Renal Cell Carcinoma With Extensive Tumor Thrombus Into the Inferior Vena Cava and Right Atrium in a 70-Year-Old Man.

The case of a male patient is reported, who presented with renal carcinoma and tumor thrombus in the inferior vena cava (IVC) extending from the right atrium (RA) to the bifurcation of IVC, common and external right iliac vein thrombosis, common and deep right femoral vein thrombosis, right popliteal vein thrombosis, with pulmonary and hepatic metastasis, treated with sorafenib. Renal cell carcinoma (RCC), the most common form of kidney cancer, occurs in 90% of cases and is nearly twice as common in men as in women. The diagnosis of RCC is accompanied by intravascular tumor thrombus in 10% of cases, and further extension of the tumor reaching RA is detected in approximately 1% of all patients. Therapy for advanced renal cell cancer has evolved considerably in the past decade, with new agents greeted like "buried treasure." Before 2005, the widely used systemic agents were cytokine interferon alfa and interleukin-2, which yielded modest efficacy and substantial toxicity. Tyrosine kinase inhibitors (TKIs) increase progression-free survival and/or overall survival as both first-line and second-line treatments for metastatic RCC. Sorafenib is an oral multikinase inhibitor with activity against Raf-1 serine/threonine kinase, B-Raf, vascular endothelial growth factor receptor-2 (VEGFR-2), platelet-derived growth factor receptor (PDGFR), FMS-like tyrosine kinase 3 (FLT-3), and c-KIT.

Subclinical myocardial impairment in SLE: insights from novel ultrasound techniques and clinical determinants.

AIMS: Myocardial damage is frequent and often silent in systemic lupus erythematosus (SLE). The aim of the study was to determine the prevalence of myocardial damage by novel ultrasound techniques and to systematically assess the relationship between subclinical cardiac dysfunction and SLE-related clinical parameters. MATERIAL AND METHODS: Seventy-five consecutive SLE patients without evidence of cardiac disease and seventy-three controls underwent standard transthoracic echocardiography using classical and novel ultrasound techniques: tissue Doppler imaging and speckle tracking echocardiography. Patient characteristics, cumulative organ damage and laboratory data were retrieved by medical chart review. RESULTS: Within the cohort, 89.3% of the patients were female; mean+/-SD age and median (IQR) disease duration were 43.2+/-12.5 years and 8.03(6.3) years, respectively. SLE patients exhibited a significant decrement in endocardial longitudinal strain (-18.4% vs 19.3%, p=0.001) compared with controls. Diastolic dysfunction was detected in 34 (45.3%) of SLE patients. Major determinants of systolic and diastolic dysfunction were hypertension (p=0.023 and p<0.001, respectively), associated antiphospholipid syndrome (APS) (p<0.001 and p<0.001, respectively), cumulative damage accrual (p<0.001 and p=0.003, respectively), and disease duration (p=0.03 and p<0.001, respectively). Notably, anti-Ro antibodies were present in 37% of the SLE patients who had better systolic longitudinal performance. Neither disease activity, nor specific organ involvement, were associated with myocardial impairment. CONCLUSION: Systolic longitudinal and diastolic performance impairments are frequent findings in SLE patients without overt cardiovascular disease. Cumulative organ damage, disease duration, APS, and hypertension are major determinants for early heart involvement in SLE patients.

Insights into the mechanism of idiopathic left ventricular tachycardia: a case report and literature review.

Left ventricular posterior fascicular tachycardia (LVPFT) is an idiopathic form of VT characterized by right bundle branch block morphology and left axis deviation. The mechanism of LPFVT is thought to be localized reentry close to the posterior fascicle. We present the case of a 24-year-old medical student who was admitted to the emergency department complaining of palpitations. The ECG showed an aspect suggestive of LVPFT. Vagal maneuvers, adenosine and i.v. Metoprolol were ineffective in terminating the arrhythmia. Conversion to sinus rhythm was obtained 10 h later, with i.v Amiodarone. The ECG in sinus rhythm showed left posterior fascicular block. Because antiarrhythmic drugs were not desired by the patient, VT ablation was proposed. The electrophysiological study identified the mechanism of arrhythmia to be reentry using the slowly conducting verapamil-sensitive fibers as the antegrade limb and the posterior fascicle as the retrograde limb. Radiofrequency applications near the posterior fascicle, in the lower half of the interventricular septum, at the junction of the two proximal thirds with the distal third interrupted the tachycardia and made it non-inducible at programmed stimulation. The case is unusual as the patient had a left posterior fascicular block during sinus rhythm before ablation. This demonstrates that the reentry circuit of VT does not need antegrade conduction through the posterior fascicle for perpetuation.

Distance between the Left Atrial Appendage and Mitral Annulus Evaluated by CARTO 3 Integrated Computed Tomography Imaging.

OBJECTIVE: To measure distances between pulmonary veins (PV) and mitral annulus (MA) using angiographic computed tomography (CT) and to compare them with the left atrial appendage-MA (LAA-MA) line. MATERIALS AND METHODS: Data from 46 catheter ablation procedures for atrial fibrillation involving 36 males, mean age 53 years, range 27-78 years, were analyzed. Three types of mitral isthmus lines were measured using angiographic CT images integrated in the CARTO 3 system (Biosense Webster): the distance between the right superior PV and MA (RSPV-MA), the right inferior PV and MA (RIPV-MA), and the left inferior PV and MA (LIPV-MA). They were compared with the length of the LAA-MA line. RESULTS: The mean value of LIPV-MA was 29 ± 11.2 mm, RIPV-MA 39 ± 8.2 mm, and RSPV-MA 48 ± 8.2 mm. The circumflex artery (CxA) and the coronary sinus (CS) were closest to the LIPV-MA line. Compared with the three isthmus lines, the LAA-MA was the shortest (24.7 ± 15.6 mm), and the difference was statistically significant (p < 0.05). CONCLUSION: The angiographic CT provided detailed information regarding the anatomy of the left atrium and distances between atrial structures. The LAA-MA was shorter than the other three lines with the CxA and CS situated at a distance.

Recovery of Ventriculo-Atrial Conduction after Adrenaline in Patients Implanted with Pacemakers.

BACKGROUND: Ventriculo-atrial (VA) conduction can have negative consequences for patients with implanted pacemakers and defibrillators. There is concern whether impaired VA conduction could recover during stressful situations. Although the influence of isoproterenol and atropine are well established, the effect of adrenaline has not been studied systematically. The objective of this study was to determine if adrenaline can facilitate recovery of VA conduction in patients implanted with pacemakers. METHODS: A prospective study was conducted on 61 consecutive patients during a 4-month period (April-July 2014). The presence of VA conduction was assessed during the pacemaker implantation procedure. In case of an impaired VA conduction, adrenaline infusio was used as a stress surrogate to test conduction recovery. RESULTS: The indications for pacemaker implantation were: sinus node dysfunction in 18 patients, atrioventricular (AV) block in 40 patients, binodal dysfunction (sinus node+ AV node) in two patients and other (carotid sinus syndrome) in one patient. In the basal state, 15/61 (24.6%) presented spontaneous VA conduction and 46/61 (75.4%) had no VA conduction. After administration of adrenaline, there was VA conduction recovery in 5/46 (10.9%) patients. CONCLUSIONS: Adrenaline infusion produced recovery of VA conduction in 10.9% of patients with absent VA conduction in a basal state. Recovery of VA conduction during physiological or pathological stresses could be responsible for the pacemaker syndrome, PMT episodes, or certain implantable cardiac defibrillator detection issues.