Fractured sternal wire causing a cardiac laceration.

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.

Impact of Federal Lung Cancer Screening Policy on the Incidence of Early-stage Lung Cancer.

BACKGROUND: In December 2013 the US Preventative Services Task Force (USPSTF) recommended annual lung cancer screening for high-risk patients. The Centers for Medicare & Medicaid Services (CMS) later announced coverage in 2015. The impact of these federal decisions at the population level is unknown. METHODS: Using the Surveillance, Epidemiology, and End Results database, we studied changes in lung cancer incidence by stage and linked to US census data to obtain age-adjusted estimates standardized to the US population. Based on age at diagnosis we stratified patients as age-eligible or age-ineligible for screening. We used difference-in-differences regression to determine the effect of screening on lung cancer incidence by stage. RESULTS: For all age groups the incidence of early-stage lung cancer both before and after the USPSTF guidelines remained relatively stable at 12.8 ± 0.52 and 13.5 ± 0.92 per 100,000 patients, respectively (P = .068). However the difference-in-differences analysis estimated an absolute increase in the age-adjusted incidence by 3.4 per 100,000 persons in the age-eligible group after the announcement of the guidelines (P = .007). The effect was even larger after the CMS decision (4.3/100,000 persons, P < .001). Similarly there was a 14.2 per 100,000 persons absolute reduction in the incidence of advanced-stage lung cancer (P < .001). CONCLUSIONS: The 2013 USPSTF lung cancer screening guidelines and CMS coverage decisions were associated with an increased incidence of early-stage lung cancer and decreased incidence of advance-staged lung cancer at the population level.

Malignant solitary fibrous tumor of the pleura.

BACKGROUND: Solitary fibrous tumors of the pleura are rare diseases of the thoracic cavity. They frequently grow unnoticed until they exert compressive effects on adjacent organs. Treatment of solitary fibrous tumors of the pleura is surgical resection. Post-operative surveillance is recommended to identify early recurrent disease. CASE PRESENTATION: We present a rare case of a 76-year-old female patient with no previous pulmonary history who presented with progressive dyspnea, fatigue, and involuntary weight loss. On chest X-ray and computed chest tomography scan, she was found to have a 16.7 cm × 12.8 cm × 10.1 cm bulky mass occupying the left hemithorax with associated compressive atelectasis of the lung. She underwent a computed tomography guided biopsy that revealed the mass to be a solitary fibrous tumor. The patient underwent left muscle sparing lateral thoracotomy with complete resection of the tumor. Post procedure, the left lung fully expanded. 18 months post-resection, she developed a 3.3 cm × 1.7 cm tumor along the left internal thoracic artery lymph node chain which was histologically identical to the resected tumor. The patient is currently being treated with bevacizumab and temozolomide. CONCLUSION: Solitary fibrous tumors are very rare pleural tumors. Surgical resection is the treatment of choice followed by close post-operative surveillance.

Giant coronary artery aneurysms involving more than one coronary artery: case report.

BACKGROUND: Coronary artery aneurysms are rare findings in patients undergoing coronary angiography. The presence of multiple coronary artery aneurysms located in more than one coronary artery is even more uncommon. The pathophysiology of such aneurysms is unknown, but the majority are often due to atherosclerosis, congenital heart disease, or vasculitis. CASE PRESENTATION: We present a rare case of a 78-year-old female patient who presented with unstable angina and non-ST segment elevation myocardial infarction. On coronary angiography, she was found to have three separate 1 cm saccular aneurysms involving the proximal left anterior descending coronary artery. The right coronary artery could not be visualized. Computed chest tomography revealed a 6.6 × 6.3 cm saccular aneurysm of the right coronary artery, and a 4.4 cm fusiform aneurysm of the ascending aorta. The patient gave no history of percutaneous coronary intervention or cardiac surgical procedures. She had a previous history of endovascular stenting of an abdominal aortic aneurysm. The sizable right coronary artery aneurysm showed extrinsic compression of both the right atrium and ventricle with right ventricular hypokinesis. Serological studies for vasculitis were all negative. Pathology of the aneurysm wall revealed calcific atherosclerosis without evidence of vasculitis. The patient underwent subtotal resection of the right coronary aneurysm with ligation of the proximal and distal ends of the right coronary artery and double bypass surgery to the left anterior descending and right posterior descending coronary arteries. CONCLUSION: The presence of multiple, large coronary artery aneurysms is very rare. Treatment can be challenging and should be individualized. Surgical treatment is recommended for giant coronary artery aneurysms to prevent potential complications.