Mitral Valve Repair of the Anterior Leaflet: Are We There Yet?

Mitral regurgitation is one of the most prevalent valvulopathies with a disease burden that incurs significant healthcare costs globally. Surgical repair of the posterior mitral valve leaflet is a standard treatment, but approaches for repairing the anterior mitral valve leaflet are not widely established. Since anterior leaflet involvement is less common and more difficult to repair, fewer studies have investigated its natural history and treatment options. In this review, we discuss surgical techniques for repairing the anterior leaflet and their outcomes, including survival, reoperation, and recurrence of regurgitation. We show that most patients with mitral regurgitation from the anterior leaflet can be repaired with good outcomes if performed at centers with expertise. Additionally, equal consideration for early repair should be given to patients with mitral regurgitation from both anterior and posterior pathology. However, more studies to better evaluate the efficacy and safety of anterior mitral valve leaflet repair are needed.

Postoperative Chylothorax in Neonates and Infants after Congenital Heart Disease Surgery-Current Aspects in Diagnosis and Treatment.

Postoperative chylothorax is a rare complication following cardiac surgery for congenital heart disease (CHD) in the pediatric population, including neonates and infants. Multiple mechanisms are involved in the development of postoperative chylous effusions, mainly the traumatic injury of lymphatic vessels, systemic venous obstruction and dysfunction of the right ventricle. In this review, we focus on the existing evidence regarding the definition and diagnosis of postoperative chylothorax in children with CHD, as well as current therapeutic approaches, both nutritional and interventional, for the management of these patients. As part of nutritional management, we specifically comment on the use of defatted human milk and its effect on both chylothorax resolution and patient growth. A consensus with regard to several key aspects of this potentially significant complication is warranted given its impact on the cost, morbidity and mortality of children with CHD.

Short Leukocyte Telomere Length Precedes Clinical Expression of Atherosclerosis: The Blood-and-Muscle Model.

RATIONALE: Short telomere length (TL) in leukocytes is associated with atherosclerotic cardiovascular disease (ASCVD). It is unknown whether this relationship stems from having inherently short leukocyte TL (LTL) at birth or a faster LTL attrition thereafter. LTL represents TL in the highly proliferative hematopoietic system, whereas TL in skeletal muscle represents a minimally replicative tissue. OBJECTIVE: We measured LTL and muscle TL (MTL) in the same individuals with a view to obtain comparative metrics for lifelong LTL attrition and learn about the temporal association of LTL with ASCVD. METHODS AND RESULTS: Our Discovery Cohort comprised 259 individuals aged 63±14 years (mean±SD), undergoing surgery with (n=131) or without (n=128) clinical manifestation of ASCVD. In all subjects, MTL adjusted for muscle biopsy site (MTLA) was longer than LTL and the LTL-MTLA gap similarly widened with age in ASCVD patients and controls. Age- and sex-adjusted LTL (P=0.005), but not MTLA (P=0.90), was shorter in patients with ASCVD than controls. The TL gap between leukocytes and muscle (LTL-MTLA) was wider (P=0.0003), and the TL ratio between leukocytes and muscle (LTL/MTLA) was smaller (P=0.0001) in ASCVD than in controls. Findings were replicated in a cohort comprising 143 individuals. CONCLUSIONS: This first study to apply the blood-and-muscle TL model shows more pronounced LTL attrition in ASCVD patients than controls. The difference in LTL attrition was not associated with age during adulthood suggesting that increased attrition in early life is more likely to be a major explanation of the shorter LTL in ASCVD patients. CLINICAL TRIAL REGISTRATION: URL: http://www.clinicaltrials.gov. Unique identifier: NCT02176941.

Evolution in experimental Fontan circulation: a review.

Experimental right heart bypass operations have influenced the evolution of current application of the Fontan procedure. In this review, we summarize the evolution and progress of the experimental Fontan operation (FO) and discuss the questions raised so far. The evolution and progress of the experimental FO is analyzed in this review by collecting data retrieved from English literature research. The establishment of Fontan circulation on an experimental animal model is extremely difficult and until today, a chronic experimental model has never been described. Computational fluid dynamics (CFD) has played a significant role in the investigation of the hemodynamic characteristics of the FO and has been applied to the design and integration of the procedure. CFD was also employed to evaluate the performance of assisted Fontan circulation. Accumulated experience from the experimental studies and clinical practice, in combination with the cooperation of different fields in medicine and positive sciences, are definitely expected to help the evolution furthermore.

Early and late morbidity and mortality and life expectancy following thoracoscopic talc insufflation for control of malignant pleural effusions: a review of 400 cases.

BACKGROUND: Malignant pleural effusion is a common sequelae in patients with certain malignancies. It represents a terminal condition with short median survival (in terms of months) and the goal is palliation. Aim of our study is to analyze morbidity, mortality and life expectancy following videothoracoscopic talc poudrage. MATERIALS AND METHODS: From September 2004 to October 2009, 400 patients underwent video-assisted thoracic surgery (VATS) for malignant pleural effusion. The conditions of patients were assessed and graded before and after treatment concerning morbidity, mortality, success rate of pleurodesis and median survival. RESULTS: The median duration of follow up was 40 months (range 4-61 months). All patients demonstrated notable improvement in dyspnea. Intraoperative mortality was zero. The procedure was well tolerated and no significant adverse effects were observed. In hospital mortality was 2% and the pleurodesis success rate was 85%. A poor Karnofsky Performance Status and delay between diagnosis of pleural effusion and pleurodesis were statistically significant factors for in-hospital mortality. The best survival was seen in breast cancer, followed by ovarian cancer, lymphoma and pleural mesothelioma. CONCLUSIONS: Video-assisted thoracoscopic talc poudrage is an effective and safe procedure that yields a high rate of successful pleurodesis and achieves long-term control with marked dyspnea decrease.

Blurred vision due to choroidal metastasis as the first manifestation of lung cancer: a case report.

BACKGROUND: Reduction in visual acuity combined with blurred vision is rarely the first sign of lung cancer and very few cases have been announced globally. CASE PRESENTATION: A case of a 46-year-old man who admitted with blurred vision is presented. His medical history, apart from a mild gastritis under treatment was negative. Ocular examination revealed a decrease in visual acuity due to a choroidal tumor. Further image body scans demonstrated a right lung lesion with dissemination to other organs. Diagnosis of a non-small cell lung cancer established after a VATS biopsy carried out. CONCLUSION: Blurred vision due to choroidal metastasis as the primary symptom of lung cancer is very uncommon. A great index of suspicion is essential when a choroidal lesion appears.

Pneumopericardium following tracheostomy closure.

Air within the pericardial sac is an unusual finding and its cause remains elusive. A case of a 41-year-old man with pneumopericardium following an episode of persistent cough one day after tracheostomy closure is presented. Conservative management with hemodynamic monitoring and serial chest X-rays was effective.

Cutaneous skull metastasis from uterine leiomyosarcoma: a case report.

BACKGROUND: Cutaneous metastases in the facial region occur in less than 0.5% of patients with metastatic cancer. CASE PRESENTATION: A 52-year-old woman who admitted with a lung and a skull skin nodule is presented. She had a known diagnosis of uterine leiomyosarcoma following an extended total hysterectomy two years ago. Excision biopsy of both nodules revealed metastatic disease. CONCLUSION: The appearance of a cutaneous nodule in a patient with a history of uterine leiomyosarcoma might indicate a metastatic tumor lesion. Biopsy and immunohistochemistry are essential for correct diagnosis.

Tension pneumocephalus complicating Pancoast tumor resection.

A case of tension pneumocephalus following Pancoast tumor resection is presented. Conservative management was successful. The presenting symptoms and signs, diagnostic methods and options for treatment are discussed and reviewed.

Facial skin metastasis due to small-cell lung cancer: a case report.

INTRODUCTION: Cutaneous metastases in the facial region occur in less than 0.5% of patients with metastatic cancer. They are an important finding and are not often the first sign leading to diagnosis. CASE PRESENTATION: We describe the case of a 64-year-old male patient who presented with dyspnea, pleuritic pain, loss of weight and a nodule on his left cheek. A chest X-ray revealed a left upper lobe mass with mediastinal lymphadenopathy. Excision biopsy of the facial nodule revealed small-cell lung carcinoma. Palliative chemo-radiotherapy was administered and the patient survived for 12 months. CONCLUSION: A high index of suspicion is necessary for the early detection of facial cutaneous metastases. Appropriate treatment may prolong patient survival.

Paraneoplastic pemphigus regression after thymoma resection.

BACKGROUND: Among human neoplasms thymomas are associated with highest frequency with paraneoplastic autoimmune diseases. CASE PRESENTATION: A case of a 42-year-old woman with paraneoplastic pemphigus as the first manifestation of thymoma is reported. Transsternal complete thymoma resection achieved pemphigus regression. The clinical correlations between pemphigus and thymoma are presented. CONCLUSION: Our case report provides further evidence for the important role of autoantibodies in the pathogenesis of paraneoplastic skin diseases in thymoma patients. It also documents the improvement of the associated pemphigus after radical treatment of the thymoma.

Tracheal laceration following double-lumen intubation during Ivor Lewis esophagogastrectomy.

A case of a 48-year-old man with an iatrogenic membranous tracheal wall rupture after double-lumen intubation during Ivor Lewis esophagogastrectomy is presented. Tracheal injury was successfully managed surgically with the use of a bovine pericardial patch and reinforcement with the gastric conduit which was moved toward the posterior wall of the membranous trachea sealing the wall laceration.

Re-expansion pulmonary edema following video-assisted thoracic surgery for recurrent malignant pleural effusion.

A rare case of a unilateral re-expansion pulmonary edema following video-assisted thoracic surgery for malignant pleural effusion is described.

Distant forearm muscle metastasis from squamous cell lung carcinoma.

A case of a 59-year-old man with a distant forearm muscular metastasis due to squamous cell lung carcinoma is presented. Fourteen months after a right pneumonectomy the patient was readmitted with a mass in the right forearm and pain in the right elbow during flexion. He underwent an en bloc wide resection of the tumor, which was confirmed to be metastatic. Twelve months after excision and adjuvant chemoradiotherapy he remains in complete remission.