone reduces morbidity and mortality in patients with opioid use disorder. The initiation of buprenorphine in the emergency department (ED) has been associated with increased rates of outpatient treatment linkage and decreased drug use when compared to patients randomized to receive standard ED referral. As such, the ED has been increasingly recognized as a venue for the identification and initiation of treatment for opioid use disorder, but no formal American College of Emergency Physicians (ACEP) recommendations on the topic have previously been published.

Opioid Prescribing at Discharge in Opioid-Naïve Trauma Patients.

Background: Opioid analgesics remain mainstay of treatment for trauma-related pain despite growing concerns for opioid dependency or misuse. The purpose of this study was to evaluate opioid prescribing at hospital discharge after traumatic injury.

Methods: This is a single-center, retrospective analysis of patients ≥18 years of age admitted for ≥24 hours with a primary diagnosis of traumatic injury.

Tricuspid regurgitation and in-hospital outcomes after transcatheter aortic valve replacement in high-risk patients.

Background: The prognostic impact of tricuspid regurgitation (TR) following transcatheter aortic valve replacement (TAVR) is uncertain, and the management of patients with severe aortic stenosis and significant TR undergoing TAVR is unclear.

Methods: Retrospective study investigating the role of TR severity on hospital outcomes in high risk patients with severe aortic stenosis undergoing TAVR.

Results: A total of 174 participants were included in the present study.

A Country in Crisis: Opioid Sparing Solutions for Acute Pain Management.

The United States is currently in the midst of an opioid epidemic that has led to previously unforeseen opioid misuse, abuse, and death. A major emphasis is being placed on reducing the exposure patients have to opioids, whenever possible, in an effort to hopefully reduce the risk of dependency, addiction, and overdose. However, opioid alternatives must be chosen carefully to ensure efficacy, safety, and availability for patients within the community.

Successful Use of Sternal-Sparing Minimally Invasive Surgery for Proximal Ascending Aortic Pathology.

Background: A sternal-sparing approach to surgery of the proximal aorta could decrease postoperative morbidity.

Methods: To determine the potential benefits of using a minimally invasive right thoracotomy approach for the treatment of ascending aortic pathology, we retrospectively reviewed our experience in patients who required circulatory arrest for the treatment of ascending aortic pathology (with or without aortic valve involvement) between January 2009 and November 2014 (N = 177). We compared baseline characteristics, intraoperative characteristics, and postoperative clinical outcomes between those who underwent a sternotomy (n = 103) and those who underwent a minimally invasive right thoracotomy approach (n = 74).

Isolated and concomitant minimally invasive minithoracotomy aortic valve surgery.

Objective: To evaluate whether the outcomes of minimally invasive aortic valve surgery were similar in younger versus older patient groups, as well as whether concomitant minimally invasive aortic valve replacement (AVR) surgeries added significant risks in these populations.

Methods: We performed a single-institution retrospective analysis of 1018 patients undergoing isolated AVR and 378 patients undergoing concomitant AVR procedures over a 6-year period. All surgeries were via a right minithoracotomy approach, and patients who underwent reoperation were excluded.

Pericardial Herniation of Small Bowel Post Minimally Invasive Hybrid Maze of Atrial Fibrillation.

Background: Herniation of intraabdominal contents into the pericardial cavity is exceptionally rare, and when seen, it is most often the result of trauma, postsurgical complication, or genetic defect. There have been only a few case reports describing spontaneous bowel herniation into the pericardium in minimally invasive cardiac procedures like cardiac ablation, pacemaker placement, and minimally invasive coronary artery bypass graft.

Case Report: We report the case of a 65-year-old man who presented to an urgent care center complaining of abdominal and chest pain.

Hybrid repair of aortic arch aneurysms: a comprehensive review.

Open total arch replacement (TAR) has become safer with refinements in cerebral protection techniques. The frequent extension of aortic arch aneurysms into the descending thoracic aorta customarily requires a two-staged conventional elephant trunk procedure, carrying relatively high mortality and morbidity risks and high rates of rupture in the interval between the two open surgeries. The technical demands and invasive nature of TAR has therefore precluded many high-risk patients from being surgical candidates for aneurysm repair.

Outcomes of minimally invasive double valve surgery.

Background: Double valve surgery is associated with an increased peri-operative morbidity and mortality. A less invasive right thoracotomy approach may be a viable alternative to median sternotomy surgery in these higher-risk patients.

Methods: We retrospectively analyzed the baseline demographics, operative characteristics, and post-operative outcomes of patients who underwent minimally invasive double valve surgery between January 2009 and December 2011 at our institution.

Percutaneous coronary intervention followed by minimally invasive valve surgery compared with median sternotomy coronary artery bypass graft and valve surgery in patients with prior cardiac surgery.

Background: In patients with prior cardiac surgery requiring re-operative coronary and valve surgery, a hybrid approach of percutaneous coronary intervention followed by minimally invasive valve surgery (PCI + MIVS) may be an alternative to the standard median sternotomy coronary artery bypass and valve surgery (CABG + valve).

Methods: The outcomes of patients with prior cardiac surgery, presenting with coronary artery and valvular disease, who underwent PCI + MIVS (N=39) were retrospectively compared with those who underwent CABG + valve (N=28) via a repeat median sternotomy, between February 2009 and April 2014.

Results: The mean age for the PCI + MIVS versus CABG + valve group was 75±9 and 72±11 years (P=0.

Outcomes of a hybrid approach of percutaneous coronary intervention followed by minimally invasive aortic valve replacement.

Background: In patients requiring coronary revascularization and aortic valve replacement, a combined approach of percutaneous coronary intervention followed by minimally invasive aortic valve replacement may be a viable treatment strategy.

Methods: The outcomes of 123 consecutive patients with significant coronary artery and aortic valve disease, who underwent percutaneous coronary intervention followed by elective minimally invasive aortic valve replacement between February 2009 and April 2014, were retrospectively evaluated.

Results: The cohort consisted of 80 males and 43 females, with a mean age of 75.

Complications Associated With Femoral Cannulation During Minimally Invasive Cardiac Surgery.

Background: Different types of cannulation techniques are available for minimally invasive cardiac surgery. At our institution, we favor a femoral platform for most minimally invasive cardiac procedures. Here, we review our results utilizing this cannulation approach.

Right Minithoracotomy Approach for Replacement of the Ascending Aorta, Hemiarch, and Aortic Valve.

A minimally invasive right anterior thoracotomy approach is the preferred technique used at our institution for isolated aortic valve pathology. We have recently introduced more complex concomitant minimally invasive procedures through this access site. Here, we describe how we perform a replacement of the ascending aorta and aortic valve with and without the use of circulatory arrest through a 6-cm right minimally invasive thoracotomy incision.

Outcomes of aortic valve and concomitant ascending aorta replacement performed via a minimally invasive right thoracotomy approach.

Objective: Replacement of the aortic valve with concomitant replacement of the ascending aorta performed via a minimally invasive right anterior thoracotomy approach has not been reported. We evaluated the feasibility and safety of this procedure.

Methods: We retrospectively reviewed all minimally invasive aortic valve replacements (AVRs) with concomitant replacement of the ascending aorta performed at our institution between January 1, 2012, and December 30, 2012.

Reducing blood utilization by implementation of a type-and-screen transfusion policy a single-institution experience.

Objectives: The Blood Utilization Committee implemented a standardized protocol for the preoperative blood order for cardiac patients. The aim of our study was to assess the improvement in blood utilization using the crossmatch to transfusion ratio (C:T).

Methods: Four months of retrospective data were collected, which included all RBC crossmatch requests and all RBC units transfused.

Endovascular treatment of an acute ascending aortic intramural hematoma.

Introduction: Herein, we present a case of an elderly gentleman who presented with an extensive intramural hematoma of the aorta which was treated with a percutaneous placement of an endovascular stent.

Presentation Of Case: A 79-year-old male with a history of hypertension presented to the emergency department because of sudden onset of substernal chest pain radiating to his back. A chest computerized tomography scan was performed that demonstrated a Type A aortic wall intramural hematoma involving the arch and ascending aorta dissecting both antegrade and retrograde from a penetrating ulcer located in the descending aorta, immediately distal to the left subclavian artery.

Multiple left internal mammary artery-to-pulmonary artery fistulae 15 years after coronary artery bypass grafting.

Left internal mammary artery (LIMA)-to-pulmonary artery fistulae rarely develop after coronary artery bypass grafting. Fewer than 30 cases of these fistulae have been reported since 1947. Nevertheless, this entity should be considered as a cause of recurrent angina after bypass surgery, in the absence of other causes.