Purulent Pericarditis as the First Manifestation of Esophageal Carcinoma.

INTRODUCTION: Purulent pericarditis secondary to esophago-pericardial fistula is a serious complication that has been previously reported in patients with esophageal cancer treated with radio/chemotherapy and esophageal stenting. However, the presence of esophago-pericardial fistula as the first manifestation of advanced carcinoma of the esophagus is exceedingly infrequent. We report the case of a 61-year-old male who presented with sepsis, cardiac tamponade and septic shock who was found to have an esophago-pericardial fistula secondary to squamous carcinoma of the esophagus. Emergency pericardiocentesis was performed with subsequent hemodynamic improvement. The drained pericardial fluid was purulent in nature and cultures were positive for Streptococcus anginosus. A CT scan followed by upper gastrointestinal endoscopy with tissue biopsy confirmed the diagnosis of squamous cell carcinoma of the esophagus. A self-expanding covered stent was endoscopically placed to exclude the fistula and restore the esophageal lumen. In this report, we discuss some aspects related to the diagnosis and management of this serious clinical entity.

Left Ventricular Papillary Fibroelastoma.

INTRODUCTION: Cardiac papillary fibroelastoma is a rare benign primary cardiac tumor typically found on the valvular structures of the heart. Nonvalvular papillary fibroelastomas are exceedingly rare. We report the case of a 66-year-old male who presented with cerebellar infarctions and was found to have a mobile mass attached to the endocardial surface of the anteroseptal wall of the left ventricle. Cardiac magnetic resonance imaging demonstrated late gadolinium enhancement. Surgical excision of the cardiac mass was performed via the transaortic approach without intra-operative complications. Histopathologic examination confirmed the diagnosis of a papillary fibroelastoma. Some aspects related to the etiology, diagnosis and management of this entity are discussed.

Accumulation of Inflammatory Mediators in the Normal Pericardial Fluid.

There is paucity of studies that focus on the composition of pericardial fluid under resting conditions. The purpose of this study is to determine the levels of inflammatory mediators in pericardial fluid and their correlation with plasma levels in patients undergoing elective cardiac surgery. We conducted a prospective cohort study on candidates for elective aortic valve replacement surgery. Pericardial fluid and peripheral venous blood samples were collected after opening the pericardium. Levels of interleukin 1α (IL-1α); interleukin 1ß (IL-1ß); interleukin 2 (IL-2) interleukin 4 (IL-4); interleukin 6 (IL-6); interleukin 8 (IL8); interleukin 10 (IL10); tumor necrosis factor-α (TNF-α), interferon-γ (IFN-γ), vascular endothelial growth factor (VEGF), monocyte chemotactic protein-1 (MCP-1) epidermal growth factor (EGF), soluble E-selectin, L-selectin, P-selectin, intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1) were determined in both pericardial fluid and serum samples. A total of 45 patients with a mean age of 74 years were included of which 66% were males. Serum levels of all study mediators were within normal limits. Serum and pericardial levels of IL-1 α, IL-1 ß, IL-2, IL-4, and IL-10 were similar. Levels of VEGF, EGF, VCAM-2, ICAM 1, E-selectin, P-selectin, and L-selectin were significantly lower in pericardial fluid than in serum. However, levels of IL-6, IL-8, TNF-α, IFN-γ, MCP-1, and MCP-1 were significantly higher in the pericardial fluid than in serum. Under normal conditions, the pattern of distribution of different inflammatory mediators in the pericardial fluid does not reflect serum levels. This may either reflect the condition of the underlying myocardium and epicardial fat or the activity of the mesothelial and mononuclear cells present in pericardial fluid.

Biomechanical characteristics of different methods of neo-chordal fixation to the papillary muscles.

BACKGROUND AND AIM OF THE STUDY: Several techniques have been described for neo-chordal fixation to the papillary muscles without any reported clinical differences. The objective of this study is to compare in vitro the biomechanical properties of four of these common techniques. METHODS: We studied the biomechanical properties of expanded polytetrafluoroethylene neo-chordal fixation using four techniques: nonknotted simple stitch, nonknotted figure-of-eight stitch, knotted pledgeted mattress stitch, and knotted pledgeted stitch using commercially available prefabricated loops. Neo-chordae were submitted to a total of 20 traction-relaxation cycles with incremental loads of 1, 2, and 4 N. We calculated the elongation, the force-strain curve, elasticity, and the maximum tolerated load before neo-chordal failure. RESULTS: The elongation of the neo-chordae was lowest in the simple stitch followed by the figure-of-eight, the pledgeted mattress, and he commercially prefabricated loops (p < .001). Conversely, the elastic modulus was highest in the simple stitch followed by the figure-of-eight, the pledgeted mattress, and the prefabricated loops (p < .001). The maximum tolerated load was similar with the simple stitch (28.87 N) and with the figure-of-eight stitch (31.39 N) but was significantly lower with the pledgeted mattress stitch (20.51 N) and with the prefabricated loops (7.78 N). CONCLUSION: In vitro, neo-chordal fixation by nonknotted simple or nonknotted figure-of-eight stitches resulted in less compliance as opposed to the use of knotted pledgeted stitches. Fixation technique seemed to influence neo-chordal biomechanical properties, however, it did not seem to affect the strength of the suture when subjected to loads within physiological ranges.

Clinical study of an outbreak of postoperative mediastinitis caused by Serratia marcescens in adult cardiac surgery.

OBJECTIVES: Nosocomial infection caused by Serratia marcescens after cardiac surgery is rare but causes high rates of morbidity and mortality. Knowledge about postoperative mediastinitis due to S. marcescens is limited. The purpose of this work was to study the clinical presentation, management and outcome of an outbreak of postoperative sternal infection due to S. marcescens. METHODS: During a 7-week period, a total of 54 patients underwent open heart procedures in our hospital. A postoperative wound infection caused by S. marcescens was diagnosed in 10 patients. We performed a clinical study to investigate patient characteristics and outcomes as well as the possible source of the infection. RESULTS: The mean age of the infected patients was 74.5 ± 10 years. Mediastinitis was present in 6 cases, superficial wound infection in 3 and isolated bacteraemia in 1. Purulent exudate through the sternal incision was observed in all infected cases except in 1 patient, who presented only with bacteraemia. Serratia marcescens was isolated from the samples taken from all infected wounds. The mean time elapsed between the operation and the isolation S. marcescens was 5.9 ± 2.4 days. Response to treatment was favourable in all cases except 1, who died. Contamination of the aqueous chlorhexidine solution used to prepare the patients' skin with S. marcescens was reported. Microbiological studies demonstrated that S. marcescens strains isolated from patients and from the aqueous chlorhexidine solution belonged to the same clone. CONCLUSIONS: The use of an aqueous chlorhexidine solution contaminated with S. marcescens caused an outbreak of postoperative sternal wound infections. The time elapsed between wound contamination and signs of infection was brief, but the systemic inflammatory response and tissue necrosis were limited. Alcohol-based solutions are recommended for the prevention of surgical site infections.

Myxoma of the aortic valve.

Myxomatous tumours can arise from different cardiac structures. They have a special predilection for the left atrium and are an exceedingly uncommon finding in cardiac valves. We report the case of a 28-year old man who presented with a stroke and was found to have a mass arising from his aortic valve. The patient underwent a successful surgical excision of the aortic valve with the implantation of a mechanical prosthesis. The histopathological examination of the aortic valve confirmed the diagnosis of myxoma. Some aspects related to the diagnosis and management of this entity are discussed in this article.

A simple technique to rule out occlusion of right coronary artery after aortic valve surgery.

Mechanical occlusion of the right coronary artery during aortic valve surgery is an infrequent but serious complication. Early recognition and expeditious management are important to reduce mortality. We developed a safe, quick, and easy technique to assess right coronary artery flow after aortic valve surgery. Direct intraoperative right coronary artery flow was measured by placing a transit-time flowmeter probe around the right coronary artery. We were able to promptly detect severe right coronary artery insufficiency in patients with acute unexpected right ventricular failure after aortic valve replacement.