To investigate whether preoperative renal artery involvement independently predicts postoperative acute kidney injury (AKI) and renal atrophy in patients with Debakey IIIb aortic dissection who underwent thoracic endovascular aortic repair (TEVAR), and to explore the association between AKI and renal atrophy. Retrospective analysis of 82 patients. AKI was defined per KDIGO criteria. Renal atrophy was defined as a renal length reduction >1.00 cm. Univariate analysis compared clinical variables between groups, while binary logistic regression analyzed AKI risk factors and generalized estimating equations (GEE) identified independent predictors of renal atrophy. Patients with renal artery involvement had higher postoperative serum creatinine and lower pre-/postoperative estimated glomerular filtration rate (p<0.05). AKI incidence was identical between groups (9.76% each, p=1.00). GEE analysis showed renal artery involvement was an independent predictor of renal atrophy [OR (95%CI): 4.71 (1.94-11.44), p=0.001]. No factors were significantly associated with AKI in logistic regression. Preoperative renal artery involvement does not correlate with postoperative AKI but independently predicts long-term renal atrophy after TEVAR in Debakey IIIb dissection.
These contrasting images are presented by Philip Alexander, MD, a native Texan, retired physician, and accomplished musician and artist. After 41 years as an internal medicine physician, Dr. Phil retired from his practice in College Station in 2016. A lifelong musician and former music professor, he often performs as an oboe soloist for the Brazos Valley Symphony Orchestra. He began exploring visual art in 1980, evolving from pencil sketches-including an official White House portrait of President Ronald Reagan-to the computer-generated drawings featured in this journal. His images, which first appeared in this journal in the spring of 2012, are his own original creations. If you would like to see your art published in the Methodist DeBakey Cardiovascular Journal, submit your creation online at journal.houstonmethodist.org as a "Humanities" entry.
Cardiopulmonary resuscitation is a critical intervention for cardiac arrest, but its forceful chest compressions can lead to skeletal injuries, including rare vertebral fractures CASE PRESENTATION: This case report details a 78-year-old woman with a history of cardiac surgery and obesity who suffered a fatal cardiac arrest due to a DeBakey type II aortic dissection. Despite 30 minutes of advanced manual CPR, she succumbed to cardiogenic shock. Autopsy revealed an incidental transvertebral fracture of the 8th thoracic vertebra alongside multiple bilateral rib fractures, with no evidence of pre-existing trauma LITERATURE REVIEW: A systematic literature search was conducted in three major scientific databases and reported according to PRISMA 2020, with structured eligibility criteria and methodological quality appraisal of included reports. Results were evaluated by two independent reviewers. Data on demographics, anatomy, bone comorbidities, and CPR were extracted independently and reviewed collectively CONCLUSIONS: A systematic literature review of 16 studies identified 23 cases of CPR-related vertebral fractures, predominantly in the mid-to-lower thoracic spine, with Th10 being the most affected level. Pre-existing conditions such as osteopenia, osteoporosis, and kyphosis increase susceptibility to these injuries by compromising spinal integrity. The biomechanical forces of CPR, combined with structural vulnerabilities, contribute to this rare complication. This case underscores the importance of post-mortem examinations in distinguishing CPR-related injuries from traumatic causes, aiding forensic investigations. Clinicians and forensic pathologists should remain vigilant for vertebral fractures as a potential CPR complication, particularly in elderly patients with predisposing bone conditions, to ensure accurate diagnosis and avoid medico-legal issues.
Conotruncal anomalies comprise a heterogeneous group of congenital heart defects arising from abnormal embryologic development of the cardiac outflow tract and the great arteries. Aortic root dilatation represents a frequent yet comparatively underexplored finding in this population, and clear guidelines regarding surveillance and surgical treatment remain limited. This article reviews mechanisms of aortic root dilatation, diagnostic evaluation, and surgical indications and principles for aortic root surgery in adults with conotruncal anomalies, including lesion-specific considerations for Tetralogy of Fallot, d-transposition of the great arteries, truncus arteriosus, and double outlet right ventricle.
Helmet use significantly reduces the risk of traumatic brain injury among cyclists; however, the influence of alcohol use on helmet-wearing adherence remains understudied in large national data sets. The goal of this study was to investigate the relationship between alcohol use and helmet use in injured cyclists. This study is a retrospective cross-sectional analysis of 155 766 cyclists with traumatic injuries from the National Trauma Data Bank spanning 8 years (2017-2023). Cyclists were categorized by blood alcohol concentration (BAC) as follows: not screened, sober (BAC <0.02), impaired (BAC 0.02-0.08), intoxicated (BAC ≥0.08), and multidrug intoxicated (BAC ≥0.08 plus ≥1 positive drug screen). The primary outcome was helmet usage. Secondary outcomes included mortality, hospital and intensive care unit length of stay, Injury Severity Score, and adverse events. Comorbid substance use disorders were considered as covariates. Alcohol use was associated with a dose-response decrease in helmet use. Helmet adherence was 45.9% in sober cyclists (n=51 566), compared with 19.9% in impaired (n=1592), 9.8% in intoxicated (n=8327), and 6.2% in multidrug intoxicated cyclists (n=3823; p<0.001). Alcohol use was associated with higher mortality rates (OR=2.3; p<0.001) and a greater proportion of injuries in the head and neck region (OR=1.4; p<0.001). Alcohol use when cycling was significantly associated with comorbid alcohol, tobacco, and substance use disorders (p<0.001). An interaction effect was observed between alcohol use and comorbid alcohol use disorder, where individuals with a history of alcohol use disorder exhibited a lower baseline helmet use that further declined with increasing BAC. Alcohol use demonstrated a significant dose-response relationship with helmet non-usage among cyclists, particularly among those with substance use disorders. This relationship represents a critical public safety concern requiring further investigation to address its public health implications. Retrospective Epidemiologic/Prognostic study, Level III.
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Obesity is a chronic disease linked to high mortality and morbidity after cardiac procedures, but its relationship to outcomes after total aortic arch replacement (TAR) remains unclear. We examined TAR data to determine whether obesity is associated with greater perioperative risk. Among 787 TARs performed from 1990 to 2023, we excluded patients who lacked body mass index (BMI) data, had nonelective or nonstandard repairs, or were underweight (BMI <18.5 kg/m2). The remaining 521 patients did not have obesity (18.5 ≤BMI <30; n = 389) or did (BMI ≥30; n = 132). Patients with obesity were class 1 (30 ≤ BMI < 35), class 2 (35 ≤ BMI < 40), or class 3 (BMI ≥40). We compared preoperative and perioperative variables for BMI ≥30 (obesity) versus BMI <30. Adverse events were operative mortality, persistent stroke, spinal cord deficit, and renal failure. We performed multivariable logistic regression and Kaplan-Meier survival analysis. Patients with obesity had greater rates of obstructive sleep apnea, transient spinal cord deficit, and acute renal dysfunction than patients with normal weight. During repair, the use of antegrade cerebral perfusion often exceeded 30 minutes in patients with obesity. Operative mortality and adverse events did not differ among BMI or obesity groups. Greater BMI was not predictive of operative mortality, whereas chronic kidney disease (odds ratio, 2.28; P = .01), pulmonary disease (1.87, P < .001), longer aortic clamp time (1.01, P = .03), and antegrade cerebral perfusion time >30 minutes (2.17, P = .047) were. Survival did not differ significantly by obesity status. Obesity was not associated with operative mortality or adverse events in patients who underwent TAR. Therefore, patients should not be deemed ineligible for TAR on the basis of obesity alone.
Hypothermia is classically defined as a reduction in the body's core temperature below 95.0°F (35.0 °C). Most reported cases of hypothermia are due to environmental exposure to low ambient temperatures (accidental hypothermia). Other causes of hypothermia include sepsis, severe hypothyroidism (myxedema coma), acute spinal cord injury, diabetic ketoacidosis, multisystem trauma, and prolonged cardiac arrest. Frostbite, chillblain and trench foot all have specific therapies to prevent limb loss. There have been significant advances in these therapeutic options over the past decade which are detailed in this issue.
Coronary obstruction due to displacement of calcified native valve leaflets over the coronary ostia is a life-threatening complication of transcatheter aortic valve replacement (TAVR). Undermining iatrogenic coronary obstruction with radiofrequency needle (UNICORN) has emerged as an innovative electrosurgical method for preventing coronary obstruction, primarily in valve-in-valve TAVR. A native-valve modification is described. First, the target leaflet is traversed using transcatheter electrosurgery with angiographic and echocardiographic guidance. Then a series of balloon valvotomies are performed followed by leaflet laceration with a large noncompliant balloon before implantation of the balloon-expandable transcatheter heart valve. Malalignment in traversing the target aortic leaflet can lead to ineffective splay or damage to nearby structures. The modified UNICORN TAVR technique is an alternative to bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction when bulky leaflet calcification is present at the leaflet tip, while also preserving superior coronary access compared with the snorkel technique.
Ischemic heart disease (IHD) presents a growing global health burden across diverse geographic and socioeconomic settings. Clinical practice guidelines are typically developed by professional societies in high-income countries, often with limited consideration of implementation barriers in other healthcare settings. We sought to understand clinicians' use of IHD guidelines in their practice, perceived deficiencies, implementation barriers, and differences between doctors practicing in high-income countries (HIC) or in low-/middle-income countries (LMIC). An internet-based, international survey of physicians treating patients with IHD, (July 26, 2025-November 15, 2025), inquiring about participants' demographics, experience, and views of IHD guidelines as related to their practice. Responses were provided by 587 clinicians from 97 countries. Approximately half (51.8%) considered the IHD guidelines as mostly or fully applicable in their country, a view more preponderant in HIC (67.3%) than in LMIC (48.8%; p = 0.0125). Most (63.2%) thought IHD guidelines were highly applicable in HIC, but only 9.0% deemed the same for LMIC. The greatest barriers to guideline implementation were their being mostly relevant for HIC (72%), and cost, with the latter selected more frequently by the LMIC than the HIC group (61.7% v 20.4%; p < 0.00001). Desires for future guidelines included availability in digital format, and inclusion of co-authors from LMIC. Survey respondents indicated that current IHD guidelines do not address the needs of clinicians and patients in LMIC as effectively as they do for those in HIC. Respondents advocated for future guidelines to have specific recommendations for differing socio-economic environments, and consideration of cost reimbursement.
Atrioventricular valvular regurgitation (AVVR) is a principal determinant of morbidity and mortality in adults with congenital heart disease (ACHD), and surgical management carries substantial operative risk owing to prior sternotomies, distorted intracardiac anatomy, impaired ventricular function, and lesion-specific hemodynamic fragility. Transcatheter edge-to-edge repair (TEER)-using MitraClip or TriClip (Abbott) or PASCAL/PASCAL ACE (Edwards Lifesciences)-has emerged as a compelling alternative in high-surgical-risk acquired valvular disease and is rapidly expanding into ACHD. We review the anatomic substrate, device-specific technical considerations, preprocedural imaging requirements, and clinical evidence supporting TEER across the principal ACHD substrates: congenitally corrected transposition of the great arteries (TGA) with systemic tricuspid regurgitation, atrial switch repairs for dextro-TGA, atrioventricular septal defects, and single-ventricle Fontan circulations. We also address procedural challenges unique to ACHD, including venous access anomalies, altered transseptal geometry, absent conventional echocardiographic windows, and iatrogenic stenosis risk in morphologically abnormal valves. Multidisciplinary selection integrating ACHD structural expertise, advanced imaging, and procedural TEER experience is requisite for safe outcomes.
Desmoplastic trichilemmoma (DTM) is a rare and benign variant of conventional trichilemmoma which presents a diagnostic challenge. It closely mimics malignant neoplasms, particularly basal cell carcinoma (BCC), because of overlapping clinical and histopathological features. Accurate differentiation is crucial to prevent misdiagnosis and management. The aim of this study was to synthesize the available clinical and histopathological data on DTM by presenting 2 new cases and conducting a systematic review of the literature. A retrospective query was conducted of database from 2012 to 2026 identifying 2 DTM cases. In addition, a systematic review of the PubMed database was performed for English language publications from 1990 to present day, yielding 29 publications for inclusion. The addition of 2 new cases brings the total number of DTMs in the compiled dataset to 94 cases. DTM typically presents as a solitary lesion on the head and neck of older adults, ranging in size from 0.3 to 7 cm, with rare cases reported on the chest, vulva, and lower extremities. Histopathologically, its lobular and cord-like growth pattern, peripheral palisading, and desmoplastic stroma closely mimic BCC. Immunohistochemically, the current cases showed immunoreactivity for CD34 and a concurrent negativity for BerEP4. Based on the current findings and review data, 8 CD34-positive/BerEP4-negative and 10 CD34-positive DTMs were identified. Accurate distinction between DTM and BCC requires careful histological examination, which is enhanced by the application of the proposed CD34-BerEP4 dual-marker approach. This diagnostic utility guides appropriate clinical management and prevents unnecessary or inadequate treatment.
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Cardiovascular disease (CVD) constitutes the leading cause of mortality and morbidity in India, accounting for >26% of all national deaths, with a concerning shift toward earlier onset among younger populations. Despite this burden, effective prevention remains limited by low health literacy, fragmented interventions, and inadequate emphasis on preventive care leading to delayed identification and inadequate treatment of cardiovascular (CV) risk factors. Hridayamrit Foundation (HAF) is a youth-led organization addressing these gaps through an innovative public health model centered on cardiovascular health promotion and prevention. This article presents HAF's organizational framework, flagship initiatives, evaluation strategy, and preliminary impact as a novel, replicable model for youth-driven cardiovascular prevention in low- and middle-income countries (LMICs).
To establish contemporary national benchmarks for penetrating head injury (PPHI) in children and adolescents by characterizing its epidemiology, age, race/ethnicity, mechanism, and intent, and to identify independent predictors of mortality, in order to inform age- and mechanism-specific prevention. Retrospective cohort study of children and adolescents aged 1-17 years with PPHI in the American College of Surgeons Trauma Quality Improvement Program (TQIP) database, 2019-2023. PPHI comprised firearm, cut/pierce, and animal-bite mechanisms with documented head-region involvement. Patients were stratified into four developmental age groups (1-4, 5-9, 10-14, 15-17 years). Outcomes included overall (emergency department and in-hospital) mortality, neurosurgical intervention, length of stay, and hospital-acquired infection (HAI). Animal bites were summarized as a separate descriptive subgroup; the multivariable mortality model was restricted to firearm and cut/pierce mechanisms, with a sensitivity analysis varying the head-injury severity threshold. Among 9,046 children and adolescents with PPHI, 73.8% were male and 49.9% were aged 15-17 years. Mechanism and intent shifted markedly with age: animal bites predominated among children aged 1-4 years (61.3% of that group), whereas firearms accounted for 88.2% of injuries in adolescents aged 15-17 years. Injuries were predominantly unintentional before age 10 (80.9%); self-inflicted injury peaked at ages 10-14 (21.1%); and assault predominated at ages 15-17 (63.4%). Overall mortality was 25.4% and rose from 12.2% in children aged 1-9 years to 31.3% in those aged 10-17 years. Firearms caused 6,199 injuries (68.5%) and 97.7% of all deaths. Independent predictors of mortality included firearm mechanism, self-inflicted intent, non-Hispanic Black race, lower Glasgow Coma Scale score, higher Injury Severity Score, and direct (non-transferred) arrival. PPHI in U.S. children and adolescents comprises three distinct epidemiologic phenotypes, animal bites in young children, self-inflicted firearm injury peaking in early adolescence, and firearm assault concentrated among older, predominantly non-Hispanic Black adolescents. Firearms drive nearly all mortality. These national benchmarks support tailored, phenotype-specific prevention rather than a single undifferentiated strategy.
Land-based military deployers to Afghanistan and/or Southwest Asia (SWA) encountered exposure to high concentrations of respirable particulate matter (PM) from multiple sources, including desert dust, burn pit smoke, and military occupations. Adverse lung health effects following deployment have been noted, including upper and lower respiratory tract symptoms, asthma, and small airway and other abnormalities on lung biopsy. The American Thoracic Society (ATS) convened a Workshop in 2018 to review studies assessing post-deployment respiratory health, describe emerging research, and highlight knowledge gaps. Progress on understanding post-deployment health prompted a second ATS Workshop to update current knowledge by 1) reviewing new studies linking exposure assessments to symptoms and/or clinical disease; 2) describing the spectrum of lung pathology reported in previously deployed personnel; 3) evaluating current knowledge of long-term health outcomes after deployment; 4) reviewing data from recent experimental models of deployment-related respiratory diseases (DRRDs); and 5) providing recommendations for future research priorities. Workshop participants agreed that there is substantial evidence linking deployment-related exposures to respiratory symptoms, pulmonary diagnoses, and lung pathology. Knowledge gaps include understanding: 1) the extent and mechanisms through which specific exposures result in impaired pulmonary function, small airways disease, and potentially future chronic pulmonary diseases; 2) the contribution of exposure-related foreign material in the lung to clinical and pathologic findings; and 3) the relationship of pathologic findings to respiratory health, especially those involving small airways.
Right ventricular outflow tract (RVOT) dysfunction is a common and clinically significant late complication in adults with congenital heart disease (ACHD), often after repair of conotruncal anomalies, Ross intervention, or isolated pulmonary valve disease. Pulmonary regurgitation, stenosis, or mixed lesions can result in RV dilation, dysfunction, arrhythmias, and exercise limitation. RVOT dysfunction often requires either surgical or transcatheter intervention, with careful patient selection, imaging, and planning. Surgical pulmonary valve replacement remains the reference standard for complex anatomies, whereas transcatheter pulmonary valve replacement offers a less invasive, repeatable solution in suitable conduits, bioprostheses, and increasingly often in patched RVOTs. Long-term outcomes have improved with advances in imaging, device technology, and perioperative care; however, complications such as valve degeneration, infective endocarditis, and arrhythmias persist. This review provides a comprehensive synthesis of epidemiology, pathophysiology, indications, surgical and transcatheter management strategies, and lifelong complications after RVOT reintervention in ACHD patients.
As alternatives to conventional coronary artery bypass grafting (CABG), robot-assisted CABG (R-CABG) and percutaneous coronary intervention (PCI) offer less invasive treatments for coronary artery disease (CAD). However, data comparing outcomes of R-CABG versus PCI are limited. Databases were systematically searched for studies comparing R-CABG versus PCI. Random-effects models were used to calculate pooled odds ratios (ORs) with 95% confidence intervals (CIs), both overall and stratified by left main or multivessel (LM+MV) or isolated left anterior descending artery (LAD) disease. Kaplan-Meier curves were digitally extracted to reconstruct individual participant data (IPD), from which hazard ratios (HRs) were estimated for survival analyses. Six retrospective studies, including 1,896 patients (R-CABG: 894, 47.1%), were analyzed. The mean age was 63.8 ± 11.3 years, and 78.7% were male patients. Follow-up ranged from 2 to 8 years. Overall, R-CABG was associated with a lower odds of target vessel revascularization (TVR; OR = 0.50, 95% CI: 0.27 to 0.93, P = 0.03) and myocardial infarction (MI; OR = 0.44, 95% CI: 0.26 to 0.76, P < 0.01), with no significant difference in all-cause mortality. Among patients with LM+MV disease, R-CABG reduced TVR and MI. In LAD lesions, R-CABG significantly lowered the likelihood of MI (OR = 0.18, 95% CI: 0.04 to 0.71) as well as major adverse cardiovascular events (MACE; OR = 0.51, 95% CI: 0.28 to 0.93). Time-to-event analysis from reconstructed IPD demonstrated significantly improved freedom from reintervention (HR = 0.31, 95% CI: 0.16 to 0.60) and MACE (HR = 0.24, 95% CI: 0.15 to 0.60) with R-CABG, whereas no significant difference was found for all-cause mortality. R-CABG was associated with less TVR and MI compared with PCI in CAD patients, with no difference in all-cause mortality.
Adults with congenital heart disease (ACHD) represent a growing population of adults in the United States, necessitating lifelong care by ACHD specialists. Often, patients may be lost to follow-up after pediatric care or elude detection until adulthood, presenting to the emergency room with common clinical complaints such as chest pain, dyspnea on exertion, or palpitations. This review demystifies common clinical presentations in pulmonary stenosis, branch pulmonary stenosis, coarctation of the aorta, and subaortic stenosis and their associated pathophysiology, salient clinical features, multimodality diagnostic findings, and indication for intervention.