Tracheal adenoid cystic carcinoma with microscopic positive margin-how we approached with a systematic analysis review of its management.

Purpose: Adenoid cystic carcinoma (ACC) of the trachea is a rare malignancy. We report a patient with ACC who underwent multimodal management including tracheal resection. A systematic review was also conducted on tracheal resection for ACC. Methods: A literature search was conducted on MEDLINE, Embase, and PubMed using the search terms "trachea AND adenoid cystic carcinoma AND (surgery OR resection)" and articles from 2000 to August 2021 were identified. A total of 29 journal articles were included in the review. Results: A total of 403 patients underwent surgery for tracheal ACCs. The mean age was 48.1 years and 54.7% were female. The commonest anatomical location was the lower trachea (46.9%). The mean time from symptom onset to diagnosis was 16.6 months with the commonest symptom being dyspnoea (52%). Fifty-eight percent of the patients had intraluminal growth. Tracheal resection (46.2%) and access via thoracotomy (41.4%) were the commonest procedures described. The mean length of trachea resected was 39.2 mm and the mean tumour size was 31.5 mm. 16.8% of lymph nodes were involved and 73.8% of cases had positive resection margins. The overall complication rate was 1.4-5.4% and the in-hospital mortality rate was 9.8%. The overall survival reported was 61.7% at 5 years and 54.6% at 10 years. Conclusion: Surgical resection followed by adjuvant radiotherapy is the mainstay in the treatment of tracheal ACC, notwithstanding the high rates of involved margins. Achieving tension-free anastomosis should be the first priority given the favourable response of adjuvant therapies in reducing recurrence rate and improving overall survival.

Aortic root pseudoaneurysm: a case report and literature review.

Pseudoaneurysms of the aortic root are rare. A case of prosthetic aortic valve infection progressing from a confined intramural abscess to a ruptured abscess communicating with the aorta and forming a large pseudoaneurysm is described. Additionally, data from all cases and case series, published between 2000 and 2021, was analyzed. A PUBMED search for the keywords "aortic root mycotic aneurysm," "aortic root abscess AND infective endocarditis," and "aortic root mycotic aneurysm AND infective endocarditis" yielded 152 publications (with 157 cases described): Aortic pseudoaneurysm is more common in males (80.9%, n = 127). Mean age is 51 years (4 months-84 years). The most common symptom is fever (68.5%, n = 102). Mean time until diagnosis is 27.2 days. Embolic complications are present in 17.8% (n = 28) at diagnosis. Most cases are due to valvular infections (n = 72 cases, 45.9%). Prior cardiac surgery is documented in 49.0% (n = 77). The mean time interval for developing aortic root abscess following heart surgery is 32.2 months. 22.3% (n = 35) are immunocompromised. Aetiological agents were Staphylococcus sp. (34.1%, n = 47) and Streptococcus sp. (23.2%, n = 32). Mean antimicrobial therapy lasts 58.5 days. Outcome with surgery is superior to medical treatment: overall inpatient mortality 18.5% (n = 27); with surgery 12.2% (n = 15 out of 123 patients), with only medical management 47.8% (n = 11 out of 23 patients). In conclusion, aortic root pseudoaneurysm occurs most commonly in middle-aged male patients. History of prior aortic procedures is commonly present. Correct diagnosis hinges on detailed history, transoesophageal echocardiography, and computed tomography (CT) aorta. Surgery is the preferred therapeutic option. Supplementary Information: The online version contains supplementary material available at 10.1007/s12055-023-01580-x.

Syndrome of ventricular septal defect and aortic regurgitation - A 22-year review of its management

Abstract Introduction: The presence of aortic regurgitation (AR) in the setting of ventricular septal defect (VSD) has always been a management challenge. Methods: This is a retrospective study looking at patients who underwent VSD closure with or without aortic valve intervention between January 1st, 1992 and December 31st, 2014 at the Institute Jantung Negara. This study looked at all cases of VSD and AR, where AR was classified as mild, moderate, and severe, the intervention done in each of this grade, and the durability of that intervention. The interventions were classified as no intervention (NI), aortic valve repair (AVr), and aortic valve replacement (AVR). Results: A total of 261 patients were recruited into this study. Based on the various grades of AR, 105 patients had intervention to their aortic valve during VSD closure. The rest 156 had NI. All patients were followed up for a mean time of 13.9±3.5 years. Overall freedom from reoperation at 15 years was 82.6% for AVr. Various factors were investigated to decide on intervening on the aortic valve during VSD closure. Among those that were statistically significant were the grade of AR, size of VSD, age at intervention, and number of cusp prolapse. Conclusion: We can conclude from our study that all moderate and severe AR with small VSD in older patients with more than one cusp prolapse will need intervention to their aortic valve during the closure of VSD.

3D Rapid Prototyping Heart Model Validation for Teaching and Training - A Pilot Project in a Teaching Institution

Abstract Introduction: Rapid prototyping is a process by which three-dimensional (3D) computerized surface models are converted into physical models. In this study, a 3D heart bio model was created using the rapid prototyping method and the accuracy of this heart model was assessed by clinicians. Methods: The two-dimensional images of normal heart from gated computed tomography scan datasets were used to create a 3D model of the heart. The slices were then processed using the software BioModroid and printed with the 3D printer. The evaluation of the model was performed by a questionnaire answered by four cardiothoracic surgeons, 12 cardiologists, five radiologists, and nine surgical registrars. Results: Eighty-six percent of the anatomy structures showed in this model scored 100% accuracy. Structures such as circumflex branch of left coronary artery, great cardiac vein, papillary muscle, and coronary sinus were each rated 77%, 70%, 70%, and 57% accurate. Among 30 clinicians, a total of 93% rated the model accuracy as good and above; 64% of the clinicians evaluated this model as an excellent teaching tool for anatomy class. As a visual aid for surgery or interventional procedures, the model was rated excellent (40%), good (50%), average (23%), and poor (3%); 70% of the clinicians scored the model as above average for training purpose. Overall, this 3D rapid prototyping cardiac model was rated as excellent (33%), good (50%), and average (17%). Conclusion: This 3D rapid prototyping heart model will be a valuable source of anatomical education and cardiac interventional management.

Syndrome of Ventricular Septal Defect and Aortic Regurgitation - A 22-Year Review of its Management.

INTRODUCTION: The presence of aortic regurgitation (AR) in the setting of ventricular septal defect (VSD) has always been a management challenge. METHODS: This is a retrospective study looking at patients who underwent VSD closure with or without aortic valve intervention between January 1st, 1992 and December 31st, 2014 at the Institute Jantung Negara. This study looked at all cases of VSD and AR, where AR was classified as mild, moderate, and severe, the intervention done in each of this grade, and the durability of that intervention. The interventions were classified as no intervention (NI), aortic valve repair (AVr), and aortic valve replacement (AVR). RESULTS: A total of 261 patients were recruited into this study. Based on the various grades of AR, 105 patients had intervention to their aortic valve during VSD closure. The rest 156 had NI. All patients were followed up for a mean time of 13.9±3.5 years. Overall freedom from reoperation at 15 years was 82.6% for AVr. Various factors were investigated to decide on intervening on the aortic valve during VSD closure. Among those that were statistically significant were the grade of AR, size of VSD, age at intervention, and number of cusp prolapse. CONCLUSION: We can conclude from our study that all moderate and severe AR with small VSD in older patients with more than one cusp prolapse will need intervention to their aortic valve during the closure of VSD.

3D Rapid Prototyping Heart Model Validation for Teaching and Training - A Pilot Project in a Teaching Institution.

INTRODUCTION: Rapid prototyping is a process by which three-dimensional (3D) computerized surface models are converted into physical models. In this study, a 3D heart bio model was created using the rapid prototyping method and the accuracy of this heart model was assessed by clinicians. METHODS: The two-dimensional images of normal heart from gated computed tomography scan datasets were used to create a 3D model of the heart. The slices were then processed using the software BioModroid and printed with the 3D printer. The evaluation of the model was performed by a questionnaire answered by four cardiothoracic surgeons, 12 cardiologists, five radiologists, and nine surgical registrars. RESULTS: Eighty-six percent of the anatomy structures showed in this model scored 100% accuracy. Structures such as circumflex branch of left coronary artery, great cardiac vein, papillary muscle, and coronary sinus were each rated 77%, 70%, 70%, and 57% accurate. Among 30 clinicians, a total of 93% rated the model accuracy as good and above; 64% of the clinicians evaluated this model as an excellent teaching tool for anatomy class. As a visual aid for surgery or interventional procedures, the model was rated excellent (40%), good (50%), average (23%), and poor (3%); 70% of the clinicians scored the model as above average for training purpose. Overall, this 3D rapid prototyping cardiac model was rated as excellent (33%), good (50%), and average (17%). CONCLUSION: This 3D rapid prototyping heart model will be a valuable source of anatomical education and cardiac interventional management.

Identification of novel scaffold using ligand and structure based approach targeting shikimate kinase.

Tuberculosis (TB) remains a major global health problem. It causes ill-health among millions of people each year and rank as the second leading cause of death from an infectious disease worldwide, after the human immunodeficiency virus (HIV). Shikimate kinase is one of the major enzymes targeted for TB. Most approaches to overcome TB were based on synthesis and screening of a known compounds to obtain a few representatives with desired potency. In this study, we have applied a virtual screening approach which combines ligand- and structure-based approaches to screen a large library of compounds as a starting point for the identification of new scaffolds for the development of shikimate kinase inhibitors. The combined approach has identified 2 new scaffolds as potential inhibitors of shikimate kinase. To prove the approach, few of the molecules and their derivatives, a total of 17 compounds, were synthesized. The compounds were tested for biological activity and shows moderate activity against shikimate kinase. The shikimate kinase enzyme inhibition study reveals that the compounds showed inhibition (IC50) at concentrations of 50 µg/mL (Compounds 21, 22, 24, 25, 26, 27, 30, 32, 34) and 25 µg/mL (14, 19, 23, 31, 33).

Mediastinal liposarcoma: a rare visceral mediastinal tumour.

Liposarcoma is the second most common type of soft tissue malignancy in adults. They are malignant tumours with a mesenchymal origin. Mediastinal liposarcoma accounts for <1% of mediastinal tumours and 2% of liposarcoma. We report a patient with mediastinal liposarcoma who presented with cardiac tamponade, 25 years after the initial liposarcoma in the popliteal fossa.

Obstructive sleep apnoea and open heart surgery: a review of its incidence and impact to patients.

BACKGROUND: Obstructive sleep apnea (OSA) is a serious health disorder which contributes to cardiovascular complications, decreased work productivity, automobile accidents, and death. This condition is characterized by a temporary cessation of breathing resulting due to upper airway closure during a person's sleep. Strain to the heart caused by this repetitive hypoxic insult can lead to postoperative complications for patients undergoing heart surgery. Recognizing cardiac surgical patients with OSA is important. Early recognition and intervention such as use of BiPAP device can reduce the postoperative complications due to OSA. METHODS: The aim of this study is to identify the incidence of unrecognized OSA in cardiac surgical patients. This is a retrospective analysis of a prospective data of the study which was done between July 2012 and July 2013 in University Malaya Medical Center. All patients undergoing elective cardiac surgery were recruited and the demographic data, questionnaire and the portable sleep study results were obtained. Patients were followed up till 30 days to record any complications. Data were entered in SPSS version 17 and analysis was done. RESULTS: The incidence of OSA was 61.4% and 43.5% were moderate to severe OSA. There was male predominance of OSA (79%) with a mean age of 60 years. OSA subjects had shorter inter-incisor distance (4.18±0.6 cm) and larger waistline (94.1±12.1 cm). The STOP-Bang questionnaire has a sensitivity of 75.8% in predicting apnoa-hypopnea index (AHI) ≥5/hour. CONCLUSIONS: OSA can be diagnosed with a simple screening questionnaire and a bedside portable sleep study. Cardiac patients diagnosed with OSA can be pre-emptively given extra attention in managing their postoperative care.

A Flowmeter Technique to Exclude Internal Mammary Artery Anastomosis Error in an Arrested Heart.

The revision of an internal mammary artery graft anastomosis because of a technical error can be time-consuming and complicated and may lead to complications. Here, we describe the technical details and our early experience of using a standard transit-time flowmeter to exclude technical errors and facilitate rapid decision making for anastomosis revision in an arrested heart during aortic cross-clamping in the absence of ultrasound guidance.

Catalytic microwave pyrolysis of oil palm fiber (OPF) for the biochar production.

Microwave pyrolysis of oil palm fiber (OPF) with three types of Na-based catalysts was experimentally investigated to produce biochar. Sodium hydroxide (NaOH), sodium chloride (NaCl), and sodium carbonate (Na2CO3) with purity 99.9% were selected for this investigation. Microwave muffle reactor (Model: HAMiab-C1500) with a microwave power controller including a microwave generator was used to perform the microwave pyrolysis. OPF particles were used after removing foreign materials, impurities, and dust. Microwave power ranges from 400 to 900 W, temperature ranges from 450 to 700 °C, and N2 flow rates ranges from 200 to -1200 cm3/min were used along with all three Na-based catalysts for this investigation. Lower microwave power, temperature, and N2 flow rate have been found favorable for higher yield of biochar. NaOH is to be found as the more suitable catalyst than NaCl and Na2CO3 to produce biochar. A maximum biochar yield (51.42 wt%) has been found by using the catalysts NaOH at N2 flow rate of 200 cm3/min. One sample of the biochar (maximum yield without catalysts) was selected for further characterization via thermo gravimetric analysis (TGA), scanning electron microscopy (SEM), BET surface area, Fourier transform infrared spectroscopy (FTIR), and ultimate and proximate analysis. SEM and BET surface area analysis showed the presence of some pores in the biochar. High percentage of carbon (60.24 wt%) was also recorded in the sample biochar. The pores and high percentage of carbon of biochar have significant impact on soil fertilization by increasing the carbon sequestration in the soil. It assists to slow down the decomposition rate of nutrients from soil and therefore enhances the soil quality.

Design, Synthesis, and Characterization of Some Hybridized Pyrazolone Pharmacophore Analogs against Mycobacterium tuberculosis.

Twenty-seven hybridized pyrazolone analogs were designed, docked, synthesized in two series and evaluated for their in vitro antimycobacterial properties. In the first series, four Schiff base derivatives, 6b, 7b, 7h, and 7i, show good antitubercular activity with minimum inhibition concentration (MIC) values in the range of 32.56-42.55 µM. In the second series, two compounds, 8b and 8c, possessed significant antitubercular activity with MIC <0.37 and <0.44 µM, respectively; they were even more potent than the standards pyrazinamide (12.99 µM), ciprofloxacin (4.82 µM), and streptomycin (5.36 µM), with a selectivity index of >630. Compounds 8b and 8c showed shikimate kinase inhibition activity at 5.84 and 6.93 µM, respectively. The activity and docking results lead to the conclusion that the compounds without double bond in the imine side chain and hydrophobic clashes at the pyrazolone end are necessary for good accommodation in the binding pocket and for imparting flexibility. All the compounds were also tested for antimicrobial activity (antibacterial and antifungal) and show highly significant activities against all the microorganisms tested.

Metastatic Adenocarcinoma Presenting as Extensive Cavoatrial Tumor Thrombus.

The presence of tumor thrombus in the right atrium is frequently the result of direct intraluminal extension of infra-diaphragmatic malignancy into the inferior vena cava (IVC) or supradiaphragmatic carcinoma into the superior vena cava (SVC). Right atrial tumor thrombus with extension into both SVC and IVC has not been reported in the literature. We present a patient who presented with symptoms of right atrial and SVC obstruction. Imaging revealed presence of a thrombus in the right atrium, extending to the SVC and IVC, with the additional findings of a left adrenal mass and multiple liver lesions. The histopathological examination of the right atrial mass revealed metastatic adenocarcinoma cells. The patient was given a presumptive diagnosis of metastatic adenocarcinoma, most likely adrenal in origin, with multiple hepatic lesions suspicious for metastasis. The clinical outcome of the patient was not favorable; the patient succumbed before the adrenal mass could be confirmed to be the primary tumor. This case highlights that in patients manifesting with extensive cavoatrial thrombus as, the existence of primary carcinoma should be considered especially in the adrenal cortex or in the lung.

Effect of sternal closure with biological bone adhesive on pain visual analogue score and serum cytokine.

OBJECTIVES: Recently a biocompatible bone adhesive was introduced in addition to the sternal wires to expedite sternal union and improve patient recovery. In this study we aim to objectively assess the biomarker of pain in patient who received the biocompatible bone adhesive. METHODS: A total of 62 patients who underwent sternotomy were prospectively randomised to receive either conventional wire closure (CWC); 32 patients or adhesive enhanced closure in addition to sternal wire (AEC); 30 patients. Patients were monitored postoperatively at certain time intervals for incisional pain, serum Interleukin-6 (IL-6) level, analgesia used and postoperative complications. All patients were followed up for 4 weeks. RESULTS: The post-operative pain scores with coughing were significantly higher in the CWC group at 24 hours and 48 hours. The postoperative IL 6 levels were significantly higher in the CWC group in comparison with the AEC group at 6 hours, 24 hours, and 48 hours. There were no significant differences in term of additional analgesia used. No adverse events from adhesive bone cement were observed during follow up. CONCLUSIONS: Adhesive-enhanced sternal closure resulted in modest reduction of pain confirmed by reduction of pain biomarker. Justification of its routine use requires larger multicentre study.

Strategy for ventricular septal defect closure after prior gastric pull-through.

A 9-year-old boy was referred with a perimembranous ventricular septal defect. At birth, he had undergone a right thoracotomy with ligation of a tracheoesophageal fistula, cervical esophagostomy, and feeding gastrostomy. At 2 years of age, he had gastric tube reconstruction with a pull-through retrosternally, anterior to the heart, and an end-to-end esophagogastric anastomosis. Via a right anterolateral thoracotomy through the previous scar, the entire gastric tube was mobilized away from the sternum to facilitate a median sternotomy. With the patient supine, a median sternotomy was performed without difficulty, and the ventricular septal defect was closed under cardiopulmonary bypass.

Imaging of an atypical pericardial cyst.

Pericardial cysts are uncommon mediastinal lesions that are usually congenital in origin. Patients are usually asymptomatic and the cysts are generally discovered on routine radiography for unrelated purposes. This case illustrates a symptomatic presentation of a haemorrhagic pericardial cyst in which radiographic, echocardiographic and multislice (MRI and CT) imaging were performed. The imaging findings were not typical of pericardial cysts leading to a diagnostic quandary despite the varied imaging techniques. In conclusion, it is important to appreciate that the imaging findings of pericardial cysts can be varied. Radiologists and clinicians alike should be aware of this variability.