Predicting severe proximal left anterior descending coronary artery stenosis using proximal left anterior descending coronary artery tortuosity and the angle between the left main and anterior descending coronary arteries: a retrospective cross-sectional study.

Background: Coronary bifurcation angles influence plaque initiation in the coronary artery, and changes in blood flow caused by tortuosity in the coronary arteries can reduce blood pressure distal to the tortuous portion of the coronary artery, leading to myocardial ischemia. We aimed to describe two factors (coronary artery tortuosity and bifurcation angle) as one descriptor for the evaluation of proximal left anterior descending coronary artery (LAD) disease. Methods: We reviewed the medical records of 133 consecutive patients who underwent computed tomography angiography (CTA) for angina symptoms between November 2019 and January 2020. The patients were divided into two groups according to the presence of significant LAD stenosis on CTA (defined as LAD stenosis >50%). The straight length of the vessel was measured using the central luminal line of the flow path, and, calculated using proprietary algorithms in TeraRecon software. We used three-dimensional volume rendering and two-dimensional axial images to measure the left main coronary artery (LM)-LAD angles. Results: In the univariate analysis, there were significant differences in the linear distance between the endpoints of the 20 mm actual curve of the LAD (d20), cosine value for LM-LAD angle (cosθ) <0.8, age, presence of hypertension or diabetes, and number of pack years [hazard ratio (HR): 2.70, 8.04, 1.05, 3.70, 2.82, and 1.04; P=0.029, P<0.001, P=0.020, P=0.024, P=0.021, and P=0.002, respectively]. However, in the multivariate analysis, the cosθ multiplied by d20 (d20*cosθ) <15.5, presence of hypertension and number of pack years (HR: 11.36, 4.54, and 1.04; P<0.001, P=0.019, and P=0.003, respectively) were predictors of significant proximal LAD stenosis. Conclusions: As the tortuosity and LM-LAD angle increased (d20 and cosθ decreased, respectively), the chance of proximal LAD lesions formation increased. d20*cosθ might be useful as a predictor of proximal LAD stenosis.

High-Grade Surface Osteosarcoma of the Rib Mimicking a Neurogenic Tumor: Radiologic and Pathologic Findings.

Osteosarcoma commonly occurs in the intramedullary cavity of long bones such as the femur, tibia, and humerus in children and adolescents. Osteosarcoma occurring as a primary tumor in the chest wall is rare. Only a limited number of such cases have been documented in the existing literature. Herein, we present radiologic and pathologic findings of a high-grade surface osteosarcoma of the rib mimicking a neurogenic tumor in a 44-year-old woman.

Two Cases of Severe Complications Due to an Esophageal Fish Bone Foreign Body.

Cases of foreign body ingestion are encountered relatively often in clinical settings; however, serious complications are rare. In such cases, mediastinal abscess due to esophageal perforation can become a life-threatening complication. We encountered two cases of severe complications due to an esophageal fish bone foreign body. The first case was a 40-year-old male with an intramural esophageal abscess due to a fish bone after eating fish five days before visiting the hospital. The patient underwent surgical treatment, but the esophageal abscess did not improve; so, the abscess was drained through endoscopic mucosal dissection, and the abscess improved. In the second case, a 64-year-old male, who had eaten fish three days before visiting the hospital, had esophageal perforation by a fish bone, and abscess formation in the mediastinum and the lesser sac in the abdominal cavity were observed. Although surgical treatment was performed, the intra-abdominal abscess formation was not controlled; so, percutaneous drainage (PCD) was inserted, and the abscess improved. Both patients were discharged without any complications. Here, we report two cases that were improved through surgical treatments and additional treatments such as endoscopic dissection and PCD.

Conversion to Veno-arteriovenous Extracorporeal Membrane Oxygenation for Differential Hypoxia.

Background: Patients who require initial venoarterial extracorporeal membrane oxygenation (VA ECMO) support may need to undergo veno-arteriovenous ECMO (VAV ECMO) conversion. However, there are no definitive criteria for conversion to VAV ECMO. We report 9 cases of VAV ECMO at Gyeongsang National University Changwon Hospital, Gyeongsang National University College of Medicine. Methods: Of 158 patients who received ECMO support between January 2017 and June 2019, 82 were supported by initial VA ECMO. We retrospectively reviewed the medical records of 9 patients (7 men and 2 women; age, 53.1±19.4 years) who had differential hypoxia and required VAV ECMO support. Percutaneous transaortic catheter venting was used to detect the differential hypoxia. Results: Among the 82 patients who received VA ECMO support, 9 (10.9%) had differential hypoxia and required conversion to VAV ECMO support. The mean time from VA ECMO support to VAV ECMO support and the mean duration of the VAV support were 2.1±2.2 days and 1.9±1.5 days, respectively. The average peak inspiratory pressure before and after VAV ECMO application was 23.89±3.95 cmH2O and 20.67±5.72 cmH2O, respectively, decreasing by an average of 3.2±3.5 cmH2O (p=0.040). The PaO2/FiO2 ratio was kept below 100 mm Hg in survivors and non-survivors for 116±65.4 and 250±124.9 minutes, respectively (p=0.016). Six patients underwent extracorporeal cardiopulmonary resuscitation, of whom 4 survived (67%). The overall survival rate of patients who underwent conversion from VA ECMO to VAV ECMO was approximately 56%. Conclusion: Rapid detection of differential hypoxia is required when VA ECMO is applied, and efficient conversion to VAV ECMO may be critical for patient survival.

Additional Extracorporeal Membrane Oxygenation Pump Without an Oxygenator for Transseptal Left Atrial Decompression: A Case Report.

A 63-year-old man developed chest pain and dyspnea. Venoarterial-venous extracorporeal membrane oxygenation (ECMO) was applied to the patient due to failing heart after percutaneous coronary intervention. We used an additional ECMO pump without an oxygenator for transseptal left atrial (LA) decompression and performed a heart transplant. Transseptal LA decompression with venoarterial ECMO is not always effective for severe left ventricular dysfunction. Here, we report a case of the effective use of additional ECMO pump without an oxygenator for transseptal LA decompression through controlling the blood flow rate of the transseptal LA catheter.

Fulminant Giant Cell Myocarditis following Heterologous Vaccination of ChAdOx1 nCoV-19 and Pfizer-BioNTech COVID-19.

A 48-year-old female patient underwent a heart transplantation for acute fulminant myocarditis, following heterologous vaccination with the ChAdOx1 nCoV-19 and Pfizer-BioNTech COVID-19. She had no history of severe acute respiratory syndrome coronavirus-2 infection. She did not exhibit clinical signs or have laboratory findings of concomitant infection before or after vaccination. Heart transplantation was performed because her heart failed to recover with venoarterial extracorporeal oxygenation support. Organ autopsy revealed giant cell myocarditis, possibly related to the vaccines. Clinicians may have to consider the possibility of the development of giant cell myocarditis, especially in patients with rapidly deteriorating cardiac function and myocarditis symptoms after COVID-19 vaccination.

The serial connection of two extracorporeal membrane oxygenators for patient with refractory hypoxemia.

A 34-year-old man developed severe hypoxemia and hypercapnia due to acute respiratory distress during ventilator care after surgery with acute intracranial hemorrhage. Severe hypoxemia had not been corrected even with maximum extracorporeal membrane oxygenation (ECMO) flow and full ventilator settings. We applied a novel technique for the serial connection of two veno-venous ECMO circuits for optimal oxygen delivery and CO2 removal and could wean VV ECMO. The use of serial connection of two VV ECMO circuits may be considered worthwhile when severe hypoxemia or hypercapnia are not improved and the use of protective ventilators is not permitted.

Left Ventricular Decompression by Transaortic Catheter Venting in Extracorporeal Membrane Oxygenation.

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been widely applied to patients with cardiogenic shock. Left ventricle (LV) decompression is important when LV distension develops with pulmonary edema. The purpose of this study was to present the results of transaortic catheter venting (TACV) performed during VA-ECMO. We retrospectively reviewed the medical records of 18 patients who underwent both VA-ECMO and TACV between January 2017 and December 2019. Venoarterial extracorporeal membrane oxygenation was applied uneventfully. Lactate level and norepinephrine requirement for patients of weaning success were lower than those of patients of weaning failure after the application of TACV (p = 0.032 and p = 0.015, respectively). The successful weaning rate of ECMO was 77.8% (15/18) and survival rate was 50% (9/18). Transaortic catheter venting may be an easy, safe, and effective technique for LV decompression in patients with VA-ECMO for cardiogenic shock. Also, this technique may be helpful as an alternative or bridge method.

Chemical pleurodesis with Viscum album L. extract for secondary spontaneous pneumothorax in elderly patients.

BACKGROUND: Secondary spontaneous pneumothorax is generally managed by surgery, if pneumothorax was not improved following chest tube insertion or in the event of persistent air leakage lasting more than 5 days. However, if surgery is not an option, chemical pleurodesis with sclerosants can be performed. Several sclerosants have been used in the chemical pleurodesis of secondary spontaneous pneumothorax, However, there is still controversy for what is the ideal sclerosant for Secondary spontaneous pneumothorax. The use of Viscum album L. for chemical pleurodesis in patients with secondary spontaneous pneumothorax aged >65 years has not been described to date, despite its extensive use. The authors tried to find out the effect of Viscum album L. for sclerosant for Secondary spontaneous pneumothorax in elder. METHODS: This retrospective analysis examined 25 patients (aged >65 years) with secondary spontaneous pneumothorax with persistent air leakage who underwent chemical pleurodesis with Abnova Viscum-F® (V. album L.). RESULTS: The duration of chest tube drainage was 5.08 days after chemical pleurodesis. Adverse effects related to chemical pleurodesis with Abnova Viscum-F® were fever (7/25), pain (4/25), leukocytosis (10/25), and dyspnea with desaturation (7/25); however all the patients recovered without sequela and were subsequently discharged. CONCLUSIONS: The present study demonstrated the successful use of chemical pleurodesis with V. album L. in the management of elderly patients with secondary spontaneous pneumothorax. Because of the high probability of dyspnea with desaturation in the elderly, caution must be exercised.

Veno-Arterial-Venous Extracorporeal Membrane Oxygenation in a Critically Ill Patient with Coronavirus Disease 2019.

Patients with cardiopulmonary failure may not be fully supported with typical configurations of extracorporeal membrane oxygenation (ECMO), either veno-arterial (VA) or veno-venous (VV). Veno-arterial-venous (VAV)-ECMO is a technique used to support the cardiopulmonary systems during periods of inadequate gas exchange and perfusion. In the severe case of coronavirus disease 2019 (COVID-19), which simultaneously affects the heart and lung, VAV-ECMO may improve a patient's recovery potential. We report the case of a 72-year-old woman with acute respiratory distress syndrome and circulatory failure following COVID-19, who was treated with VAV-ECMO.

Diagnosis of multiple pulmonary cavernous hemangiomas via dual-layer spectral CT: A case report.

RATIONALE: Cavernous hemangioma is a benign vascular tumor, which very rarely occurs in the lung. When appearing as multiple nodules on chest CT, this tumor can be misdiagnosed as metastatic malignancy. PATIENT CONCERNS: A 72-year-old woman presented with incidentally found multiple lung nodules on chest radiograph. DIAGNOSES: Based on information derived from dual-layer spectral CT images, the possibility of slow flow vascular tumor such as cavernous hemangioma was suggested. A pathologic diagnosis of pulmonary cavernous hemangioma was made via video-assisted thoracoscopic biopsy. INTERVENTIONS: After tissue confirmation, the patient was discharged without further intervention. OUTCOMES: The patient recovered without any event. Follow-up chest CT performed 6 months later showed no significant interval change in nodule size and distribution. LESSONS: Material decomposition images obtained from dual energy CT can help physicians understand the character of tumor vascularity for an accurate diagnosis of pulmonary cavernous hemangioma.

Malignant pulmonary embolism associated with renal sarcoma: A case report.

RATIONALE: The preoperative diagnosis of massive pulmonary tumor embolism associated with renal neoplasms is relatively rare. In most cases, pulmonary tumor embolism is detected intraoperatively during renal tumor resection. Moreover, primary renal sarcoma is rare, and primary renal sarcoma complicated by pulmonary tumor embolism is extremely rare; accordingly, there is no optimal treatment for such cases. Herein, we report a case of renal sarcoma associated with pulmonary tumor embolism. PATIENT CONCERNS: A 39-year-old man was admitted to the emergency room owing to the sudden onset of dyspnea and palpitation. DIAGNOSIS: Contrast-enhanced computed tomography (CT) revealed a large mass in the right kidney involving the infrahepatic inferior vena cava, with massive pulmonary emboli in both the pulmonary arteries. INTERVENTIONS: Emergency pulmonary embolectomy with radical nephrectomy was performed. OUTCOMES: The patient experienced apparent remission of dyspnea, and resolution of right ventricle dysfunction. However, although remnant emboli were detected in the segmental arteries on postoperative CT, complete resolution of pulmonary embolism was observed after adjuvant chemotherapy. LESSONS: Thus, concomitant cytoreductive nephrectomy with pulmonary embolectomy along with chemotherapy may be effective for patients with renal sarcoma with pulmonary tumor embolism.

Impact of diffusing lung capacity before and after neoadjuvant concurrent chemoradiation on postoperative pulmonary complications among patients with stage IIIA/N2 non-small-cell lung cancer.

BACKGROUND AND OBJECTIVE: This study aims to evaluate the impact of diffusing capacity of the lung for carbon monoxide (DLco) before and after neoadjuvant concurrent chemoradiotherapy (CCRT) on postoperative pulmonary complication (PPC) among stage IIIA/N2 non-small-cell lung cancer (NSCLC) patients. METHODS: We retrospectively studied 324 patients with stage IIIA/N2 NSCLC between 2009 and 2016. Patients were classified into 4 groups according to DLco before and after neoadjuvant CCRT; normal-to-normal (NN), normal-to-low (NL), low-to-low (LL), and low-to-very low (LVL). Low DLco and very low DLco were defined as DLco < 80% predicted and DLco < 60% predicted, respectively. RESULTS: On average, DLco was decreased by 12.3% (±10.5) after CCRT. In multivariable-adjusted analyses, the incidence rate ratio (IRR) for any PPC comparing patients with low DLco to those with normal DLco before CCRT was 2.14 (95% confidence interval (CI) = 1.36-3.36). Moreover, the IRR for any PPC was 3.78 (95% CI = 1.68-8.49) in LVL group compared to NN group. The significant change of DLco after neoadjuvant CCRT had an additional impact on PPC, particularly after bilobectomy or pneumonectomy with low baseline DLco. CONCLUSIONS: The DLco before CCRT was significantly associated with risk of PPC, and repeated test of DLco after CCRT would be helpful for risk assessment, particularly in patients with low DLco before neoadjuvant CCRT.

Perforation of inferior vena cava and duodenum by strut of inferior vena cava filter: A case report.

INTRODUCTION: An Inferior vena cava (IVC) filter is an intravascular filter that is implanted into the IVC to prevent pulmonary embolism in medical, surgical, and trauma patients. The insertion of an IVC filter is a relatively safe procedure, but rarely may be associated with symptomatic perforation of the IVC wall, particularly in the long term. PATIENT CONCERNS AND DIAGNOSIS: A 74-year-old-woman with a medical history of IVC filter insertion visited the emergency department complaining of abdominal pain. A computed tomography scan showed perforation of the IVC wall and penetration into the duodenum by one of the filter's struts. INTERVENTIONS: We performed a laparotomy to remove the IVC filter. OUTCOMES: Postoperatively, the patient was admitted to the general ward. On hospital day 12, she was discharged without any complications. We followed her up and computed tomography did not show any abnormal findings six months after discharge. LESSONS: There is currently no evidence testifying to the benefits of IVC filter removal. Detailed, evidence-based guidelines on the indications, timing and procedure for IVC filter removal are needed. Documenting cases of long-term complications of IVC filter s such as in this patient serve to accelerate the publication of updated guidelines and are aimed at improving outcomes of similar cases in the future.

Management of acute type A aortic dissection with acute lower extremities malperfusion.

BACKGROUND: Acute type A aortic dissection complicated by malperfusion is a life - threatening emergency. The optimal management strategy for malperfusion remains controversial. CASE PRESENTATION: A 46-year-old man presented to another institution with acute type A aortic dissection with abdominal aorta occlusion. Motor and sensory grade of both lower extremities were zero. Immediate antegrade distal perfusion of both lower extremities was achieved, and total arch replacement with left axillo-bifemoral bypass was performed. At the time of discharge, motor and sensory grades of both lower extremities were 2 and 3, respectively. CONCLUSION: This case demonstrates many of the techniques in the management of acute type A aortic dissection with abdominal aorta occlusion. In this case, direct antegrade perfusion of both lower extremities and axillo-bifemoral bypass may be helpful for patients presenting with severe malperfusion of both lower extremities with acute type A aortic dissection.

Sternal reconstruction with bone cement block using the rigid plate fixation technique.

Chest computed tomography demonstrated a suspected primary tumor in the upper sternal body of a 48-year-old woman who presented with sternal pain. After being diagnosed with chondrosarcoma, she underwent sternal resection. Subsequent chest wall reconstruction was performed after careful planning using a bone cement block made of polypropylene mesh and polymethylmethacrylate. The block was fixed to the manubrium and ribs using the SternaLock System. She was discharged following an uneventful postoperative recovery, and is currently undergoing follow-up.

Adenocarcinoma masked by re-expansion pulmonary edema after chest drainage for pneumothorax.

Re-expansion pulmonary edema is a rare complication that may occur after chest drainage performed for pneumothorax. This condition manifests as areas of ground-glass opacities (GGO) and septal thickening on imaging studies. In the case reported here, chest computed tomography (CT) showed diffuse ground-glass opacity secondary to ruptured bullae in a patient who underwent chest tube drainage for pneumothorax, suggesting re-expansion pulmonary edema. Histopathological examination of lung tissue resected from the vicinity of the bullae showed focal adenocarcinoma, which was masked by re-expansion pulmonary edema on preoperative computed tomography. Right upper lobectomy with mediastinal lymph node dissection was performed on postoperative day 3.

Heparin-free veno-venous ECMO applied to a patient with severe lung contusion and hypovolemic shock due to trauma.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) plays a crucial role when the lung is extensively damaged and when conventional management has failed. ECMO provides adequate tissue oxygenation and an opportunity for lung recovery. However, ECMO remains contraindicated in patients with a risk of bleeding because of systemic anticoagulation during the treatment. A 26-yearold female experienced polytrauma due to a traffic accident 1 h before arrival. Simple chest radiography and chest computed tomography showed a large right hemopneumothorax with atelectasis of the right lung and severe contusion of the left lung. Heparin-free VV-ECMO was applied peripherally via both femoral veins. Under the ECMO support, right lower lobectomy was successfully performed. Although contraindicated in polytraumatic patients with hemorrhagic shock, surgical repair with the application of ECMO may be feasible if bleeding is well controlled. The patient was discharged without significant complications.

Clinical usefulness of the angle between left main coronary artery and left anterior descending coronary artery for the evaluation of obstructive coronary artery disease.

BACKGROUND: A wider angle between the left anterior descending coronary artery (LAD) and left circumflex coronary artery (LCX) has been suggested to induce plaque formation in the arterial system via changes in shear stress. However, the relationship between the left main coronary artery (LM)-LAD angle and LAD stenosis has not been investigated. Therefore, we aimed to evaluate the associations between the LM-LAD and LAD-LCX angles and LAD stenosis. METHODS: Coronary computed tomography angiographies (CTAs) of 201 patients with suspected coronary artery disease were analyzed. Angle measurements were performed twice by experts using CTA images, and the values were averaged. The patients were divided into two groups, based on the presence of significant LAD stenosis (luminal diameter narrowing ≥50%) on CTA. RESULTS: The mean LM-LAD and LAD-LCX angles were 37.46° and 63.04°, respectively. The LM-LAD and LAD-LCX angles of the group with significant LAD stenosis were significantly wider than that of the group with nonsignificant LAD stenosis (P<0.001; P = 0.020, respectively). In a multivariate analysis, an LAD-LCX angle greater than 60° showed a trend toward predicting significant LAD stenosis (HR, 3.14; 95% CI: 0.96-1026; P = 0.058). In contrast, an LM-LAD angle greater than 40° was a significant predictor of significant LAD stenosis (HR, 12.2; 95% CI: 2.60-56.52; P = 0.001). CONCLUSIONS: The results of the present study may suggest that a wider LM-LAD angle could be used to identify patients at higher risk for coronary artery disease (CAD). Thus, close follow-up and preventive management of other risk factors may be needed in such cases.

Invasive thymoma with multiple ring calcifications and osseous metaplasia: A case report.

An 8.0 × 7.0 × 3.0 cm calcified anterior mediastinal mass was found in a 57-year-old man during a regular health checkup. The tumor had invaded the pericardium and phrenic nerve. The Masaoka-Koga classification was stage III. Multiple ring calcifications were present in the gross feature, and osseous metaplasia was observed in the histologic examination. World Health Organization histologic classification of the tumor was type B2. The patient is currently undergoing chemotherapy and radiation therapy to prevent tumor recurrence. To our knowledge, this is the first case of multiple ring calcifications and osseous metaplasia in invasive thymoma.