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Palmieri V, Yijin X, Fischbach P, Whitehill R. Safety of same-day discharge without anticoagulation for left-sided radiofrequency catheter ablations in pediatrics. Heart Rhythm 2024; 21:592-599. [PMID: 38215810 DOI: 10.1016/j.hrthm.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 12/19/2023] [Accepted: 01/04/2024] [Indexed: 01/14/2024]
Abstract
BACKGROUND For left-sided radiofrequency catheter ablation (LCA) in pediatrics, significant practice variability exists regarding anticoagulation and discharge practices. Given the lack of data in pediatric patients, the risks and benefits of these practices are not well defined. OBJECTIVE The purpose of this study was to evaluate the safety of same-day discharge and use of aspirin (ASA) in pediatric patients following LCA. METHODS We performed a retrospective cohort study of pediatric patients who underwent LCA from 2010 to 2020 at our institution. Discharge timing and ASA usage were based on operator preference. The primary outcome was incidence of postablation anticoagulation complications reported within 1 month of the procedure. RESULTS Three hundred seventy-six patients underwent LCA and met inclusion criteria. Median [25th, 75th percentiles] age was 13.9 [10.5, 16.2] years; 18 (4.7%) had a history of structural heart disease. The most common substrates for ablation were Wolff-Parkinson-White syndrome (183 patients [48.7%]), concealed accessory pathway (159 patients [42.3%]), and ectopic atrial tachycardia (10 patients [2.7%]). Three hundred thirty-eight patients (89.9%) were discharged on the day of LCA. Seventy-six patients (20.2%) were prescribed ASA at discharge. Of those who underwent follow-up (273 patients [72.6%]), 7 (2.7%) reported an anticoagulation complication (5 with hematoma, 2 with headache). One of these patients was prescribed ASA; none required readmission. There was no correlation between anticoagulation complications and same-day discharge or with ASA usage. CONCLUSION Given the rare incidence of anticoagulation complications in pediatric patients undergoing LCAs, same-day discharge from the electrophysiology laboratory without anticoagulation should be considered.
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Affiliation(s)
- Vincent Palmieri
- Children's Healthcare of Atlanta Cardiology, Atlanta, Georgia; Emory University School of Medicine, Atlanta, Georgia.
| | - Xiang Yijin
- Emory University School of Medicine, Atlanta, Georgia
| | - Peter Fischbach
- Children's Healthcare of Atlanta Cardiology, Atlanta, Georgia; Emory University School of Medicine, Atlanta, Georgia
| | - Robert Whitehill
- Children's Healthcare of Atlanta Cardiology, Atlanta, Georgia; Emory University School of Medicine, Atlanta, Georgia
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2
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Clark BC, Olen M, Dechert B, Brateng C, Jarosz B, Smoots K, Connell P, Dupanovic ST, Fenrich A, Hill AC, LaPage M, Mah D, McCanta A, Malloy-Walton L, Pflaumer A, Radbill A, Tanel R, Whitehill R, Dalal A. Current State of Cardiac Implantable Electronic Device Remote Monitoring in Pediatrics and Congenital Heart Disease: A PACES-Sponsored Quality Improvement Initiative. Pediatr Cardiol 2024; 45:114-120. [PMID: 38036754 DOI: 10.1007/s00246-023-03348-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Accepted: 11/07/2023] [Indexed: 12/02/2023]
Abstract
Cardiac implantable electronic device (CIED) remote transmissions are an integral part of longitudinal follow-up in pediatric and adult congenital heart disease (ACHD) patients. To evaluate baseline CIED remote monitoring (RM) data among pediatric and ACHD centers prior to implementation of a Pediatric and Congenital Electrophysiology Society (PACES)-sponsored quality improvement (QI) project. This is a cross-sectional study of baseline CIED RM. Centers self-reported baseline data: individual center RM compliance was defined as high if there was > 80% achievement and low if < 50%. A total of 22 pediatric centers in the USA and Australia submitted baseline data. Non-physicians were responsible for management of the RM program in most centers: registered nurse (36%), advanced practice provider (27%), combination (23%), and third party (9%). Fifteen centers (68%) reported that > 80% of their CIED patients are enrolled in RM and only two centers reported < 50% participation. 36% reported high compliance of device transmission within 14 days of implant and 77% of centers reported high compliance of CIED patients enrolled in RM. The number of centers achieving high compliance differed by device type: 36% for pacemakers, 50% for ICDs, and 55% for Implantable Cardiac Monitors (ICM). All centers reported at least 50% adherence to recommended follow-up for PM and ICD, with 23% low compliance rate for ICMs. Based on this cross-sectional survey of pediatric and ACHD centers, compliance with CIED RM is sub-optimal. The PACES-sponsored QI initiative will provide resources and support to participating centers and repeat data will be evaluated after PDSA cycles.
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Affiliation(s)
- Bradley C Clark
- Division of Cardiology, Department of Pediatrics, Masonic Children's Hospital, University of Minnesota, 2450 Riverside Ave, AO-405, Minneapolis, MN, 55454, USA.
| | - Melissa Olen
- Division of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Brynn Dechert
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Caitlin Brateng
- Division of Cardiology, Children's Hospital of Colorado, Aurora, CO, USA
| | - Beth Jarosz
- Division of Cardiology, Children's National Medical Center, Washington, DC, USA
| | - Karen Smoots
- Division of Cardiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Patrick Connell
- Division of Cardiology, Texas Children's Hospital, Houston, TX, USA
| | | | - Arnold Fenrich
- Division of Cardiology, Dell Children's Medical Center, Austin, TX, USA
| | - Allison C Hill
- Division of Cardiology, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Martin LaPage
- Division of Pediatric Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Douglas Mah
- Division of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - Anthony McCanta
- Division of Cardiology, Children's Hospital of Orange County, Orange, CA, USA
| | | | - Andreas Pflaumer
- Royal Children's Hospital, MCRI and University of Melbourne, Melbourne, AU, USA
| | - Andrew Radbill
- Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ronn Tanel
- Division of Pediatric Cardiology, University of California-San Francisco, San Francisco, CA, USA
| | - Robert Whitehill
- Division of Cardiology, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Aarti Dalal
- Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Edelson JB, Zak V, Goldberg D, Fleming G, Mackie AS, Patel JK, Files M, Downing T, Richmond M, Acheampong B, Cartoski M, Detterich J, McCrindle B, McHugh K, Hansen JE, Wagner J, Maria MD, Weingarten A, Nowlen T, Yoon JK, Kim GB, Williams R, Whitehill R, Kirkpatrick E, Yin S, Ermis P, Lubert AM, Stylianou M, Freemon D, Hu C, Garuba OD, Frommelt P, Goldstein BH, Paridon S, Garg R. The Effect of Udenafil on Heart Rate and Blood Pressure in Adolescents With the Fontan Circulation. Am J Cardiol 2024; 210:183-187. [PMID: 37918818 PMCID: PMC10872492 DOI: 10.1016/j.amjcard.2023.09.115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 09/26/2023] [Accepted: 09/30/2023] [Indexed: 11/04/2023]
Abstract
The Fontan Udenafil Exercise Longitudinal (FUEL) trial showed that treatment with udenafil was associated with improved exercise performance at the ventilatory anaerobic threshold in children with Fontan physiology. However, it is not known how the initiation of phosphodiesterase 5 inhibitor therapy affects heart rate and blood pressure in this population. These data may help inform patient selection and monitoring after the initiation of udenafil therapy. The purpose of this study is to evaluate the effects of udenafil on vital signs in the cohort of patients enrolled in the FUEL trial. This international, multicenter, randomized, double-blind, placebo-controlled trial of udenafil included adolescents with single ventricle congenital heart disease who had undergone Fontan palliation. Changes in vital signs (heart rate [HR], systolic [SBP] and diastolic blood pressure [DBP]) were compared both to subject baseline and between the treatment and the placebo groups. Additional exploratory analyses were performed to evaluate changes in vital signs for prespecified subpopulations believed to be most sensitive to udenafil initiation. Baseline characteristics were similar between the treatment and placebo cohorts (n = 200 for each). The groups demonstrated a decrease in HR, SBP, and DBP 2 hours after drug/placebo administration, except SBP in the placebo group. There was an increase in SBP from baseline to after 6-min walk test in the treatment and placebo groups, and the treatment group showed an increase in HR (87.4 ± 15.0 to 93.1 ± 19.4 beats/min, p <0.01) after exercise. When comparing changes from baseline to the 26-week study visit, small decreases in both SBP (-1.9 ± 12.3 mm Hg, p = 0.03) and DBP (-3.0 ± 9.6 mm Hg, p <0.01) were seen in the treatment group. There were no clinically significant differences between treatment and placebo group in change in HR or blood pressure in the youngest age quartile, lightest weight quartile, or those on afterload-reducing agents. In conclusion, initiation of treatment with udenafil in patients with Fontan circulation was not associated with clinically significant changes in vital signs, implying that for patients similar to those enrolled in the FUEL trial, udenafil can be started without the requirement for additional monitoring after initial administration.
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Affiliation(s)
- Jonathan B Edelson
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, Pennsylvania.
| | | | - David Goldberg
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Greg Fleming
- Duke Children's Pediatric and Congenital Heart Center, Durham, North Carolina
| | - Andrew S Mackie
- Division of Cardiology, Stollery Children's Hospital, Edmonton, Alberta, California
| | - Jyoti K Patel
- Division of Cardiology, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew Files
- Division of Pediatric Cardiology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Tacy Downing
- Division of Cardiology, Children's National Hospital, Washington, District of Columbia
| | - Marc Richmond
- Division of Pediatric Cardiology, Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York
| | - Ben Acheampong
- Children's Hospital and Medical Center, University of Nebraska, Omaha, Nebraska
| | - Mark Cartoski
- Nemours Cardiac Center, Nemours / Alfred I. DuPont Hospital for Children, Wilmington, Delaware
| | - Jon Detterich
- Division of Cardiology, Children's Hospital Los Angeles, Los Angeles, California
| | - Brian McCrindle
- Department of Pediatrics, The Labatt Family Heart Centre, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Kimberly McHugh
- Division of Pediatric Cardiology, Medical University of South Carolina, Charleston, South Carolina
| | - Jesse E Hansen
- Division of Cardiology, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, Michigan
| | - Jonathan Wagner
- Ward Family Heart Center, Children's Mercy Kansas City, Kansas City, Missouri; Division of Clinical Pharmacology, Children's Mercy Kansas City, Kansas City, Missouri
| | - Michael Di Maria
- Department of Pediatrics, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | - Angela Weingarten
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Todd Nowlen
- Heart Center, Phoenix Children's Hospital, Phoenix, Arizona
| | - Ja Kyoung Yoon
- Department of Pediatrics, Sejong General Hospital, Bucheon, South Korea
| | - Gi Beom Kim
- Seoul National University College of Medicine, Seoul National University Children's Hospital, Seoul, South Korea
| | - Richard Williams
- Division of Pediatric Cardiology, University of Utah, Primary Children's Hospital, Salt Lake City, Utah
| | - Robert Whitehill
- Emory University, School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Edward Kirkpatrick
- Division of Pediatric Cardiology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Suellen Yin
- Department of Cardiology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Peter Ermis
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Adam M Lubert
- Cincinnati Children's Hospital Heart Institute, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Mario Stylianou
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood, Institute, National Institutes of Health, Bethesda, Maryland
| | - D'Andrea Freemon
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood, Institute, National Institutes of Health, Bethesda, Maryland
| | | | - Olukayode D Garuba
- Division of Pediatric Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Peter Frommelt
- Division of Pediatric Cardiology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Bryan H Goldstein
- Division of Cardiology, UPMC Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Stephen Paridon
- Division of Cardiology, The Children's Hospital of Philadelphia, Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Ruchira Garg
- Departments of Cardiology and Pediatrics, Cedars-Sinai Guerin Children's and Smidt Heart Institute, Los Angeles, California
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Madani R, Aronoff E, Posey J, Basu M, Zinyandu T, Chai P, Whitehill R, Maher KO, Beshish AG. Incidence and recovery of post-surgical heart block in children following cardiac surgery. Cardiol Young 2023; 33:1150-1156. [PMID: 35903026 DOI: 10.1017/s1047951122002025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND A subset of patients who develop post-surgical heart block have recovery of atrioventricular node function. Factors predicting recovery are not understood. We investigated our centre's incidence of post-surgical heart block and examine factors associated with recovery of atrioventricular node function. METHODS We conducted a single-centre retrospective study of patients 0 - 21 years who underwent cardiac surgery between January 2010 and December 2019 and experienced post-operative heart block. Data including patient and clinical characteristics and operative variables were collected and analysed. RESULTS Of 6333 surgical hospitalisations, 128 (2%) patients developed post-operative heart block. Of the 128 patients, 90 (70%) had return of atrioventricular node function, and 38 (30%) had pacemaker placement. Of the 38 patients who underwent pacemaker placement, 6 (15.8%) had recovery of atrioventricular node function noted on long-term follow-up. Median time from onset of heart block to late atrioventricular node recovery was 13 days (Interquartile range: 5 - 117). Patients with single-ventricle physiology (p = 0.04), greater weight (p = 0.03), and shorter cardiopulmonary bypass time (p = 0.015) were more likely to have recovery. The use of post-operative steroids was similar between all groups (p = 0.445). Infectious or wound complications were similar between pacemaker groups (p = 1). CONCLUSIONS Two per cent of patients who underwent congenital cardiac surgery developed post-operative heart block, and 0.6% underwent pacemaker placement. Early recovery of atrioventricular node was associated with greater weight at the time of surgery, single-ventricle physiology, and shorter cardiopulmonary bypass time. Late recovery of atrioventricular node conduction following pacemaker placement occurred in 15.8% of patients.
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Affiliation(s)
- Rohit Madani
- Department of Pediatrics, Division of Cardiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | | | - Jessica Posey
- Department of Pediatrics, Division of Cardiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Mohua Basu
- Qualitative Analyst, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Tawanda Zinyandu
- Senior Research Coordinator, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Paul Chai
- Department of Surgery, Division of Cardiothoracic Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Robert Whitehill
- Department of Pediatrics, Division of Cardiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Kevin O Maher
- Department of Pediatrics, Division of Cardiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Asaad G Beshish
- Department of Pediatrics, Division of Cardiology, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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5
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Shah M, Borquez AA, Cortez D, McCanta A, De Filippo P, Whitehill R, Imundo J, Moore JP, Sherwin E, Howard T, Rosenthal E, Kertesz N, Chang P, Madan N, Kutalek S, Hammond B, Janson CM, Ramesh Iyer V, Williams MR. Transcatheter Leadless Pacing in Children: A PACES Collaborative Study in the Real-World Setting. Circ Arrhythm Electrophysiol 2023; 16:e011447. [PMID: 37039017 DOI: 10.1161/circep.122.011447] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
BACKGROUND Transcatheter Leadless Pacemakers (TLP) are a safe and effective option for adults with pacing indications. These devices may be an alternative in pediatric patients and patients with congenital heart disease for whom repeated sternotomies, thoracotomies, or transvenous systems are unfavorable. However, exemption of children from clinical trials has created uncertainty over the indications, efficacy, and safety of TLP in the pediatric population. The objectives of this study are to evaluate clinical indications, procedural characteristics, electrical performance, and outcomes of TLP implantation in children. METHODS Retrospective data were collected from patients enrolled in the Pediatric and Congenital Electrophysiology Society TLP registry involving 15 centers. Patients ≤21 years of age who underwent Micra (Medtronic Inc, Minneapolis, MN) TLP implantation and had follow-up of ≥1 week were included in the study. RESULTS The device was successfully implanted in 62 of 63 registry patients (98%) at a mean age of 15±4.1 years and included 20 (32%) patients with congenital heart disease. The mean body weight at TLP implantation was 55±19 kg and included 8 patients ≤8 years of age and ≤30 kg in weight. TLP was implanted by femoral (n=55, 87%) and internal jugular (n=8, 12.6%) venous approaches. During a mean follow-up period of 9.5±5.3 months, there were 10 (16%) complications including one cardiac perforation/pericardial effusion, one nonocclusive femoral venous thrombus, and one retrieval and replacement of TLP due to high thresholds. There were no deaths, TLP infections, or device embolizations. Electrical parameters, including capture thresholds, R wave sensing, and pacing impedances, remained stable. CONCLUSIONS Initial results from the Pediatric and Congenital Electrophysiology Society TLP registry demonstrated a high level of successful Micra device implants via femoral and internal venous jugular approaches with stable electrical parameters and infrequent major complications. Long-term prospective data are needed to confirm the reproducibility of these initial findings.
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Affiliation(s)
- Maully Shah
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia (M.S., C.M.J., V.R.I.)
| | - Alejandro A Borquez
- Department of Pediatrics, University of California, Rady Children's Hospital, San Diego (A.A.B., M.R.W.)
| | - Daniel Cortez
- Department of Pediatrics, University of Minnesota, Minneapolis (D.C.)
- Department of Pediatrics, University of California, Davis, Sacramento (D.C)
| | - Anthony McCanta
- Department of Pediatrics, University of California, Children's Hospital of Orange County, Irvine (A.M.)
| | - Paolo De Filippo
- Cardiovascular Department, Ospedale Papa Giovanni XXIII Hospital, Bergamo, Italy (P.D.F.)
| | - Robert Whitehill
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, GA (R.W.)
| | - Jason Imundo
- Department of Pediatrics, Penn State Health Children's Hospital, Hershey, PA (J.I.)
| | - Jeremy P Moore
- Department of Pediatrics, University of California, Los Angeles, Mattel Children's Hospital (J.P.M.)
| | - Elizabeth Sherwin
- Department of Pediatrics, George Washington University School of Medicine, Children's National Medical Center, DC (E.S.)
| | - Taylor Howard
- Department of Pediatrics, Baylor University, Texas Children's Hospital, Houston (T.H.)
| | - Eric Rosenthal
- Evelina Children's Hospital, Guys & St Thomas' NHS Trust, London, United Kingdom (E.R.)
| | - Naomi Kertesz
- Department of Pediatrics, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus (N.K.)
| | - Philip Chang
- Department of Pediatrics, University of Florida, Shands Children's Hospital, Gainesville (P.C.)
| | - Nandini Madan
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher's Hospital of Children (N.M.)
| | - Steven Kutalek
- Department of Medicine, Drexel University College of Medicine, Philadelphia, PA (S.K.)
| | - Benjamin Hammond
- Department of Pediatrics, Lerner College of Medicine, Cleveland Clinic, OH (B.H.)
| | - Christopher M Janson
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia (M.S., C.M.J., V.R.I.)
| | - V Ramesh Iyer
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Children's Hospital of Philadelphia (M.S., C.M.J., V.R.I.)
| | - Matthew R Williams
- Department of Pediatrics, University of California, Rady Children's Hospital, San Diego (A.A.B., M.R.W.)
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Lynch A, Tatangelo M, Ahuja S, Steve Fan CP, Min S, Lafreniere-Roula M, Papaz T, Zhou V, Armstrong K, Aziz PF, Benson LN, Butts R, Dragulescu A, Gardin L, Godown J, Jeewa A, Kantor PF, Kaufman BD, Lal AK, Parent JJ, Richmond M, Russell MW, Balaji S, Stephenson EA, Villa C, Jefferies JL, Whitehill R, Conway J, Howard TS, Nakano SJ, Rossano J, Weintraub RG, Mital S. Risk of Sudden Death in Patients With RASopathy Hypertrophic Cardiomyopathy. J Am Coll Cardiol 2023; 81:1035-1045. [PMID: 36922089 DOI: 10.1016/j.jacc.2023.01.012] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Revised: 11/29/2022] [Accepted: 01/09/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND Genetic defects in the RAS/mitogen-activated protein kinase pathway are an important cause of hypertrophic cardiomyopathy (RAS-HCM). Unlike primary HCM (P-HCM), the risk of sudden cardiac death (SCD) and long-term survival in RAS-HCM are poorly understood. OBJECTIVES The study's objective was to compare transplant-free survival, incidence of SCD, and implantable cardioverter-defibrillator (ICD) use between RAS-HCM and P-HCM patients. METHODS In an international, 21-center cohort study, we analyzed phenotype-positive pediatric RAS-HCM (n = 188) and P-HCM (n = 567) patients. The between-group differences in cumulative incidence of all outcomes from first evaluation were compared using Gray's tests, and age-related hazard of all-cause mortality was determined. RESULTS RAS-HCM patients had a lower median age at diagnosis compared to P-HCM (0.9 years [IQR: 0.2-5.0 years] vs 9.8 years [IQR: 2.0-13.9 years], respectively) (P < 0.001). The 10-year cumulative incidence of SCD from first evaluation was not different between RAS-HCM and P-HCM (4.7% vs 4.2%, respectively; P = 0.59). The 10-year cumulative incidence of nonarrhythmic deaths or transplant was higher in RAS-HCM compared with P-HCM (11.0% vs 5.4%, respectively; P = 0.011). The 10-year cumulative incidence of ICD insertions, however, was 5-fold lower in RAS-HCM compared with P-HCM (6.9% vs 36.6%; P < 0.001). Nonarrhythmic deaths occurred primarily in infancy and SCD primarily in adolescence. CONCLUSIONS RAS-HCM was associated with a higher incidence of nonarrhythmic death or transplant but similar incidence of SCD as P-HCM. However, ICDs were used less frequently in RAS-HCM compared to P-HCM. In addition to monitoring for heart failure and timely consideration of advanced heart failure therapies, better risk stratification is needed to guide ICD practices in RAS-HCM.
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Affiliation(s)
- Aine Lynch
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto Ontario, Canada
| | - Mark Tatangelo
- Ted Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Sachin Ahuja
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
| | - Chun-Po Steve Fan
- Ted Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Sandar Min
- Genetics and Genome Biology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Myriam Lafreniere-Roula
- Applied Health Research Centre, St Michael's Hospital of Unity Health Toronto, Toronto, Ontario, Canada
| | - Tanya Papaz
- Genetics and Genome Biology, Hospital for Sick Children, Toronto, Ontario, Canada; Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada
| | - Vivian Zhou
- Genetics and Genome Biology, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kathryn Armstrong
- Department of Pediatrics, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Peter F Aziz
- Department of Pediatrics, Cleveland Clinic Children's Hospital, Cleveland, Ohio, USA
| | - Lee N Benson
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto Ontario, Canada
| | - Ryan Butts
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Andreea Dragulescu
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto Ontario, Canada
| | - Letizia Gardin
- Department of Pediatrics, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | - Justin Godown
- Department of Pediatrics, Monroe Carrell Jr Children's Hospital at Vanderbilt University, Nashville, Tennessee, USA
| | - Aamir Jeewa
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto Ontario, Canada
| | - Paul F Kantor
- Department of Pediatrics, Children's Hospital of Los Angeles, Los Angeles, California, USA
| | - Beth D Kaufman
- Department of Pediatrics, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California, USA
| | - Ashwin K Lal
- Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, Utah, USA
| | - John J Parent
- Department of Pediatrics, Riley Children's Hospital, Indianapolis, Indiana, USA
| | - Marc Richmond
- Department of Pediatrics, Morgan Stanley Children's Hospital, Columbia University Medical Center, New York, New York, USA
| | - Mark W Russell
- Department of Pediatrics, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Seshadri Balaji
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA
| | - Elizabeth A Stephenson
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto Ontario, Canada
| | - Chet Villa
- Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - John L Jefferies
- Department of Pediatrics, University of Tennessee Health Sciences Centre, Memphis, Tennessee, USA
| | - Robert Whitehill
- Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Jennifer Conway
- Department of Pediatrics, Stollery Children's Hospital, Edmonton, Alberta, Canada
| | - Taylor S Howard
- Department of Pediatrics, Texas Children's Hospital, Houston, Texas, USA
| | - Stephanie J Nakano
- Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Joseph Rossano
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Robert G Weintraub
- Department of Cardiology, The Royal Children's Hospital of Melbourne, Melbourne, Victoria, Australia
| | - Seema Mital
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto Ontario, Canada; Ted Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada.
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7
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Conway J, Min S, Villa C, Weintraub RG, Nakano S, Godown J, Tatangelo M, Armstrong K, Richmond M, Kaufman B, Lal AK, Balaji S, Power A, Baez Hernandez N, Gardin L, Kantor PF, Parent JJ, Aziz PF, Jefferies JL, Dragulescu A, Jeewa A, Benson L, Russell MW, Whitehill R, Rossano J, Howard T, Mital S. The Prevalence and Association of Exercise Test Abnormalities With Sudden Cardiac Death and Transplant-Free Survival in Childhood Hypertrophic Cardiomyopathy. Circulation 2023; 147:718-727. [PMID: 36335467 PMCID: PMC9977414 DOI: 10.1161/circulationaha.122.062699] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Hypertrophic cardiomyopathy (HCM) can be associated with an abnormal exercise response. In adults with HCM, abnormal results on exercise stress testing are predictive of heart failure outcomes. Our goal was to determine whether an abnormal exercise response is associated with adverse outcomes in pediatric patients with HCM. METHODS In an international cohort study including 20 centers, phenotype-positive patients with primary HCM who were <18 years of age at diagnosis were included. Abnormal exercise response was defined as a blunted blood pressure response and new or worsened ST- or T-wave segment changes or complex ventricular ectopy. Sudden cardiac death (SCD) events were defined as a composite of SCD and aborted sudden cardiac arrest. Using Kaplan-Meier survival, competing outcomes, and Cox regression analyses, we analyzed the association of abnormal exercise test results with transplant and SCD event-free survival. RESULTS Of 724 eligible patients, 630 underwent at least 1 exercise test. There were no major differences in clinical characteristics between those with or without an exercise test. The median age at exercise testing was 13.8 years (interquartile range, 4.7 years); 78% were male and 39% were receiving beta-blockers. A total of 175 (28%) had abnormal test results. Patients with abnormal test results had more severe septal hypertrophy, higher left atrial diameter z scores, higher resting left ventricular outflow tract gradient, and higher frequency of myectomy compared with participants with normal test results (P<0.05). Compared with normal test results, abnormal test results were independently associated with lower 5-year transplant-free survival (97% versus 88%, respectively; P=0.005). Patients with exercise-induced ischemia were most likely to experience all-cause death or transplant (hazard ratio, 4.86 [95% CI, 1.69-13.99]), followed by those with an abnormal blood pressure response (hazard ratio, 3.19 [95% CI, 1.32-7.71]). Exercise-induced ischemia was also independently associated with lower SCD event-free survival (hazard ratio, 3.32 [95% CI, 1.27-8.70]). Exercise-induced ectopy was not associated with survival. CONCLUSIONS Exercise abnormalities are common in childhood HCM. An abnormal exercise test result was independently associated with lower transplant-free survival, especially in those with an ischemic or abnormal blood pressure response with exercise. Exercise-induced ischemia was also independently associated with SCD events. These findings argue for routine exercise testing in childhood HCM as part of ongoing risk assessment.
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Affiliation(s)
- Jennifer Conway
- Department of Pediatrics, Stollery Children’s Hospital, Edmonton, Canada (J.C.)
| | - Sandar Min
- Genetics and Genome Biology, Hospital for Sick Children, Toronto, Canada (S. Min, S. Mital)
| | - Chet Villa
- Department of Pediatrics, Cincinnati Children’s Hospital, OH (C.V.)
| | - Robert G. Weintraub
- Department of Cardiology, The Royal Children’s Hospital, Melbourne, Australia (R.G.W.)
| | - Stephanie Nakano
- Department of Pediatrics, Children’s Hospital Colorado, Aurora (S.N.)
| | - Justin Godown
- Department of Pediatrics, Monroe Carrell Jr Children’s Hospital at Vanderbilt, Nashville, TN (J.G.)
| | - Mark Tatangelo
- Ted Rogers Computational Program, Peter Munk Cardiac Centre, University Health Network, Toronto, Canada (M.T.)
| | - Kathryn Armstrong
- Department of Pediatrics, BC Children’s Hospital, Vancouver, British Columbia, Canada (K.A.)
| | - Marc Richmond
- Department of Pediatrics, Morgan Stanley Children’s Hospital, Columbia University Medical Centre, New York, NY (M.R.)
| | - Beth Kaufman
- Department of Pediatrics, Lucile Packard Children’s Hospital, Stanford University, Palo Alto, CA (B.K.)
| | - Ashwin K. Lal
- Department of Pediatrics, Primary Children’s Hospital, University of Utah, Salt Lake City (A.K.L.)
| | - Seshadri Balaji
- Department of Pediatrics, Oregon Health and Science University, Portland (S.B.)
| | - Alyssa Power
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (A.P., N.B.H.)
| | - Nathanya Baez Hernandez
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX (A.P., N.B.H.)
| | - Letizia Gardin
- Department of Pediatrics, Children’s Hospital of Eastern Ontario, Ottawa, Canada (L.G.)
| | - Paul F. Kantor
- Department of Pediatrics, Children’s Hospital of Los Angeles, CA (P.F.K.)
| | - John J. Parent
- Department of Pediatrics, Riley Children’s Hospital, Indianapolis, IN (J.J.P.)
| | - Peter F. Aziz
- Department of Pediatrics, Cleveland Clinic Children’s Hospital, OH (P.F.A.)
| | - John L. Jefferies
- Department of Pediatrics, University of Tennessee Health Sciences Centre, Memphis (J.L.J.)
| | - Andreea Dragulescu
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Canada (A.D., A.J., L.B., S. Mital)
| | - Aamir Jeewa
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Canada (A.D., A.J., L.B., S. Mital)
| | - Lee Benson
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Canada (A.D., A.J., L.B., S. Mital)
| | - Mark W. Russell
- Department of Pediatrics, University of Michigan Health System, Ann Arbor (M.W.R.)
| | - Robert Whitehill
- Department of Pediatrics, Children’s Healthcare of Atlanta, GA (R.W.)
| | - Joseph Rossano
- Department of Pediatrics, Children’s Hospital of Philadelphia, PA (J.R.)
| | - Taylor Howard
- Department of Pediatrics, Texas Children’s Hospital, Houston (T.H.)
| | - Seema Mital
- Genetics and Genome Biology, Hospital for Sick Children, Toronto, Canada (S. Min, S. Mital).,Department of Pediatrics, Hospital for Sick Children, University of Toronto, Canada (A.D., A.J., L.B., S. Mital).,Ted Rogers Centre for Heart Research, Toronto, Canada (S. Mital)
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Palmieri V, Madani R, Kelleman M, Fischbach P, Whitehill R. B-PO05-135 SAME DAY DISCHARGE AND OUTPATIENT ANTICOAGULATION COMPLICATIONS FOR LEFT-SIDED CATHETER ABLATION PROCEDURES IN PEDIATRICS. Heart Rhythm 2021. [DOI: 10.1016/j.hrthm.2021.06.1054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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9
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Lynch A, Ahuja S, Miron A, Nakano S, Howard T, Villa C, Armstrong K, Kaufman B, Gardin L, Whitehill R, Parent J, Godown J, Henderson H, Aziz P, Colan S, Seshadri B, Kantor P, Russell M, Lal A, Butts R, Richmond M, Conway J, Weintraub R, Rossano J, Mital S. Sudden Cardiac Death and ICD Use in Rasopathy-Associated Hypertrophic Cardiomyopathy. J Heart Lung Transplant 2021. [DOI: 10.1016/j.healun.2021.01.1821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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10
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Whitehill R, Campbell R. The "Great Debate" continues. Heart Rhythm 2020; 17:1656-1657. [PMID: 32470626 DOI: 10.1016/j.hrthm.2020.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 05/19/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Robert Whitehill
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia.
| | - Robert Campbell
- Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, Georgia
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11
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Dasgupta S, Kelleman M, Whitehill R, Fischbach P. Recurrent single echo beats after cryoablation of atrioventricular nodal reentrant tachycardia: The pediatric population. Indian Pacing Electrophysiol J 2020; 20:173-177. [PMID: 32311435 PMCID: PMC7517539 DOI: 10.1016/j.ipej.2020.04.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 04/08/2020] [Accepted: 04/11/2020] [Indexed: 10/29/2022] Open
Abstract
BACKGROUND Cryoablation for atrioventricular nodal reentrant tachycardia (AVNRT) is effective and safe with a reported limitation of lower success and higher recurrence rates. We have observed cases in which slow pathway conduction was eliminated as demonstrated by atrial extra-stimulus testing within 1 min of cryo-energy delivery but returned following tissue rewarming. Frequently, slow pathway conduction persisted despite multiple acutely successful lesions over a broad anatomic region. We aimed to determine if return of slow pathway conduction after elimination during cryoablation represents a risk for recurrent AVNRT with the same intermediate term results as slow pathway ablation. We hypothesize that remnant single echo beats in the absence of sustained slow pathway conduction and inducible AVNRT is an acceptable end point after clear slow pathway elimination during cryoablation. METHODS Retrospective chart review of patients undergoing attempted slow pathway ablation for AVNRT using solely cryoablation between January 2015-January 2018. RESULTS Forty-four patients met inclusion criteria with at-least 2 features of dual AVN physiology. 19 patients had return of slow pathway conduction shortly after clear elimination during cryoablation (Group A) while 25 did not (Group B). All in Group A had recurrent single echo beats but none had sustained slow pathway conduction at the end of the procedure nor AVNRT recurrence at 1 year. CONCLUSION Recurrent single echo beats with absent sustained slow pathway conduction and non-inducible AVNRT may be an acceptable endpoint for slow pathway ablation of AVNRT using cryoablation when there is elimination of slow pathway demonstrated during energy delivery.
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Affiliation(s)
- Soham Dasgupta
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | | | - Robert Whitehill
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Peter Fischbach
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GA, USA
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12
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Dasgupta S, Dave I, Whitehill R, Fischbach P. Chemical cardioversion of atrial flutter and fibrillation in the pediatric population with Ibutilide. Pacing Clin Electrophysiol 2020; 43:322-326. [PMID: 32086826 DOI: 10.1111/pace.13890] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Revised: 01/20/2020] [Accepted: 02/16/2020] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Atrial flutter (AFL) and atrial fibrillation (AF) are common in pediatric patients with congenital heart disease and structurally normal hearts as well. Chemical cardioversion is attractive for patients with AFL/AF for a short period of time because of the ability to avoid sedation. We review a single center's experience with Ibutilide in pediatric patients in an effort to report on its safety and efficacy. METHODS We performed a retrospective chart review of pediatric patients (0-21 years) who underwent chemical cardioversion for AFL/AF with Ibutilide (January 2011-February 2019). Patients on another antiarrhythmic medication or attempted chemical cardioversion with another drug were excluded. RESULTS There were 21 patients who met inclusion criteria. Thirteen of the 21 (62%) patients were successfully cardioverted with Ibutilide (10 out of 13 had AF and four out of 13 required a second dose). There were no significant differences in baseline characteristics between those who were successfully cardioverted compared to those who were not. Administration of magnesium prior to administration did not appear to have an effect on the success rate. There was a significant increase in rate corrected QT interval (QTc) post Ibutilide administration, which returned to baseline prior to discharge. One patient had symptomatic bradycardia needing intravenous fluids and another had torsades requiring electrical cardioversion during Ibutilide administration. CONCLUSIONS The success rate of chemical cardioversion with Ibutilide was similar in our experience as compared to studies in the adult population and the other lone pediatric study. Although adverse events were uncommon, Ibutilide administration warrants close monitoring and fully defining its efficacy warrants further pediatric experience.
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Affiliation(s)
- Soham Dasgupta
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Ishaan Dave
- Department of Biostatistics, Emory University, Atlanta, Georgia
| | - Robert Whitehill
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Peter Fischbach
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia
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13
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Whitehill R, Fischbach P, Posey J, Shaw F, Mao C. Temporary transvenous atrioventricular synchronous pacing using a single lead in a pediatric patient. HeartRhythm Case Rep 2020; 5:593-596. [PMID: 31890584 PMCID: PMC6926181 DOI: 10.1016/j.hrcr.2019.09.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Robert Whitehill
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Peter Fischbach
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Jessica Posey
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Fawwaz Shaw
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Chad Mao
- Division of Pediatric Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, Georgia.,Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
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14
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Dasgupta S, Madani R, Figueroa J, Cox D, Ferguson E, Border W, Sachdeva R, Fischbach P, Whitehill R. Myocardial deformation as a predictor of right ventricular pacing‐induced cardiomyopathy in the pediatric population. J Cardiovasc Electrophysiol 2019; 31:337-344. [DOI: 10.1111/jce.14312] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 10/28/2019] [Accepted: 12/06/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Soham Dasgupta
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of AtlantaEmory University Atlanta Georgia
| | - Rohit Madani
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of AtlantaEmory University Atlanta Georgia
| | - Janet Figueroa
- Department of BiostatisticsEmory University Atlanta Georgia
| | - David Cox
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of AtlantaEmory University Atlanta Georgia
| | - Eric Ferguson
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of AtlantaEmory University Atlanta Georgia
| | - William Border
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of AtlantaEmory University Atlanta Georgia
| | - Ritu Sachdeva
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of AtlantaEmory University Atlanta Georgia
| | - Peter Fischbach
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of AtlantaEmory University Atlanta Georgia
| | - Robert Whitehill
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of AtlantaEmory University Atlanta Georgia
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15
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Dasgupta S, Fischbach P, Whitehill R. VOLTAGE MAPPING TO GUIDE PACEMAKER LEAD PLACEMENT IN CONGENITAL HEART DISEASE. J Am Coll Cardiol 2019. [DOI: 10.1016/s0735-1097(19)33121-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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16
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Whitehill R, Fischbach P, Oster ME. Single ventricle, many arrhythmias. J Thorac Dis 2018; 10:S4040-S4042. [DOI: 10.21037/jtd.2018.09.66] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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17
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Kaptain GJ, Shaffrey CI, Alden TD, Young JN, Whitehill R. The influence of secondary gain on surgical outcome: a comparison between cervical and lumbar discectomy. Neurosurg Focus 2012; 5:e6. [PMID: 17137290 DOI: 10.3171/foc.1998.5.2.9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Although the expectation of monetary compensation has been associated with failures in lumbar discectomy, the issue has not been investigated in patients undergoing cervical disc surgery. The authors analyzed the relationship between economic forms of secondary gain and surgical outcome in a group of patients with a common pay scale, retirement plan, and disability program. All procedures were performed at the Portsmouth Naval Medical Center between 1993 and 1995; active-duty military servicepersons treated for cervical radiculopathy were prospectively included. Clinical, demographic, and financial factors were analyzed to determine which were predictive of outcome. Financial data were used to create a compensation incentive, which is proportional to the patient's rank, years of service, potential disability, retirement eligibility, and base pay and reflects the monetary incentive of disability. The results of cervical surgery were compared to a previously reported companion population of patients treated for lumbar disc disease. A good outcome was defined as a return to active duty, whereas a referral for disability was considered a poor surgical result. A 100% follow-up rate was obtained for 269 patients who underwent 307 cervical operations. Only 16% (43 of 269) of patients who underwent cervical operation received disability, whereas 24.7% (86 of 348) of patients who underwent lumbar discectomy obtained a poor result (p = 0.0082). Although economic forms of secondary gain were not associated with a poor outcome in cervical disease, both the rank (p = 0.002) and duration (p = 0.03) of an individual's military career were significant factors (p = 0.02). Of the medical variables tested, multilevel surgery (p = 0.03) and revision operations at the same level (p = 0.03) were associated with referral for medical discharge. Secondary gain in the form of economic compensation influences outcome in lumbar but not cervical disc surgery patients; the increased rate of disability referral in patients who underwent lumbar discectomy may reflect an expectation of economic compensation. Social factors that are independent of the anticipation of economic compensation seem to influence the outcome in cervical disc surgery patients.
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Affiliation(s)
- G J Kaptain
- Departments of Neurosurgery and Orthopaedics and Rehabilitation, University of Virginia Health Sciences Center, Charlottesville, Virginia; Department of Neurosurgery, Portsmouth Naval Medical Center, Portsmouth, Virginia; Department of Neurosurgery, Henry Ford Hospital, Detroit, Michigan; and Northwest Neurological Surgery, Seattle, Washington
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18
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Elias WJ, Simmons NE, Kaptain GJ, Chadduck JB, Whitehill R. Complications of posterior lumbar interbody fusion when using a titanium threaded cage device. J Neurosurg 2000; 93:45-52. [PMID: 10879757 DOI: 10.3171/spi.2000.93.1.0045] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The authors reviewed their series of patients to quantify clinical and radiographic complications in those who underwent a posterior lumbar interbody fusion (PLIF) procedure in which a threaded interbody cage (TIC) was implanted. METHODS Sixty-seven patients underwent a posterior lumbar interbody fusion procedure in which a TIC was used. The authors excluded patients who underwent procedures in which other instrumentation was used or a nondorsal approach was performed. Fifteen percent of the cases (10 patients) were complicated by laceration of the dura. In three cases, bilateral implantation could not be performed. The average blood loss was 670 ml for all cases, and blood transfusion was required in 25% of the cases (17 patients). The rate of minor wound complication was 4.5% (three patients). One patient died. The average period of hospitalization was 4.25 days. Twenty-eight patients (42%) experienced significant low-back pain 3 months postoperatively, and in 10 (15%) of these cases it persisted beyond 1 year. In 10 patients postoperative radiculopathy was demonstrated, and magnetic resonance imaging revealed epidural fibrosis in six patients, arachnoiditis in one, and a recurrent disc herniation in one. One patient incurred a permanent motor deficit with sexual dysfunction. Pseudarthrosis was suggested radiographically with evidence of motion on lateral flexion-extension radiographs (10 cases), lucencies around the implants (seven cases), and posterior migration of the cage (two cases). Additional procedures (in 14 patients) consisted primarily of transverse process fusion with pedicle screw and plate augmentation for persistent back pain and radiographically demonstrated signs of spinal instability. In two patients with radiculopathy, migration of the TIC required that it be removed. Graft material that extruded from one implant necessitated its removal. In one patient scarectomy was performed. CONCLUSIONS Our high incidence of TIC-related complications in PLIF is inconsistent with that reported in previous studies.
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Affiliation(s)
- W J Elias
- Department of Neurosurgery, University of Virginia Health Sciences Center, Charlottesville 22908, USA
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19
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Kaptain GJ, Shaffrey CI, Alden TD, Young JN, Laws ER, Whitehill R. Secondary gain influences the outcome of lumbar but not cervical disc surgery. Surg Neurol 1999; 52:217-23; discussion 223-5. [PMID: 10511078 DOI: 10.1016/s0090-3019(99)00087-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The expectation of monetary compensation has been associated with poor outcomes in lumbar discectomy, fueling a reluctance among surgeons to treat worker's compensation cases. This issue, however, has not been investigated in patients undergoing cervical disc surgery. This study analyzes the relationship between economic forms of secondary gain and surgical outcome in a group of patients with common pay scales, retirement plans, and disability programs. METHODS All procedures were performed at the Portsmouth Naval Medical Center between 1993 and 1995; active duty military servicepersons who were treated for cervical radiculopathy were prospectively included. Clinical, demographic, and financial factors were analyzed to determine which were predictive for outcome. Financial data were used to create a compensation incentive (CI) which is proportional to the rank, years of service, potential disability, retirement eligibility, and base pay and reflects the monetary incentive of disability. The results of cervical surgery were compared to a previously reported companion population of patients treated for lumbar disc disease. A good outcome is defined as a return to active duty, whereas a referral for disability is considered a poor surgical result. RESULTS One hundred percent follow-up was obtained for 269 patients who were treated with 307 cervical operations. Only 16% (43/269) of cervical patients received disability, whereas 24.7% (86/348) of lumbar patients obtained a poor result (p = 0.0082). Although economic forms of secondary gain were not associated with outcome in cervical disease, both the position (p = 0.002) and duration of an individual's military career were significant factors (p = 0.02). Of the medical variables tested, multilevel surgery (p = 0.03) and revision operations at the same level (p = 0.03) were associated with referral for medical discharge. CONCLUSIONS Secondary gain in the form of economic compensation influences outcome in lumbar but not cervical disc surgery; this observation may in part account for the success of cervical surgery relative to lumbar discectomy. Social factors that are independent of the anticipation of economic compensation seem to influence the outcome of cervical disc surgery.
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Affiliation(s)
- G J Kaptain
- Department of Neurosurgery, University of Virginia HSC, Charlottesville 22908, USA
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Wiggins GC, Rauzzino MJ, Shaffrey CI, Nockels RP, Whitehill R, Alden TD, Shaffrey ME, Wagner J. A new technique for the surgical management of unstable thoracolumbar burst fractures: a modification of the anterior approach and an outcome comparison to traditional methods. Neurosurg Focus 1999; 7:e3. [PMID: 16918234 DOI: 10.3171/foc.1999.7.1.5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This study was conducted to determine the safety, efficacy, and complication rate associated with the anterior approach in the use of a new titanium mesh interbody fusion cage for the treatment of unstable thoracolumbar burst fractures. The experience with this technique is compared with the senior authors' (C.S., R.W., and M.S.) previously published results in the management of patients with unstable thoracolumbar burst fractures.
Between 1996 and 1999, 21 patients with unstable thoracolumbar (T12-L3) burst fractures underwent an anterolateral decompressive procedure in which a titanium cage and Kaneda device were used. Eleven of the 21 patients had sustained a neurological deficit, and all patients improved at least one Frankel grade (average 1.2 grades). There was improvement in outcome in terms of blood loss, correction of kyphosis, and pain, as measured on the Denis Pain and Work Scale, in our current group of patients treated via an anterior approach when compared with the results in those who underwent a posterior approach.
In our current study the anterior approach was demonstrated to be a safe and effective technique for the management of unstable thoracolumbar burst fractures. It offers superior results compared with the posterior approach. The addition of the new titanium mesh interbody cage to our previous anterior technique allows the patient's own bone to be harvested from the corpectomy site and used as a substrate for fusion, thereby obviating the need for iliac crest harvest. The use of the cage in association with the Kaneda device allows for improved correction of kyphosis and restoration of normal sagittal alignment in addition to improved functional outcomes.
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Affiliation(s)
- G C Wiggins
- Departments of Neurosurgery and Orthopaedic Surgery, Henry Ford Hospitals, Detroit, Michigan; and Departments of Neurological Surgery, and Orthopaedic Surgery, Division of Spine Surgery, University of Virginia Health Sciences Center, Charlottesville, Virginia
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21
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Shaffrey CI, Shaffrey ME, Whitehill R, Nockels RP. Surgical treatment of thoracolumbar fractures. Neurosurg Clin N Am 1997; 8:519-40. [PMID: 9314520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Many studies indicate that spinal canal decompression and stabilization lead to improved neurologic recovery in patients with incomplete neurologic deficits. It is recognized that surgical stabilization of unstable thoracolumbar injuries with complete neurologic deficit or without deficit reduces hospital stay, improves spinal alignment, shortens rehabilitation, and results in fewer medical complications. Unfortunately, many aspects of management remain controversial. For many injuries, more than one treatment method has been shown to be efficacious, although certain injuries have improved outcome with specific treatment modalities. This article is an overview of indications for surgery, operative approaches, types of instrumentation, and treatment options for specific thoracolumbar injuries.
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Affiliation(s)
- C I Shaffrey
- Department of Neurological Surgery, Henry Ford Hospital, Detroit, Michigan 48202-2689, USA
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Affiliation(s)
- D L Kowalk
- University of Virginia Health Sciences Center, Charlottesville 22901, USA
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Danisa OA, Shaffrey CI, Jane JA, Whitehill R, Wang GJ, Szabo TA, Hansen CA, Shaffrey ME, Chan DP. Surgical approaches for the correction of unstable thoracolumbar burst fractures: a retrospective analysis of treatment outcomes. J Neurosurg 1995; 83:977-83. [PMID: 7490641 DOI: 10.3171/jns.1995.83.6.0977] [Citation(s) in RCA: 147] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
The authors retrospectively studied 49 nonparaplegic patients who sustained acute unstable thoracolumbar burst fractures. All patients underwent surgical treatment and were followed for an average of 27 months. All but one patient achieved solid radiographic fusion. Three treatment groups were studied: the first group of 16 patients underwent anterior decompression and fusion with instrumentation; the second group of 27 patients underwent posterior decompression and fusion; and the third group of six patients had combined anterior-posterior surgery. Prior to surgical intervention, these groups were compared and found to be similar in age, gender, level of injury, percentage of canal compromise, neurological function, and kyphosis. Patients treated with posterior surgery had a statistically significant diminution in operative time and blood loss and number of units transfused. There were no significant intergroup differences when considering postoperative kyphotic correction, neurological function, pain assessment, or the ability to return to work. Posterior surgery was found to be as effective as anterior or anterior-posterior surgery when treating unstable thoracolumbar burst fractures. Posterior surgery, however, takes the least time, causes the least blood loss, and is the least expensive of the three procedures.
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Affiliation(s)
- O A Danisa
- Department of Orthopedics, University of Virginia Health Sciences Center, Charlottesville, USA
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24
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Affiliation(s)
- T L Pope
- Department of Diagnostic Radiology and Orthopedic Surgery, University of Virginia Health Sciences Center, Charlottesville
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Whitehill R. Laboratory evaluations of cervical internal fixation devices: in vivo testing. J Spinal Disord 1989; 2:282-4. [PMID: 2520087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Affiliation(s)
- R Whitehill
- Department of Orthopaedics, University of Virginia Medical Center, Charlottesville
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Coe MR, Fechner RE, Jeffrey JJ, Balian G, Whitehill R. Characterization of tissue from the bone-polymethylmethacrylate interface in a rat experimental model. Demonstration of collagen-degrading activity and bone-resorbing potential. J Bone Joint Surg Am 1989; 71:863-74. [PMID: 2545719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In previous studies, we described a layer of tissue that formed around methylmethacrylate cement that had been implanted into the posterior cervical spine of dogs. We are now reporting on a rat model in which we induced, in the interface between the bone of the posterior elements of the dorsal spine and methylmethacrylate, the formation of a layer of tissue that was morphologically similar to the tissue that had been produced in the dogs. As in the dogs, we noted macrophages and giant cells and we demonstrated that the interface tissue synthesized several basement-membrane components (type-IV collagen, laminin, and fibronectin). In addition, we demonstrated the synthesis of an additional extracellular-matrix protein--type-VI collagen. We also showed that extracts of organ cultures of tissue from the rat model degraded type-I collagen into three-quarter and one-quarter-length fragments. Such enzymatic activity is characterized of mammalian collagenase, an enzyme that is known to play a critical role in the resorption of bone.
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Affiliation(s)
- M R Coe
- University of Virginia Medical Center, Charlottesville 22908
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Affiliation(s)
- C R Clark
- Department of Orthopedic Surgery, University of Iowa Hospital, Iowa City 52242
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Koss SD, Goitz HT, Redler MR, Whitehill R. Nonunion of a midshaft clavicle fracture associated with subclavian vein compression. A case report. Orthop Rev 1989; 18:431-4. [PMID: 2717205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Fractures of the clavicle are usually treated by closed means and heal uneventfully. In this report, we present an unusual case in which the subclavian vein was compressed by a fracture callus that had formed around a clavicular nonunion. Treatment included dissection of the subclavian vein from the fracture callus and compression plating with autogenous bone grafting of the fracture. Symptoms from the patient's venous obstruction slowly resolved without further treatment. The fracture united postoperatively.
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Affiliation(s)
- S D Koss
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville
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Whitehill R, Cicoria AD, Hooper WE, Maggio WW, Jane JA. Posterior cervical reconstruction with methyl methacrylate cement and wire: a clinical review. J Neurosurg 1988; 68:576-84. [PMID: 3351586 DOI: 10.3171/jns.1988.68.4.0576] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The charts and radiographs of 20 patients who were treated for traumatic cervical instability by the Department of Neurosurgery at the University of Virginia by means of posterior reconstruction with methyl methacrylate cement and fixation wires were reviewed by the Department of Orthopaedic Surgery. Based primarily on radiographic criteria, it was found that posterior reconstruction failed to rigidly immobilize the underlying unstable motion segments in 11 patients. Four of these patients required additional surgery to correct postoperative instability. Based on this experience, cement and wire reconstructions are now recommended only when: 1) they can be limited to one cervical level; 2) No. 18 fixation wire is used; 3) wiring is performed from a facet on one side to the adjacent spinous processes; and 4) autogenous bone graft is added to the posterior elements on the side of the midline opposite the cement and wire.
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Affiliation(s)
- R Whitehill
- Department of Orthopaedics and Rehabilitation, University of Virginia Medical Center, Charlottesville
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Whitehill R, Drucker S, McCoig JA, Hooper WE, Gatesy JE, Fechner RE, Balian G. Induction and characterization of an interface tissue by implantation of methylmethacrylate cement into the posterior part of the cervical spine of the dog. J Bone Joint Surg Am 1988; 70:51-9. [PMID: 3335574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
After the implantation of methylmethacrylate cement into the posterior part of the cervical spine of the dog, a thick layer of connective tissue forms at the bone-cement interface. The tissue is six to eight millimeters thick and in all animals it surrounds the dorsal and lateral aspects of the masses of implanted cement, grows between the undersurface of the cement and the bone of the posterior elements, and completely covers that bone. This tissue was examined by light and electron microscopy and its collagenous components were extracted and analyzed biochemically by gel electrophoresis. Specific extracellular matrix proteins in the tissue at the bone-cement interface were also localized by immunohistochemistry. The tissue at the host-cement interface contained zones of fibrocytes and plump and teardrop-shaped cells within a collagenous matrix. Type-I, Type-III, and Type-V collagen were extracted and were identified by gel electrophoresis. Type-V collagen and fibronectin were localized predominantly around the plump and teardrop-shaped cells. Type-IV collagen and laminin were localized predominantly in an area just beneath the teardrop-shaped cells at the surface of the tissue overlying the cement, suggesting that a basement-membrane-like tissue had formed in this area.
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Affiliation(s)
- R Whitehill
- Department of Orthopaedics and Rehabilitation, University of Virginia Medical Center, Charlottesville 22908
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Abstract
A canine in vivo model of midcervical ligamentous instability was developed by dividing the anterior longitudinal ligament, anulus fibrosus, and all posterior ligamentous structures including the ligamentum flavum. The natural history of healing in the model, the effect on its healing by an adjacent one-level arthrodesis, and the effect of a one-level arthrodesis on normal adjacent ligamentous structures were studied radiographically, mechanically, and histologically. The authors determined that healing takes place primarily by anterior scar formation in their instability model but not to a degree sufficient to recreate normal mechanical stability. After three months, healing in the model was not affected by an adjacent arthrodesis; however, acutely, instability apparently was increased as three animals became quadriplegic between the second and fourth postoperative days. Arthrodesis did not affect adjacent normal ligamentous structures, during this period. Incomplete healing in the authors' model supports those who advocate arthrodesis as the treatment of choice for destabilizing cervical ligamentous injury. The authors previously reported the case of a patient who sustained bilateral facet dislocations adjacent to an arthrodesed segment and questioned whether this resulted from a stress-concentrating effect. This study indicates that this could well have been the case acutely. Thus, inadvertent exclusion of an unstable segment from an arthrodesis has potentially catastrophic results. Finally, the authors also have previously questioned whether arthrodesis of a midcervical segment could lead to instability of adjacent normal segments. This project does not support such a concern, at least for the three postoperative months of study.
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Affiliation(s)
- R Whitehill
- Department of Orthopaedics and Rehabilitation, University of Virginia Medical Center, Charlottesville
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Abstract
The definition of resectability has changed in the management of advanced pelvic malignancy. Most tumors previously considered unresectable can be removed by a function-preserving composite resection of the pelvis. We have performed resection in 55 such patients. Most had posterior pelvic tumors (47 patients), had previously undergone irradiation, and required a combined sacral resection. Included were patients with recurrent or locally advanced rectal cancer (32 patients), epidermoid cancer of the anorectum (seven patients), and primary pelvic malignancies (eight patients). Most had good functional recovery. The five-year actuarial survival rate was 23% (five of 25 patients survived longer than 51 months) in the patients with resected rectal cancer and 14% (one of seven patients) in the patients with resected anorectal carcinoma. Five of eight patients with primary tumors survived longer than 48 months. Lateral pelvic resections were done for five tumors that involved the ileum or ischium, and anterior resection was done in three patients for malignancy that involved the symphysis and rami. Four of these patients were living three to six years after surgery. The overall mortality rate was 7% (four of 55 patients). Composite pelvic resections can provide good local control with preservation of limb function in most patients with primary or secondary tumors of the bony pelvis.
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Affiliation(s)
- H J Wanebo
- Department of Surgery, University of Virginia Medical Center, Charlottesville
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Abstract
Pelvic recurrence is an ominous event after curative resection of rectal cancer and is rarely amenable to re-resection by conventional methods. A method to permit a composite resection of these using the abdominal sacral approach has been described previously. This report updates that experience with resection of pelvic recurrence of rectal cancer in 28 patients. Of these, 24 were done with curative intent, and four were done for palliation (mainly for infected or fungating tumor). All patients had extensive preoperative evaluation by clinical and radiologic tests, and most patients had a long free interval period of approximately 18 months, after their primary resection. Although 47 patients had exploratory surgery, only 29 had local disease amenable to resection and four had palliative resections. About half the patients had had an abdominoperineal resection, half had had an anterior resection, and one third had had previous efforts to resect the recurrence. All but one patient had been irradiated with 3000-11,000 cGy. All but two patients (of the 24 curative efforts) required a formal abdominosacral resection (through S1-2 in 12, S2-3 in 9, and S4-5 in 1). Over half the patients also required a bladder resection. There were three operative deaths (12%); one patient had a cardiac death immediately after operation and two were septic deaths at 35 and 60 days. The survivors generally had relief of sacral root pain and good motor function; most of those previously employed could return to work. The actuarial 5-year survival rate is 25% and median survival is 36 months. Long-term survival over 48 months was recorded in five of 21 surgical survivors (23.8%). Survival in a historic comparative group of 30 patients treated for local recurrence only (mainly by radiation) was 15 months median, and at 5 years the survival rate was 3% (p less than 0.001). In conclusion, selected patients with pelvic recurrence of rectal cancer may be retrieved by and returned to functional life with the composite abdominosacral resection.
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Whitehill R, Stowers SF, Fechner RE, Ruch WW, Drucker S, Gibson LR, McKernan DJ, Widmeyer JH. Posterior cervical fusions using cerclage wires, methylmethacrylate cement and autogenous bone graft. An experimental study of a canine model. Spine (Phila Pa 1976) 1987; 12:12-22. [PMID: 3554556 DOI: 10.1097/00007632-198701000-00003] [Citation(s) in RCA: 21] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
UNLABELLED Forty-eight adult mongrel dogs underwent posterior exposure of C4-C5, fixation of the two posterior spinous processes together with a no. 20-gauge cerclage wire, posterior element decortication, wound irrigation and the following: bone fusions (application of a standard volume of iliac crest autograft), polymethylmethacrylate (PMMA) fusions (application of a standard volume of methylmethacrylate cement), Combination 1 fusions (application of one-half the volume of graft used in the bone fusions, over the facet joints. Methylmethacrylate cement was pressed into position centrally to surround the posterior spinous processes and cerclage wire), Combination 2 fusions (application of the same volume of graft used in the bone fusions, over the facet joints. Methylmethacrylate cement was applied as in the Combination 1 fusions). For each preparation, six animals survived 2 weeks or 3 months. All had monthly lateral cervical radiographs. At the appropriate times, they were killed and their C4-C5 segments excised and studied mechanically and histologically. At 2 weeks all of the above preparations were mechanically inferior to normal C4-C5 segments in respect to at least one of the parameters studied. At 3 months, the bone fusions and both combination fusions had developed sufficient mechanical stability so that they were equivalent to normal segments. At this time, the PMMA fusions remained inferior to the "normals." The mechanical data for the PMMA and both combination fusions was corroborated by the histology which demonstrated a fibrosynovial layer between the cement masses and underlying posterior element bone. In the 3-month combination fusions, the lateral aspects of the posterior elements had been spanned by a fusion mass. CLINICAL RELEVANCE Previously, the authors defined some of the problems associated with constructs modeled by their PMMA fusions. This work confirms the previous research. It also demonstrates that ultimate spinal stability is produced by combination constructs. Because of the 2-week mechanical data, it is recommended that when combination constructs are used clinically, the patient's neck be protected by an external orthosis in the early postoperative period.
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Abstract
The cases of all patients treated with halo-vests for cervical trauma at the University of Virginia since 1977 were analyzed retrospectively. A standardized chart and radiographic review protocol were used to identify complications associated with the use of the orthosis. Two hundred and forty-five patients satisfied the criteria for inclusion in the study. No patient developed or suffered progression of a neurological deficit while immobilized. Complications included: pneumonia causing death (one patient); loss of reduction or progression of the spinal deformity (23 patients); spinal instability following orthotic immobilization for 3 months (24 patients); pin-track infection (13 patients); migration of anteriorly placed iliac-strut grafts (two patients); cerebrospinal fluid leakage from a halo pinhole (one patient); and miscellaneous (seven patients). The findings indicate several conclusions. The halo-vest protects patients with cervical instability from neurological injury. It does not absolutely immobilize the cervical spine nor does it prevent progressive deformity of malpositioned strut grafts. Even after a 3-month orthotic treatment period, surgery may be required on ligamentous and osseous injuries to provide spinal stability. Elderly kyphotic patients may require custom-made vests. A small subset of patients exists for whom the confining nature of the halo-vest is intolerable for 3 months.
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Whitehill R, Richman JA, Glaser JA. Failure of immobilization of the cervical spine by the halo vest. A report of five cases. J Bone Joint Surg Am 1986; 68:326-32. [PMID: 3949827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The halo vest is considered by us, as well as by the majority of orthopaedic surgeons, to be the best commercially available orthosis for control of the cervical spine. However, we have seen five patients with posterior ligament injury of the neck who sustained a recurrence of facet dislocation or subluxation while in a halo vest.
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Abstract
UNLABELLED In an attempt to enhance the immediate stability of posterior interspinous fusion constructs, the authors conducted the following project. Twenty-four adult mongrel dogs underwent a posterior C4-C5 fusion using iliac crest autogenous graft and internal fixation using either ulna struts (12) or metallic struts (12) fixed into position by sublaminar wires. Half of the animals were killed at either 1 week or 3 months postoperatively, and their C4-C5 motion segments were excised and studied radiologically, mechanically, and histologically. Both fusions created immediate and 3-month stability equivalent or superior to normal C4-C5 canine spinal segments. However, three dogs were rendered completely and two dogs incompletely quadriplegic by the surgery. CLINICAL RELEVANCE Because of the relatively high rate of neurologic injury associated with these procedures in normal dogs, the authors hesitate to endorse their use in all but complete quadriplegic patients.
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Whitehill R, Sirna EC, Young DC, Cantrell RW. Late esophageal perforation from an autogenous bone graft. Report of a case. J Bone Joint Surg Am 1985; 67:644-5. [PMID: 3884613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Whitehill R, Barry JC. The evolution of stability in cervical spinal constructs using either autogenous bone graft or methylmethacrylate cement. A follow-up report on a canine in vivo model. Spine (Phila Pa 1976) 1985; 10:32-41. [PMID: 3885415 DOI: 10.1097/00007632-198501000-00006] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Thirty-six adult mongrel dogs underwent either a posterior C4-C5 bone graft or methylmethacrylate-cerclage wire construction procedure to simulate the analogous human stabilization procedures. The dogs were divided into groups of six and allowed to live 1, 2, or 3 months after surgery. At the appropriate time they were killed and their C4-C5 spinal segments excised and studied radiologically, mechanically, and histologically. In addition, the C4-C5 spinal segments from 15 other mongrel dogs were excised and either left intact as normal (five) or prepared as one of the two constructs (five each) described above. They were also tested mechanically to provide immediate postoperative stability data. At some time during the first postoperative month the methylmethacrylate constructs lost mechanical stability. In addition, fibrous tissue was noted to have grown between the posterior laminal surface and the cement mass during this same time. Radiologically, loosening was obvious by the second postoperative month. The bone graft constructs were mechanically equivalent to or superior to the normal dogs by the second postoperative month. Likewise, they were well on their way to solid fusion radiologically and histologically by the same time. Impressed by the rapidity of deterioration in mechanical stability for the methylmethacrylate constructs, the authors further questioned their usefulness in cases of traumatic cervical spinal instability. The bone graft constructs continued to appear to be a reliable way to achieve ultimate spinal stability.
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Whitehill R, Reger SI, Fox E, Payne R, Barry J, Cole C, Richman J, Bruce J. The use of methylmethacrylate cement as an instantaneous fusion mass in posterior cervical fusions: a canine in vivo experimental model. Spine (Phila Pa 1976) 1984; 9:246-52. [PMID: 6729588 DOI: 10.1097/00007632-198404000-00004] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
The authors previously predicted the failure of posterior cervical fusions utilizing methylmethacrylate cement as an instantaneous "fusion" mass, based on research using an in vitro canine experimental model. This report describes the results of in vivo canine studies on the same subject. Three groups of dogs had application of a posterior C4-C5 20-gauge cerclage wire and autologous iliac crest bone graft; application of a posterior C4-C5 20-gauge cerclage wire and methylmethacrylate cement; or application of a C4-C5 20-gauge cerclage wire only. This group represented the control group. The dogs were allowed to live for 3 months postoperatively, at which time they were killed and their spine fusions studied radiologically, mechanically, and histologically. Five of the bone fusions united solidly radiologically. Their flexion stability was statistically superior to the others. Histologic studies confirmed solid union of the fusion mass to the underlying bone. Four of the six methylmethacrylate fusions demonstrated cerclage wire fracture and methacrylate-bone separation by the second postoperative month. At the time the dogs were killed, their flexion stability was statistically inferior to the bone fusions and tended to be inferior to the controls as well. Histologically, fibrous tissue was noted to have grown between the methacrylate "fusion" mass and the underlying bone. This work provides a mechanical explanation for the well-known success of the traditional bony fusion. It further supports our original prediction regarding the failure of methylmethacrylate "fusions."
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Miller F, Whitehill R. Carcinoma of the breast metastatic to the skeleton. Clin Orthop Relat Res 1984:121-7. [PMID: 6705334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
A review of 319 patients with breast carcinoma metastatic to the skeleton revealed a large variation in age at diagnosis, interval between diagnosis of primary disease and metastasis, and survival time with metastasis. The presence of bony metastasis only is a good prognostic sign, and the presence of neurologic defects without successful correction is a poor prognostic sign. Bone lesions are radiosensitive, and fractures usually heal with radiation. It is difficult to define impending fractures, but large lytic lesions, increased body weight, increased activity, and areas of high stress are factors that can be used to determine the risk of fracture. Femoral neck fractures should be treated by endoprostheses or total hip arthroplasty and femoral shaft fractures by appropriate internal fixation. In the present series humeral fractures were successfully managed conservatively, but it is possible that with a wider data base the advantages of immediate rigid fixation by internal fixation with methylmethacrylate cement would be more obvious. Use of methylmethacrylate should be restricted to patients with short-term survival expectancies and large defects. Most spinal metastases can be treated by radiation and orthoses, but an aggressive approach is indicated for patients with neurologic deficits. Laminectomy is indicated for lesions that produce posterior compression, anterior decompression for lesions producing anterior compression, and stabilization for alignment deformities or instability.
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Whitehill R, Reger SI, Kett RL, Payne R, Barry J. Reconstruction of the cervical spine following anterior vertebral body resection: a mechanical analysis of a canine experimental model. Spine (Phila Pa 1976) 1984; 9:240-5. [PMID: 6729587 DOI: 10.1097/00007632-198404000-00003] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
In some quadriplegic patients whose acute spinal injury consists of a vertebral body fracture with bony retropulsion anteriorly and ligamentous damage posteriorly, it is appropriate to perform a decompression of the injured spinal cord by excision of the fractured body. Reconstruction of such a spine to achieve immediate and ultimate stability can be quite difficult. This is a report of mechanical testing using a canine in vitro experimental model to simulate different general types of reconstruction systems applicable to the spine destabilized as above. The results explain some of the previously noted failures of the traditional anterior strut grafting procedures. In addition, one of the reconstruction systems tested (anterior and posterior tension bands compressing an anterior strut graft into place) appeared to have sufficient immediate stability to eliminate the need for a halo-vest in the postoperative period. If such a reconstruction system were to prove clinically applicable, it would be quite beneficial to the quadriplegic patient in his rehabilitation.
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Abstract
Twenty-five odontoid fractures that were treated nonsurgically at the University of Virginia Hospital in the last 5 years were reviewed. Motor vehicle accidents were the major cause of this injury in our series. Early recognition and firm external stabilization of Type I and Type III fractures of the odontoid resulted in union in 100% of our patients. There were 12 Type II fractures with a nonunion rate of 42%. Thus, an overall rate of union of 80% was obtained. It is suggested in the literature and by this series that early recognition, reduction, and rigid external immobilization of Types I and III fractures of the odontoid should promote bony union. Type II fractures may also be managed successfully by closed methods, although the outcome is less certain.
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Abstract
The purpose of this report is to describe our experience with the posterior interspinous fusion in the treatment of spinal injury with quadriplegia. The charts and roentgenograms of 22 patients treated with this operation by the senior author (RW) from July 1978 to June 1981 were reviewed retrospectively. Follow-up averaged 19.5 months. All injured spines had significant posterior ligamentous damage. There were 14 fracture-subluxations, two unilateral facet dislocations, and six bilateral facet dislocations. The specific operative indications included six unacceptable closed reductions, nine failures of three-month trials in a halo vest, and seven cases of predominantly ligamentous injury. All fusions were solid by the third postoperative month. There were no non-unions. There was horizontal translational deformity (2.0 and 3.0 mm, respectively) within the fusion in two cases. In one case, there was an 18 degrees kyphosis within the fusion. Flexible kyphosis adjacent to the fusion, which averaged 16 degrees, was seen in five cases. The overall rate of neurologic recovery for this group was 32%. No patient lost function. Eliminating those patients who were complete quadriplegics preoperatively, the neurologic recovery rate was 77%. In comparison with the other treatments for cervical instability, posterior interspinous fusion is seen to be safe and effective.
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Whitehill R, Moskal JT, Scully KS, Noriega LK, Longnecker DE, Bedford RF. Nitrogen-gas injection from a power reamer: a complication of closed intramedullary nailing of the femur. Technical note. J Bone Joint Surg Am 1983; 65:860-1. [PMID: 6863373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Whitehill R, Nemeth WC, Mabie KN. Symmetrical osseus metastases from renal cell carcinoma: case reports. Va Med 1983; 110:378-80. [PMID: 6880369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Whitehill R, Reger S, Weatherup N, Werthmuller C, Bruce J, Gates P, Rollins G. A biomechanical analysis of posterior cervical fusions using polymethylmethacrylate as an instantaneous fusion mass. Spine (Phila Pa 1976) 1983; 8:368-72. [PMID: 6635785 DOI: 10.1097/00007632-198305000-00005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Three posterior fusion reconstruction procedures for a canine experimental model of the C4-C5 bilateral facet dislocation are herein mechanically tested. The two procedures utilizing polymethylmethacrylate have increased angular stiffness as compared with the normal posterior soft tissue structures and the reconstruction procedure utilizing wire alone. Their ultimate moments are not significantly greater. These findings lead us to predict an increased incidence of fixation failure when polymethylmethacrylate acrylic cement preparations are used for instantaneous posterior "fusions" as compared with the more traditional wire and bone graft procedure.
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Mabie KN, Kulund DN, Whitehill R. Nonclostridial gas gangrene: late infection after hip pinning. South Med J 1983; 76:269-70. [PMID: 6337410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
An 86-year-old diabetic man had a late, gas-forming infection about Knowles pins. Although blood cultures were negative, a urinary tract infection followed by infection with the same organism in bone, muscle, and lung strongly supports hematogenous spread of E coli from the genitourinary system in this patient. The genitourinary system is well recognized as a source of bacteremia, and the skeletal system is the most often affected distant tissue when this occurs. A hematogenous cause of nonclostridial gas gangrene about an implant has not previously been reported.
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Whitehill R, Thomasson M, Wang GJ. Fusion of anterior cervical spine without rigid strut: case report. Va Med 1983; 110:46-7. [PMID: 6829217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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