Prostate Artery Embolization in the Treatment of Massive Intractable Bleeding from Prostatic Neoplasms: A Case Report and Systematic Review.

Lower urinary tract symptoms (LUTS) and hematuria are common symptoms in men with neoplasms, mainly affecting the elderly population. Prostatic arterial embolization (PAE) is a minimally invasive procedure that has shown promising results in managing LUTS and massive intractable prostatic hematuria in patients with benign prostatic hyperplasia (BPH) and prostate cancer (PCa). A few studies, however, have provided valuable insights into the durability and efficacy of PAE focusing on the long-term effectiveness, quality of life, and cancer-specific control of hemostasis and urinary symptoms. As a result of concomitant cardiovascular conditions, these patients often take anticoagulants or antithrombotics, which can worsen their hematuria and clinical status. Transurethral resection of the prostate (TURP) is considered a very high-risk procedure, even without massive bleeding, and requires discontinuation of vitamin K antagonists and antiplatelet therapies. Such patients usually have their surgery postponed, and PAE should be considered a safe alternative treatment. We aimed to report a narrative review from 1976 to June 2023 of the current state of PAE for massive and intractable hematuria, highlighting recent developments in this technique, including prospective cohort studies, and focusing on long-term outcome, safety, and complication management of patients with prostatic neoplasms who develop significant hemorrhagic symptoms. Additionally, we present a case report and a simple algorithm for treating intractable bleeding in a 92-year-old man with PCa and massive hematuria.

Nonsurgical Management of a Papillary Fibroelastoma of the Aortic Valve.

We report the case of a 63-year-old woman who had an incidental echocardiographic diagnosis of papillary fibroelastoma (PFE) of the right coronary cusp of the aortic valve. The patient was informed about the embolic risk due to the pedunculated mass located on the aortic valve but she refused the proposed surgical removal. She was followed up yearly, and each follow-up included an echocardiographic evaluation of the mass. The lady is taking lysine acetylsalycilate 160 mg daily, and after more than 19 years later, she does not complain any symptoms or complications as a result of possible embolic episodes. If on one hand, our report is provocative for PFE nonsurgical management; on the other, we do believe that in symptomatic patients PFE located in the left heart chambers, the standard of care remains surgical excision after diagnosis. Anyway, our analysis shows that further data in this issue are needed in asymptomatic patients, and surgical indication should be proposed considering carefully the risk-benefit balance.

Emergency Department Resuscitative Thoracotomy: Indications, surgical procedure and outcome. A narrative review.

BACKGROUND: Emergency Department Thoracotomy (EDRT) after traumatic Cardio-pulmonary Arrest (CPR) can be used to salvage select critically injured patients. Indications of this surgical procedure are widely debated and changed during last decades. We provide the available literature about EDRT in the effort to provide a comprehensive synthesis about the procedure, likelihood of success and patient's outcome in the different clinical setting, accepted indications and technical details adopted during the procedure for different trauma injuries. METHODS: Literature from 1975 to 2020 was retrieved from multiple databases and reviewed. Indications, contraindications, total number and outcome of patients submitted to EDRT were primary endpoints. RESULTS: A total number of 7236 patients received EDRT, but only 7.8% survived. Penetrating trauma and witnessed cardiopulmonary arrest with the presence of vital signs at the trauma center are the most favorable conditions to perform EDRT. CONCLUSIONS: EDRT should be reserved for acute resuscitation of selected dying trauma patient. Risks of futility, costs, benefits of the surgical procedure should be carefully evaluated before performing the surgical procedure.

Aortic perforation due to cardiac resynchronisation therapy defibrillator lead placement: Case report and medicolegal considerations.

A 45-year-old woman with dilated cardiomyopathy was admitted for the upgrade of a previously implanted pacemaker. Echocardiography showed intraventricular dyssynchrony and a low ejection fraction (0.35). Treatment with a cardiac resynchronization therapy defibrillator (CRT-D) was selected and the device was implanted. CRT-D interrogation revealed proper function. Following procedure termination, the patient went into cardiac arrest and died despite resuscitation attempts. An autopsy revealed that the medial aspect of the right atrium was pierced by an active lead and that the aorta had a deep lesion, 2 mm in length, on its lateral aspect. We explain the probable pathogenesis of this patient׳s death.

Unusual 25-year durability of an Ionescu-Shiley pericardial bioprosthesis.

Ionescu-Shiley valve was withdrawn from clinical use in 1987 for its early structural failure after implantation. This was due to valve design rather than the natural properties of bovine pericardium itself. We describe the unexpected 25-year survival of an Ionescu-Shiley bioprosthesis in the mitral and tricuspid positions, implanted to treat endomyocardial fibrosis. This report makes 2 important points: (1) pannus overgrowth may be a favorable determinant of the durability of xenografts, and (2) bovine pericardial valves may have excellent hemodynamic performance and tissue durability for more than 20 years in the mitral position even in young patients.

Reconstruction of anterior descending artery after removal of stents.

A 65-year-old man who had previously undergone multiple stenting on the coronary tree, was referred for urgent surgery. The left anterior descending coronary artery was found to be completely stented from the proximal to the distal portion. Open endarterectomy was required for removal of multiple thrombosed stents and reconstruction of the left anterior descending artery using left internal mammary artery. This highlights the need to spare the distal parts of coronary vessels for future surgery.

Iatrogenic circumflex coronary lesion in mitral valve surgery: case report and review of the literature.

Ischemic iatrogenic lesions can complicate surgical procedures on the mitral valve. One of the causative mechanisms is direct injury to or distortion of the circumflex coronary artery. The risk of damaging the circumflex coronary artery depends mainly upon the proximity of that vessel to the posterior segment of the mitral annulus, and this varies from patient to patient. Herein, we report a case of iatrogenic circumflex coronary artery lesion after mitral annuloplasty, and we review the literature on the subject, in order to highlight a possible relationship between iatrogenic circumflex lesions and coronary dominance. In a 60-year-old man who had severe mitral regurgitation due to prolapse of both leaflets, preoperative coronary angiography showed irregularities only along the left anterior descending coronary artery and a coronary network of right dominance. The patient underwent mitral annuloplasty (32-mm Carpentier-Edwards ring) by means of minimally invasive right thoracotomy through the right 4th intercostal space (HeartPort). When the procedure was over, and before the patient was taken to intensive care, ventricular fibrillation developed; the administration of direct-current shock (200 joules) resulted in a resumption of sinus rhythm. Repeat transesophageal echocardiography showed posterolateral dyskinesis of the left ventricle and ST-segment elevation suggestive of acute lateral myocardial infarction. Emergency cardiac catheterization revealed a subocclusion of the distal circumflex coronary artery. Dual percutaneous angioplasty and stenting (Taxus, 2.5 x 24 mm) was performed with optimal result. At the 1-year follow-up, the patient showed good results of the mitral annuloplasty.

Comparison of standard and bicaval approach in orthotopic heart transplantation: 10-year follow-up.

BACKGROUND: The present study compared 86 patients who underwent orthotopic heart transplantation by bicaval and standard techniques. METHODS: Patients already followed in the first year after heart transplantation were studied at 10 years of follow-up, this time evaluating the prevalence of arrhythmias, conduction disturbances and mitral or tricuspid regurgitation. RESULTS: The following arrhythmias were observed: atrial fibrillation (one patient from the standard group), ventricular premature beats and ventricular fibrillation (each in one patient from the bicaval group). Conduction disturbances were found in 25 patients in the standard group (48.1%) and in 19 patients in the bicaval group (55.9%, P = 0.515). Twenty patients had a mono- or bifascicular block in the standard group (38.5%) versus 19 patients in the bicaval group (55.9%); furthermore, five patients in the standard group (9.6%) and none in the bicaval group had a permanent pacemaker (Fisher's exact test: P = 0.074). Mitral regurgitation was present in 13 (26.5%) and five (16.1%) patients, respectively, in the standard and bicaval groups (Fisher's exact test: P = 0.411): it was grade 1 in 12 and five patients and grade 2 in one and zero patients, respectively. Tricuspidal regurgitation was observed in 26 (53.1%) and 13 (41.9%) patients, respectively, in the standard and bicaval groups (Fisher's exact test: P = 0.366): it was grade 1 in 23 and 13 patients and grade 2 in three and zero patients, respectively. Cumulative survival was 75% at 10 years from transplant in this relatively old population of patients (mean age = 58 years). CONCLUSION: In conclusion, our data do not support any definite mandate for either of the surgical techniques.

Valve-sparing removal of aortic fibroelastoma through ministernotomy.

Cardiac papillary fibroelastoma is a rare benign tumor which involves the heart valves and may cause thromboembolism or mechanical interference with valvular function. The case is presented of an asymptomatic, 22-year-old man in whom a fibroelastoma was localized on the ventricular aspect of the right coronary leaflet of the aortic valve. The tumor was identified during transthoracic echocardiography performed to monitor a mitral valve prolapse that had occurred at the age of 16 years. The patient underwent surgical intervention by means of a minimally invasive thoracotomy. The postoperative course was uneventful, and the patient was discharged on postoperative day 5. Due to the high incidence of embolism, the tumor must be surgically removed immediately a diagnosis is confirmed. A minimal surgical approach appears to be safe and allows good exposure of the lesion.

Nonpenetrating right atrial and pericardial trauma.

Nonpenetrating chest trauma can cause cardiac rupture. Ventricles are affected more frequently than atria. Survival is rare and depends upon prompt diagnosis and immediate surgical intervention. We report the case of a 42-year-old man involved in a car accident with consequent right atrial rupture and pericardial tearing.

Traumatic tricuspid valve rupture treated by minimally invasive thoracotomy.

Isolated valvular lesions consequent to non-penetrating trauma are rare. We present a case of a traumatic tricuspid valve rupture in a 51-year-old woman seriously involved in a motor vehicle accident 20 years earlier. She underwent tricuspid valve replacement performed via a minimally invasive thoracotomy in the right fourth intercostal space. The advantages of minimally invasive thoracotomy are discussed.

Heart transplantation in X-linked dilated cardiomyopathy.

BACKGROUND: X-linked dilated cardiomyopathy (DCM) is a clinical phenotype of dystrophinopathy characterized by preferential myocardial involvement without overt signs of skeletal muscle disease. X-linked DCM is a familiar myocardial disease characterized by ventricular dilation resulting in progressive heart failure and/or sudden death, and it may be differentiated from other DCMs. The aim of this retrospective study was to assess that patients with end-stage X-linked DCM can safely undergo heart transplantation. METHODS: Between August 1989 and January 2000, 7 patients presenting with X-linked DCM underwent heart transplantation for end-stage disease at our Institution. The patients' age ranged from 16 to 31 years (mean 24.4 years) and all were in NYHA functional class IV. RESULTS: The mean follow-up was 44 months (range 22-66 months). Only one sudden death occurred at 66 months of follow-up; all the other patients are doing well and are in NYHA functional class I. CONCLUSIONS: Our data suggest that heart transplantation can be considered as the treatment of choice for refractory cardiac failure in X-linked DCM.