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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 -
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 -
International Journal of Surgery Case... Dec 2023Mediastinal teratoma is the most common mediastinal germ cell tumor. Mature mediastinal teratomas are infrequent and often found incidentally.
INTRODUCTION AND IMPORTANCE
Mediastinal teratoma is the most common mediastinal germ cell tumor. Mature mediastinal teratomas are infrequent and often found incidentally.
CASE PRESENTATION
We report the case of a 14-year-old girl who was presented dyspnea for 2 years. A computed tomography of the chest revealed a 19 cm heterogenous right-sided anterior mediastinal mass suggesting mature teratoma. The mass compressed vital structures. The tumor was considered resectable. By hemiclamshell approach, we punctured the tumor and aspirated its contents. The tumor was totally resected en bloc with a cuff of pericardium, phrenic nerve and azygos vena. The pericardial defect was repaired using Mersilene mesh. Histopathology of the tumor revealed a mature cystic teratoma. Postoperative course was uneventful.
CLINICAL DISCUSSION
Complete surgical excision is the treatment of choice for mediastinal mature teratoma. The choice of incision for removing the tumor depend on the tumor size, location and the relashionships with the associated vital structures. Lengthy incisions were required for the safe mobilization of the tumor. In addition, contents aspiration through a small incision in the giant tumor wall helped improve tumor mobilization.
CONCLUSION
Appropriate surgical strategy for a well selected case maintains functional status and results total tumor resection.
PubMed: 37952494
DOI: 10.1016/j.ijscr.2023.109003 -
Journal of Cardiothoracic Surgery Nov 2023Appropriate management of mitral annular calcification associated with mitral valve surgery must be determined on a case-by-case basis. However, an established procedure...
Mitral valve replacement using a collar-reinforced mitral prosthesis for severe mitral annular calcification, which secures implantation in both the supra-annular and intra-atrial positions: a case report.
BACKGROUND
Appropriate management of mitral annular calcification associated with mitral valve surgery must be determined on a case-by-case basis. However, an established procedure remains uncertain.
CASE PRESENTATION
This report describes a surgical case of severe mitral and aortic valve stenosis associated with severe mitral annular calcification in a 71-year-old woman who underwent mitral valve replacement with a collar-reinforced mitral prosthesis. The patient underwent surgical repair after the treatment for heart failure. As the present patient was deemed to be at high risk for conventional mitral valve replacement, we applied a composite prosthetic valve that was enlarged circumferentially on the ventricular side of the prosthesis with a bovine pericardial patch. First, the solid calcium bar was left untouched and only the friable calcified mass that was easily scattered was removed. Subsequently, the prosthesis was secured by two mattress sutures placed in the intra-atrial position at the region of the extended calcified myocardium. Additionally, ten mattress sutures were placed in the supra-annular position at the other regions capable of passing stitches from the ventricular side to the atrial side. Finally, a 1.5 cm wide trimmed bovine pericardial collar was sutured circumferentially from the annulus to the atrial wall using running 4-0 polypropylene for reinforcement. Although temporary hemodialysis was performed for acute renal failure, the patient remained asymptomatic.
CONCLUSIONS
The present case suggests that mitral valve replacement using a collar-reinforced mitral prosthesis may be an effective technique for severe mitral annular calcification. To avoid catastrophic complications associated with treatment for severely calcified annulus, it is crucial to make a prudent preoperative decision regarding the surgical strategy under circumstances where conventional mitral valve replacement is impossible.
Topics: Female; Humans; Animals; Cattle; Aged; Mitral Valve; Atrial Fibrillation; Heart Valve Prosthesis; Heart Valve Diseases; Prosthesis Implantation; Calcinosis; Heart Valve Prosthesis Implantation; Mitral Valve Insufficiency; Treatment Outcome
PubMed: 37951918
DOI: 10.1186/s13019-023-02429-5 -
PloS One 2023Even though the preliminary experimental data suggests that cardiac Pulsed Field Ablation (PFA) could be superior to radiofrequency ablation (RFA) in terms of being able...
Even though the preliminary experimental data suggests that cardiac Pulsed Field Ablation (PFA) could be superior to radiofrequency ablation (RFA) in terms of being able to ablate the viable myocardium separated from the catheter by collagen and fat, as yet there is no formal physical-based analysis that describes the process by which fat can affect the electric field distribution. Our objective was thus to determine the electrical impact of intramyocardial fat during PFA by means of computer modeling. Computer models were built considering a PFA 3.5-mm blunt-tip catheter in contact with a 7-mm ventricular wall (with and without a scar) and a 2-mm epicardial fat layer. High voltage was set to obtain delivered currents of 19, 22 and 25 A. An electric field value of 1000 V/cm was considered as the lethal threshold. We found that the presence of fibrotic tissue in the scar seems to have a similar impact on the electric field distribution and lesion size to that of healthy myocardium only. However, intramyocardial fat considerably alters the electrical field distribution and the resulting lesion shape. The electric field tends to peak in zones with fat, even away from the ablation electrode, so that 'cold points' (i.e. low electric fields) appear around the fat at the current entry and exit points, while 'hot points' (high electric fields) occur in the lateral areas of the fat zones. The results show that intramyocardial fat can alter the electric field distribution and lesion size during PFA due to its much lower electrical conductivity than that of myocardium and fibrotic tissue.
Topics: Humans; Cicatrix; Catheter Ablation; Computer Simulation; Pericardium; Fibrosis; Computers
PubMed: 37917621
DOI: 10.1371/journal.pone.0287614 -
International Journal of Surgery Case... Nov 2023The sternum, pericardium, diaphragm, abdominal wall, and heart are all affected by the unusual congenital condition known as Cantrell pentalogy. It is a rare congenital...
INTRODUCTION
The sternum, pericardium, diaphragm, abdominal wall, and heart are all affected by the unusual congenital condition known as Cantrell pentalogy. It is a rare congenital disorder that requires multidisciplinary care. Early diagnosis and appropriate management are crucial for improving outcomes in affected individuals. To illustrate the difficulties and complexity of Cantrell pentalogy, we provide two cases.
PRESENTATION OF CASE
In case 1, a routine antenatal scan at 12 weeks' gestation revealed thoracoabdominal ectopia cordis in a 29-year-old woman. The pregnancy was terminated medically due to the severity of the anomalies and the poor prognosis. A 32-year-old patient in case 2 had a diaphragmatic hernia, thoracoabdominal ectopia cordis and midline abdominal wall abnormalities. After counselling, a medical termination was chosen. The ultra-sonographic features were confirmed by autopsy results in 2 cases.
DISCUSSION
Early diagnosis is feasible in the first trimester if ectopia cordis and omphalocele exist. Additionally, development in ultrasound technology provides us with better visualization and early diagnosis. With patients who have fully developed Cantrell syndrome and those who also have accompanying anomalies, the prognosis is often poor, with short survival and quality of life.
CONCLUSIONS
Cantrell pentalogy is a rather uncommon congenital condition. Early detection is possible in the first trimester. The severity of the illness varies greatly, and treatment is determined by the precise abnormalities present. Early diagnosis necessitates adequate initial training as well as ongoing in-service training for sonographers. Early detection and treatment are critical for improving outcomes in affected persons.
PubMed: 37879290
DOI: 10.1016/j.ijscr.2023.108941 -
Developmental Cell Nov 2023Despite their burden, most congenital defects remain poorly understood, due to lack of knowledge of embryological mechanisms. Here, we identify Greb1l mutants as a mouse...
Despite their burden, most congenital defects remain poorly understood, due to lack of knowledge of embryological mechanisms. Here, we identify Greb1l mutants as a mouse model of crisscross heart. Based on 3D quantifications of shape changes, we demonstrate that torsion of the atrioventricular canal occurs together with supero-inferior ventricles at E10.5, after heart looping. Mutants phenocopy partial deficiency in retinoic acid signaling, which reflect overlapping pathways in cardiac precursors. Spatiotemporal gene mapping and cross-correlated transcriptomic analyses further reveal the role of Greb1l in maintaining a pool of dorsal pericardial wall precursor cells during heart tube elongation, likely by controlling ribosome biogenesis and cell differentiation. Consequently, we observe growth arrest and malposition of the outflow tract, which are predictive of abnormal tube remodeling in mutants. Our work on a rare cardiac malformation opens novel perspectives on the origin of a broader spectrum of congenital defects associated with GREB1L in humans.
Topics: Humans; Animals; Mice; Crisscross Heart; Morphogenesis; Heart; Heart Ventricles; Stem Cells
PubMed: 37852253
DOI: 10.1016/j.devcel.2023.09.006 -
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 -
European Heart Journal. Case Reports Oct 2023We report a case of a 47-year-old woman with right atrial metastasis of endometrioid adenocarcinoma, which is an uncommon clinical presentation for patients with...
BACKGROUND
We report a case of a 47-year-old woman with right atrial metastasis of endometrioid adenocarcinoma, which is an uncommon clinical presentation for patients with endometrial cancer (EC). The principal aim of this case is to demonstrate the possibility of distant metastasis, something rarely encountered among this group of patients.
CASE SUMMARY
Our patient, diagnosed with EC and receiving chemotherapy and radiotherapy after surgery, was found to have enhanced 18-fluorodeoxyglucose uptake inside the right atrium on the repeat positron emission tomography-computed tomography scan at the ninth month after initial diagnosis. Following trans-oesophageal echocardiography, cardiac magnetic resonance imaging showed a hyper-vascular mass with right atrial lateral wall involvement likely to be malignant in nature. A right atrial tumour was successfully removed by cardiovascular surgeons, and a pericardial patch was placed at the site of the excised atrium. The pathological examination showed EC metastasis. Following surgery, systemic treatment was planned for recurrent EC. The patient had an uneventful recovery after the surgery.
DISCUSSION
Endometrial cancer is the most common gynaecologic malignancy and the fourth most common cancer in women. The lymphatic pathway is the main metastatic behaviour of EC; however, haematogenous metastases are not uncommon, especially in patients with higher stages of the disease. Our patient did not show any signs and symptoms of cardiac involvement. Nevertheless, clinicians should be alert for symptoms of cardiac involvement like new-onset murmur, embolism, or dyspnoea. Having known the behavioural pattern of the primary tumour, timely utilization of diagnostic imaging methods in accordance with clinical suspicions in patients with rapidly growing tumours can be lifesaving.
PubMed: 37811158
DOI: 10.1093/ehjcr/ytad461 -
Journal of Cardiothoracic Surgery Oct 2023Left ventricular free wall rupture (LVFWR) is a rare but fatal complication of acute myocardial infarction (AMI). An 81-year-old female patient with several...
Left ventricular free wall rupture (LVFWR) is a rare but fatal complication of acute myocardial infarction (AMI). An 81-year-old female patient with several cardiovascular risk factors presented to the emergency department with symptoms of developing a chronic stomachache and cold sweat. An echocardiograph showed wall motion abnormalities from the lateral to posterior wall, as well as pericardial effusion containing clots of up to 17 mm in the posterior wall that indicated LVFWR after AMI. Although she was conscious after being brought to the initial care unit, she suddenly lost consciousness and fell into electromechanical dissociation (EMD). Endotracheal intubation was immediately initiated and her pericardial drainage and intra aortic balloon pump (IABP) placement, and hemodynamics recovered. Although she had 100% obstruction in the left circumflex artery (LCX) #12 on coronary angiography (CAG), she was discharged to the Intensive Care Unit (ICU) without percutaneous coronary intervention (PCI). Conservative treatment such as intubation, sedation, pericardiocentesis and strict blood pressure management as well as treatment by IABP long-term support led to the patient being uneventfully discharged after 60 days.
Topics: Humans; Female; Aged, 80 and over; Percutaneous Coronary Intervention; Conservative Treatment; Myocardial Infarction; Heart Rupture; Echocardiography
PubMed: 37805478
DOI: 10.1186/s13019-023-02397-w