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Journal of the Intensive Care Society Nov 2023The concept of a focused ultrasound study to identify sources of haemodynamic instability has revolutionized patient care. Point-of-care ultrasound (POCUS) using...
The concept of a focused ultrasound study to identify sources of haemodynamic instability has revolutionized patient care. Point-of-care ultrasound (POCUS) using transthoracic scanning protocols, such as FUSIC Heart, has empowered non-cardiologists to rapidly identify and treat the major causes of haemodynamic instability. There are, however, circumstances when a transoesphageal, rather than transthoracic approach, may be preferrable. Due to the close anatomical proximity between the oesophagus, stomach and heart, a transoesphageal echocardiogram (TOE) can potentially overcome many of the limitations encountered in patients with poor transthoracic ultrasound windows. These are typically patients with severe obesity, chest wall injuries, inability to lie in the left lateral decubitus position and those receiving high levels of positive airway pressure. In 2022, to provide all acute care practitioners with the opportunity to acquire competency in focused TOE, the Intensive Care Society (ICS) and Association of Anaesthetists (AA) launched a new accreditation pathway, known as Focused Transoesophageal Echo (fTOE). The aim of fTOE is to provide the practitioner with the necessary information to identify the aetiology of haemodynamic instability. Focused TOE can be taught in a shorter period of time than comprehensive and teaching programmes are achievable with support from cardiothoracic anaesthetists, intensivists and cardiologists. Registration for fTOE accreditation requires registration via the ICS website. Learning material include theoretical modules, clinical cases and multiple-choice questions. Fifty fTOE examinations are required for the logbook, and these must cover a range of pathology, including ventricular dysfunction, pericardial effusion, tamponade, pleural effusion and low preload. The final practical assessment may be undertaken when the supervisors deem the candidate's knowledge and skills consistent with that required for independent practice. After the practitioner has been accredited in fTOE, they must maintain knowledge and competence through relevant continuing medical education. Accreditation in fTOE represents a joint venture between the ICS and AA and is endorsed by Association of Cardiothoracic Anaesthesia and Critical care (ACTACC). The process is led by TOE experts, and represents a valuable expansion in the armamentarium of acute care practitioners to assess haemodynamically unstable patients.
PubMed: 37841296
DOI: 10.1177/17511437231173350 -
Plastic and Reconstructive Surgery.... Nov 2023Sternal tumors are rare, comprising only 0.94% of all bone tumors, with the majority being sarcomas. An extensive composite defect is often the result of surgical...
BACKGROUND
Sternal tumors are rare, comprising only 0.94% of all bone tumors, with the majority being sarcomas. An extensive composite defect is often the result of surgical resection. Reconstruction of this anatomical area is a challenge for plastic surgeons. Reconstruction must fulfil two different tasks: restoration of soft tissues and stabilization of the chest wall. Both are well defined, and many techniques have been historically proposed.
METHODS
We present the case of a 66-year-old man affected by sternal metastasis of lung non-small cell carcinoma with sarcomatoid features. After wide tumor resection, a large defect was created.
RESULTS
The patient underwent a complex multilayer reconstruction that combined multiple techniques: Gore DualMesh to reconstruct the pericardial plane and protect the heart muscle, omental flap to facilitate integration of the mesh, titanium bars to recreate chest wall stability, and bilateral pectoralis muscle flaps to cover hardware. This multilayer reconstruction was named the "lasagna technique."
CONCLUSIONS
Due to the rarity of primary malignancies of the sternum, it is difficult to standardize a therapeutic approach. For this reason, it is necessary to customize the surgical treatment by combining several techniques and materials. Our lasagna technique may be considered a valuable option in treating these complex reconstructive cases.
PubMed: 37964922
DOI: 10.1097/GOX.0000000000005384 -
Discovery Medicine Dec 2023In China, endomyocardial fibrosis (EMF) is a type of restrictive cardiomyopathy that is rare and easy to be misdiagnosed. Our aim was to examine the value of routine...
BACKGROUND
In China, endomyocardial fibrosis (EMF) is a type of restrictive cardiomyopathy that is rare and easy to be misdiagnosed. Our aim was to examine the value of routine echocardiography (RE) combined with contrast-enhanced echocardiography (CEE) in EMF diagnosis.
METHODS
We studied 16 EMF patients retrospectively, from 2012 to 2022. All patients underwent RE, from which 11 underwent CEE. We divided the patients into three groups: biventricular EMF (Bi-EMF), right ventricular EMF (RV-EMF), and left ventricular EMF (LV-EMF) based on different lesion locations. We also analyzed the clinical and conventional ultrasound characteristics of the three groups of patients and examined the ventricle opacification (VO) and myocardial contrast echocardiography (MCE) characteristics of patients who underwent CEE.
RESULTS
All patients with EMF subtypes had the following ultrasound findings: apical occlusion on one or both sides, corresponding atrial dilatation, atrioventricular valve regurgitation in varying degrees, and cardiac diastolic dysfunction. Of the subjects, 69% had apical thrombus calcification and 81% had mild pericardial effusion. RV-EMF patients had statistically significant right atrial enlargement compared with the other two groups ( < 0.05), moderate or severe tricuspid regurgitation, and inferior vena cava (IVC) dilation. LV-EMF patients had statistically significant left atrial enlargement compared with the other two groups ( < 0.05), elevated pulmonary artery systolic pressure (PASP), and 60% of LV-EMF patients had moderate or severe mitral regurgitation. Bi-EMF patients had bilateral atrial enlargement, an IVC collapsibility index <50%, and elevated PASP. CEE was performed in 11 patients, whose ventricle opacification showed no contrast filling in the apical occluded area and the heart chambers presented the "mushroom sign" during diastole. Their myocardial contrast echocardiography (MCE) showed delayed perfusion in the thickened fibrotic endomyocardium (TFE) of the apical and subvalvular regions and perfusion defect in the apical thrombus. The number and location of thrombus determined by the MCE combined with RE were the same as those detected by cardiac magnetic resonance imaging (CMR). MCE shows that the position and range of TFE are similar to CMR.
CONCLUSIONS
EMF has characteristic RE presentation, and different EMF subtypes have unique characteristics. CEE can better display heart structure, ventricular wall motion, and tissue perfusion compared to RE. A combination of RE and CEE can make the EMF diagnosis more accurate, thereby allowing early treatment for EMF patients.
Topics: Humans; Endomyocardial Fibrosis; Retrospective Studies; Echocardiography; Myocardium; Thrombosis
PubMed: 38058070
DOI: 10.24976/Discov.Med.202335179.101 -
JACC. Advances Dec 2023Studies comparing COVID-19 vaccine-associated and classical myocarditis (CM) are lacking.
BACKGROUND
Studies comparing COVID-19 vaccine-associated and classical myocarditis (CM) are lacking.
OBJECTIVES
The purpose of this study was to compare cardiac magnetic resonance (CMR) imaging findings and short-term clinical outcomes in patients with messenger RNA COVID-19 postvaccination myocarditis (PVM) and CM.
METHODS
This was a retrospective study of patients with myocarditis: 31 with PVM and 46 with CM. Patients underwent a CMR protocol scan including T1 and T2 sequences. Late gadolinium enhancement (LGE) was expressed as percentage of left ventricular myocardial mass and the extracellular volume was calculated based on precontrast and postcontrast T1 images. Clinical outcomes included heart failure hospitalizations and mortality.
RESULTS
Study patients were predominantly male (81% in PVM vs 89% in CM, = 0.330). Patients with PVM had lower T1 values compared with CM (1,064.2 ± 67.0 ms vs 1,081.6 ± 41.9 ms, = 0.032), although T2 and extracellular volume values were similar in both groups. Left ventricular ejection fraction and LGE were similar in both groups. The most frequent location of LGE was the basal inferolateral wall. PVM more commonly demonstrated a mid-wall LGE pattern while CM demonstrated a subepicardial LGE pattern. Compared with CM, patients with PVM were more likely to have a pericardial effusion (42% vs 17%, = 0.018) and pericardial LGE (38% vs 13%, = 0.009). During short-term follow-up (median 300 days for PVM, 319 days for CM), there were no deaths or heart failure hospitalizations in either group.
CONCLUSIONS
Our study shows similar CMR imaging findings and short-term outcomes in PVM and CM, although PVM was associated with milder myocardial abnormalities and more frequent pericardial involvement.
PubMed: 38938491
DOI: 10.1016/j.jacadv.2023.100726 -
Trauma Case Reports Dec 2023Perforating chest wall injuries involving the pericardial sac in pediatric patients are exceedingly rare and pose a unique clinical challenge. Thoracic trauma in the...
UNLABELLED
Perforating chest wall injuries involving the pericardial sac in pediatric patients are exceedingly rare and pose a unique clinical challenge. Thoracic trauma in the pediatric population remains a significant cause of morbidity and mortality. We present a case of an 8-year-old boy with an acute history of a sharp injection needle embedded in his chest wall presented with severe chest pain and diaphoresis. Diagnostic evaluations included computed tomography revealed a hyperdense focus with a metallic artefact seen impacted in the interventricular septa and perforating the heart. He underwent a thoracotomy and cardioplegic arrest for needle retrieval and subsequent cardiac repair. Our case underscores the importance of a multidisciplinary approach, meticulous monitoring, and a profound understanding of the unique anatomical considerations in pediatric chest injuries.
SUMMARY
This article presents a rare and challenging case of an 8-year-old male who arrived at the emergency department with a sharp injection needle embedded in his chest wall. Despite being relatively rare in children, thoracic injuries can be severe and potentially life-threatening. A fast and accurate diagnostic approach is crucial to prevent fatal complications. Thoracic trauma in the pediatric population remains a significant cause of morbidity and mortality. Timely diagnosis and appropriate interventions are critical in improving patient outcomes. The presented case highlights the need for caution and a well-planned approach in managing such rare and complex injuries in children.
PubMed: 37964982
DOI: 10.1016/j.tcr.2023.100962 -
Journal of Cardiothoracic Surgery Dec 2023Hemopericardium is a serious complication that can occur after cardiac surgery. While most post-operative causes are due to inflammation and bleeding, patients with...
BACKGROUND
Hemopericardium is a serious complication that can occur after cardiac surgery. While most post-operative causes are due to inflammation and bleeding, patients with broken sternal wires and an unstable sternum may develop hemopericardium from penetrating trauma.
CASE PRESENTATION
We present the case of a 62-year-old male who underwent triple coronary bypass surgery and presented five months later with sudden anterior chest wall pain. Chest computed tomography revealed hemopericardium with an associated broken sternal wire that had penetrated into the pericardial space. The patient underwent a redo-sternotomy which revealed a 3.5 cm bleeding, jagged right ventricular laceration that correlated to the imaging findings of a fractured sternal wire projecting in the pericardial space. The laceration was repaired using interrupted 4 - 0 polypropylene sutures in horizontal mattress fashion between strips of bovine pericardium. The patient's recovery was uneventful and he was discharged on post-operative day four without complications.
CONCLUSION
Patients with broken sternal wires and an unstable sternum require careful evaluation and management as these may have potentially life-threatening complications if left untreated.
Topics: Humans; Male; Middle Aged; Bone Wires; Cardiac Surgical Procedures; Lacerations; Pericardial Effusion; Sternotomy; Sternum; Thoracic Injuries
PubMed: 38071382
DOI: 10.1186/s13019-023-02452-6 -
Journal of Cardiothoracic Surgery Nov 2023Hydatid cysts are most frequently located in the liver and lungs and very rarely can be found in the pericardium. Diagnosis and treatment are quite challenging, as the...
BACKGROUND
Hydatid cysts are most frequently located in the liver and lungs and very rarely can be found in the pericardium. Diagnosis and treatment are quite challenging, as the disease can present itself in many forms depending to the location and the complications that it might cause.
CASE PRESENTATION
A 22-year-old man presented to our hospital with ongoing dry cough for more than 1 month prior to admission. Other symptoms included chest pain, fatigue, low grade fever, and night sweats, which have worsened in the past 2 weeks. Physical examination revealed normal respiratory and heart function. Chest X-ray demonstrated mediastinal enlargement and left pleural effusion. Contrast-enhanced computed tomography images showed a walled cystic mass lesion measuring up to 56 × 50 mm in close proximity to the upper left atrium, ascending aorta and pulmonary artery, potentially localized in the pericardium, with a 10 mm endoatrial filling defect, findings were compatible with hydatid cyst, left pleural effusion and peripheral pulmonary upper left lobe consolidation. Cardiac involvement was excluded on magnetic resonance imaging and trans-esophageal ultrasound. The patient underwent fine needle aspiration of the affected lung and thoracocentesis. No malignancy was found, meanwhile the biopsy confirmed the presence of pulmonary infarction. In view of the imaging findings were highly suspicious of a hydatid cyst, we performed a test of antibody titers that was negative. The patient underwent left anterolateral thoracotomy, and after the opening of the pericardium, a cystic mass of 5 cm in diameter was found next to the left atrium and in close proximity with the left pulmonary veins. The content of the cyst was completely removed after the surgical area was isolated with gauze impregnated with hypertonic solution (NaCl 10%). The mass resulted to be an echinococcal cyst with multiple daughter cysts within it that did not penetrate/involve (perforate) the cardiac wall.
CONCLUSION
Pericardial echinococcosis is a very rare pathology in which a high expertise multidisciplinary approach is required. The compression mass effect caused by the cyst can lead to complications, such as in our case where the pulmonary vein was compressed, leading to pulmonary infarction. The value of radiology studies and transoesophageal ultrasound are very important in the diagnosis. Surgery in these cases is always recommended, but preferred surgical approach is questionable. In cases such as ours, we recommend anterolateral thoracotomy.
Topics: Male; Humans; Young Adult; Adult; Pulmonary Infarction; Echinococcosis; Pericardium; Mediastinal Cyst; Pleural Effusion
PubMed: 37986073
DOI: 10.1186/s13019-023-02455-3 -
Surgery Oct 2023Outcomes for patients undergoing emergency thoracic operations have not been well described. This study was designed to compare postoperative outcomes among patients...
BACKGROUND
Outcomes for patients undergoing emergency thoracic operations have not been well described. This study was designed to compare postoperative outcomes among patients undergoing emergency versus nonemergency thoracic operations.
METHODS
We retrospectively analyzed the American College of Surgeons National Surgical Quality Improvement Program database (2005-2018). We identified patients who underwent emergency thoracic operations using current procedural technology codes. Patients were then sorted into 1 of 4 cohorts: lung and chest wall, hiatal hernia, esophagus, and pericardium. Emergency versus nonemergency outcomes were compared. Univariate logistic regression was performed with "emergency status" as the independent variable and 30-day postoperative outcomes as the dependent variables. Multiple logistic regression models were performed to control for preoperative factors.
RESULTS
Of 90,398 thoracic operations analyzed, 4,044 (4.5%) were emergency. Common emergency operations were pericardial window (n = 580, 10.2%), laparoscopic hiatal hernia repair (n = 366, 8.9%), thoracoscopic partial lung decortication (n = 334, 8.1%), thoracoscopic wedge resection (n = 301, 7.3%), thoracoscopic total lung decortication (n = 256, 6.2%), and open repair of hiatal hernia without mesh (n = 254, 6.2%). In all 4 cohorts, 30-day postoperative complications occurred more frequently after emergency surgery. After controlling for patient characteristics, 8 complications were more frequent after emergency lung and chest wall surgery, 5 complications were more frequent after emergency hiatal hernia surgery, and 3 complications were more frequent after emergency pericardium surgery. Risk-adjusted complications were not different after emergency esophageal surgery.
CONCLUSION
Patients undergoing emergency thoracic operations have worse risk-adjusted outcomes than those undergoing nonemergency thoracic operations. Subset analysis is needed to determine what factors contribute to increased adverse outcomes in specific patient populations.
Topics: Humans; Retrospective Studies; Thoracic Surgery; Hernia, Hiatal; Thoracic Surgical Procedures; Postoperative Complications; Herniorrhaphy; Laparoscopy; Treatment Outcome
PubMed: 37507304
DOI: 10.1016/j.surg.2023.06.034 -
Environmental Toxicology and Chemistry Dec 2023Flumioxazin is a widely applied herbicide for the control of broadleaf weeds, including aquatic plants. Current evidence suggests that flumioxazin could induce cardiac...
Flumioxazin is a widely applied herbicide for the control of broadleaf weeds, including aquatic plants. Current evidence suggests that flumioxazin could induce cardiac defects (ventricular septal defects) in vertebrates, but the underlining mechanisms remain unclear. Because of the inhibitory effect of flumioxazin on polyphenol oxidase, the assumption is made that flumioxazin-induced cardiotoxicity is caused by oxidative stress. To verify whether oxidative stress plays an important role in flumioxazin-induced cardiotoxicity, we compared the differences in heart phenotype, oxidative stress level, apoptosis, and gene expression between flumioxazin exposure and a normal environment, and we also tested whether cardiotoxicity could be rescued with astaxanthin. The results showed that flumioxazin induced both cardiac malformations and the abnormal gene expression associated with cardiac development. Cardiac malformations included pericardial edema, cardiac linearization, elongated heart, cardiomegaly, cardiac wall hypocellularity, myocardial cell atrophy with a granular appearance, and a significant gap between the myocardial intima and the adventitia. An increase in oxidative stress and apoptosis was observed in the cardiac region of zebrafish after exposure to flumioxazin. The antioxidant astaxanthin reversed the cardiac malformations, excessive production of reactive oxygen species (ROS), and expression of genes for cardiac developmental and apoptosis regulation induced by flumioxazin. In addition, flumioxazin also activated aryl hydrocarbon receptor (AhR) signaling pathway genes (aryl hydrocarbon receptor 2 [ahr2], cytochrome p450 family subfamily a [cyp1a1], and b [cyp1b1]) and increased the concentration of porphyrins. The results suggest that excessive ROS production, which could be mediated through AhR, led to apoptosis, contributing to the cardiotoxicity of flumioxazin in zebrafish embryos. Environ Toxicol Chem 2023;42:2737-2746. © 2023 SETAC.
Topics: Animals; Zebrafish; Cardiotoxicity; Receptors, Aryl Hydrocarbon; Reactive Oxygen Species; Oxidative Stress; Embryo, Nonmammalian
PubMed: 37712518
DOI: 10.1002/etc.5746 -
The American Journal of Cardiology Nov 2023Subclinical changes in left ventricular (LV) function have been demonstrated in patients with acute-phase myocarditis (AM) despite normal LV ejection fraction. The...
Subclinical changes in left ventricular (LV) function have been demonstrated in patients with acute-phase myocarditis (AM) despite normal LV ejection fraction. The impact of AM on right ventricular (RV) and left atrial (LA) function has not been well described. This study aimed to assess for subclinical chamber dysfunction by speckle tracking echocardiography and its clinical relevance in this population. Patients with a diagnosis of AM (as per the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases) admitted to our institution from 2013 to 2018 were assessed. Patients with elevated serum troponin, normal coronary assessment, and normal LV ejection fraction on transthoracic echocardiogram were included. Clinical and echocardiographic parameters were compared with healthy age-, gender- and risk-factor matched controls. Global longitudinal strain assessed through speckle tracking echocardiography was performed using vendor independent software (v4.6; TomTec Arena, Munich, Germany). The final cohort consisted of 80 patients (40 AM patients and 40 controls). No significant differences in baseline clinical characteristics were observed between groups. Of the echocardiographic parameters, AM patients had lower LV-global longitudinal strain (p <0.01), lower RV free-wall strain (p = 0.02) and lower peak LA strain (p <0.01). There were no differences in traditional echocardiographic measures of LV, RV, and LA function appreciated between groups. The presence of multichamber involvement was associated with peak Troponin levels (p <0.01). In conclusion, our study demonstrates the presence of global subclinical myocardial dysfunction in patients with AM. Additionally, the presence of multichamber involvement was significantly associated with degree of myocardial necrosis.
Topics: Humans; Myocarditis; Ventricular Dysfunction, Left; Echocardiography; Ventricular Function, Left; Troponin
PubMed: 37769573
DOI: 10.1016/j.amjcard.2023.08.142