Chondromyxoid Fibroma of the Rib: A Rare Benign Tumor With Potential for Local Recurrence.

Chondromyxoid fibroma (CMF) is a benign cartilaginous tumor that typically occurs in the long bones of young adult males, with the clinical presentation varying from asymptomatic to localized pain, swelling, and movement restriction. We report an unusual presentation of CMF involving a rib, along with a literature review of the management of CMF. Although benign, local recurrence is not uncommon, and malignant transformation has been reported on rare occasions. En bloc surgical excision, with adequate tumor-free resection margins, of radiologically suspected chondromyxoid fibroma is crucial for the treatment and confirmation of diagnosis. A high index of suspicion, adequate treatment, and follow-up are critical for the successful management of these uncommon benign chondroid tumors.

The chicken or the egg? A case of sympathetic staphylococcal empyema thoracis and splenic abscess.

Multicavitary abscesses are uncommon in immunocompetent individuals. Splenic abscesses being relatively uncommon with an incidence of 0.1-0.7% in quoted series [ 1]. Commonly reported cases are secondary infective endocarditis. To have both a splenic abscess and empyema concurrently is rare. We describe a case of a patient with a large left-sided empyema thoracis and concurrent splenic abscess.

The role of point-of-care assessment of platelet function in predicting postoperative bleeding and transfusion requirements after coronary artery bypass grafting.

OBJECTIVE: OBJECTIVE platelet function assessment after cardiac surgery can predict postoperative blood loss, guide transfusion requirements and discriminate the need for surgical re-exploration. We conducted this study to assess the predictive value of point-of-care testing platelet function using the Multiplate® device. METHODS: Patients undergoing isolated coronary artery bypass grafting were prospectively recruited ( n = 84). Group A ( n = 42) patients were on anti-platelet therapy until surgery; patients in Group B ( n = 42) stopped anti-platelet treatment at least 5 days preoperatively. Multiplate® and thromboelastography (TEG) tests were performed in the perioperative period. Primary end-point was excessive bleeding (>2.5 ml/kg/h) within first 3 h postoperative. Secondary end-points included transfusion requirements, re-exploration rates, intensive care unit and in-hospital stays. RESULTS: Patients in Group A had excessive bleeding (59% vs. 33%, P = 0.02), higher re-exploration rates (14% vs. 0%, P < 0.01) and higher rate of blood (41% vs. 14%, P < 0.01) and platelet (14% vs. 2%, P = 0.05) transfusions. On multivariate analysis, preoperative platelet function testing was the most significant predictor of excessive bleeding (odds ratio [OR]: 2.3, P = 0.08), need for blood (OR: 5.5, P < 0.01) and platelet transfusion (OR: 15.1, P < 0.01). Postoperative "ASPI test" best predicted the need for transfusion (sensitivity - 0.86) and excessive blood loss (sensitivity - 0.81). TEG results did not correlate well with any of these outcome measures. CONCLUSIONS: Peri-operative platelet functional assessment with Multiplate® was the strongest predictor for bleeding and transfusion requirements in patients on anti-platelet therapy until the time of surgery.

How does the 'Heart Team' decision get enacted for patients with coronary artery disease?

OBJECTIVES: A heart team approach has been recommended for managing patients with coronary artery disease. Although this seems to be a new concept, we have been developing such a practice for over 8 years. In this report, the enactment of the heart team decision is reviewed and possible improvement is discussed. DESIGN: Review of 1000 heart team decisions over a 1-year period for patients with coronary artery disease. These decisions were recorded contemporaneously at the time of the team discussion. Thereafter, patient's notes were reviewed 6 months following the heart team meeting to assess whether the decision was enacted and, if not, what were the reasons for aberration. RESULTS: The heart team decision was enacted in 95.5% of patients. The reasons for aberration in the remaining 45 patients included patient's choice (refusal), unrecognised comorbidities at the time of the heart team discussion, change in patient's clinical condition requiring urgent intervention and death while awaiting procedure, among others. CONCLUSIONS: The decision of a well set-up heartteam meeting is carried out for most patients. Aberration is uncommon and usually due to unknown factors at the time of the discussion. The heart team approach ensures that patients receive best available care (most likely evidence-based), and demonstrates transparency.

Tricuspid valve chordal rupture due to airbag injury and review of pathophysiological mechanisms.

Blunt trauma to the chest is associated with significant morbidity and mortality. The latter is usually due to an aortic transection, whereas the former is related to myocardial contusion, cardiac valve injury, coronary artery disruption and intracardiac shunts due to the formation of septal defects. The main mechanisms causing these injuries are due to the sudden deceleration force and compression within the chest cavity. Moreover, there is also the sudden increase in intravascular pressure due to a mechanical compression effect and a hormonal adrenergic surge during the event. We report a case of a tricuspid valve injury caused by the deployment of the airbag during a high-speed impact car accident and the subsequent damage to the tricuspid valve chordal mechanism. The patient's management and the pathophysiological mechanisms involved in the injury are reviewed.

Heart team discussion in managing patients with coronary artery disease: outcome and reproducibility.

Recent ESC/EACTS revascularization guidelines advocate a 'Heart Team' (HT) approach in the decision-making process when managing patients with coronary disease. We prospectively assessed HT decision-making in 150 patients analysing personnel attendance, data presented, the 'actioning' of the HT decision and, if not completed, then the reasons why. Additionally, 50 patients were specifically re-discussed after 1 year in order to assess consistency in decision-making. We have two HT meetings each week. At least one surgeon, interventional cardiologist and non-interventional cardiologist were present at all meetings. Data presented included patient demographics, symptoms, co-morbidities, coronary angiography, left ventricular function and other relevant investigations, e.g. echocardiograms. HT decisions included continued medical treatment (22%), percutaneous coronary intervention (PCI; 22%), coronary-artery bypass grafting (CABG; 34%) or further investigations such as pressure wire studies, dobutamine stress echo or cardiac magnetic resonance imaging (22%). These decisions were fully undertaken in 86% of patients. Reasons for aberration in the remaining 21 patients included patient refusal (CABG 29%, PCI 10%) and further co-morbidities (28%). On re-discussion of the same patient data (n = 50) a year later, 24% of decisions differed from the original HT recommendations reflecting the fact that, for certain coronary artery disease pattern, either CABG or PCI could be appropriate.

Antithymocyte globulin induction therapy for adult heart transplantation: a UK national study.

BACKGROUND: Induction therapy with antithymocyte globulin (ATG) after heart transplantation (HTx) has never been assessed in a placebo-controlled randomized trial. We investigated trends in use of ATG and its relationship to outcome after HTx in a national cohort. METHODS: Between July 1995 and March 2008, 2,151 adult HTxs were performed. Patients given OKT3 or an interleukin-2 receptor antagonist, repeat transplants, heterotopic, and multi-organ transplants were excluded, leaving 2,086 HTx for analysis. Of these, 1,143 (55%) received induction with ATG. RESULTS: The proportion of patients given ATG increased from 26% in June 1995 to 75% in August 2007 (p < 0.01). The age and gender distributions of recipients and donors were similar in the ATG and non-ATG groups. Survival to 10 years was similar: 56.2% in the non-ATG group vs 55.9% in the ATG group (p = 0.95). The number of treated rejection episodes in the first year was lower in the ATG group (incidence rate ratio, 0.76; 95% confidence interval [CI], 0.68-0.85, p < 0.01), but the number of infective episodes was higher (incidence rate ratio, 1.18; 95% CI, 1.00-1.39, p = 0.048), and these differences remained after risk adjustment, with an adjusted incidence rate ratio of 0.85 (95% CI, 0.75-0.95, p < 0.01) and 1.21 (95% CI, 1.02-1.44; p = 0.027). Deaths due to infective causes were higher in the ATG group (p = 0.03). CONCLUSION: There has been a trend towards an increased use of induction therapy. There was no change in overall survival, but ATG induction was associated with a decreased incidence of rejection and an increase in infection.

Trends in adult heart transplantation: a national survey from the United Kingdom Cardiothoracic Transplant Audit 1995-2007.

OBJECTIVE: The management of heart failure (HF), peri-transplant care and immunosuppression has changed in the last decade. Here we describe the changes that have occurred in the UK national programme of adult heart transplantation (HTx). METHODS: Using the data accrued with the UK Cardiothoracic Transplant Audit we undertook a prospective cohort study of 2958 consecutive adult patients listed for HTx and 2005 adult orthotopic HTx performed in three time periods - Era-1 (July 1995-March 1999, 1321 listed, 907 transplanted), Era-2 (April 1999-March 2003, 842 listed, 600 transplanted) and Era-3 (April 2003-March 2007, 795 listed, 498 transplanted). RESULTS: The median time on the waiting list reduced from 109 days in Era-1 to 40 days in Era-3. The proportion of HTx in non-ambulatory HF patients requiring inotropic or circulatory support increased from 12% in Era-1 to 35% in Era-3. The proportion undergoing HTx for non-ischaemic dilated cardiomyopathy increased from 40% in Era-1 to 58% in Era-3 while ischaemic cardiomyopathy decreased. Survival after HTx remained constant (81% (95% CI: 78-83%) at 1 year in Era-1 and 80% (95% CI: 77-84%) in Era-3). There was an increase in the use of mycophenolate and induction therapy and a reduction in rejection episodes over the eras. CONCLUSIONS: Although waiting list and HTx activity have declined, HTx continues to have an important role in the management of advanced HF, especially for patients on inotropic or circulatory support. Despite a deterioration of donor organ quality, survival after HTx has remained unchanged.

Donor cardiac troponin-I: a biochemical surrogate of heart function.

OBJECTIVE: Cardiac troponin-I (cTnI) levels in the potential heart transplant donor may be a marker of heart dysfunction and predictive of recipient outcome. We studied the prevalence of cTnI elevation, its association with heart function and usability and its relationship with the time duration from coning. METHODS: In a prospective study, cTnI measurement, Swan-Ganz catheterisation and transthoracic echocardiography were performed at initial assessment in 79 potential heart donors (mean age 43 +/- 13.1 years). All donors were then managed according to a strict algorithm to optimise cardiac function, some receiving hormonal therapy as part of a randomised trial. Donor heart suitability for transplantation was assessed after 7 h of management. The association of cTnI with initial functional indices was assessed and outcome compared for donors categorised according to cTnI level < or = 1 microg l(-1) or >1 microg l(-1). RESULTS: Serum cTnI levels negatively correlated with initial cardiac index (CI) (p = 0.003), right (p < 0.001) and left ventricular ejection fraction (p = 0.001) and positively with LV Tei index (p = 0.003). Serum cTnI was >1 microg l(-1) in 29/79 donors. Higher CVP (10 +/- 5.1 vs 7.9 +/- 2.9; p = 0.026) and PAWP (12 +/- 5.4 vs 8.1 +/- 3.1; p = 0.002), lower cardiac index (2.7 +/- 1.1 vs 3.6 +/- 0.9; p = 0.001) and fractional shortening (p < 0.01) and worse wall motion score index (p < 0.01) were observed in the cTnI >1 microg l(-1) group. CTnI and functional markers correlated with the time duration from coning. CONCLUSION: The donor cTnI level represents a biochemical surrogate of functional donor heart assessment. High cTnI is associated with worse donor heart function and may act as a prompt for detailed assessment and optimisation.

Attenuation of receptor-dependent and -independent vasoconstriction in the human radial artery.

BACKGROUND: Vasodilator strategies used to treat bypass grafts in the operating theatre, such as nitrates, phosphodiesterase inhibitors and calcium channel antagonists have a broad but short-lived effect against a variety of vasoconstrictor stimuli. Treatments that react irreversibly with proteins modulating vasoconstriction have the advantage that their effects can last well into the postoperative period. In addition systemic effects are avoided as the treatment is localised to the treated graft. This study investigated the use of two clinically applied drugs; fluphenazine (SKF7171A, HCl), an irreversible calmodulin antagonist and minoxidil sulphate, an irreversible potassium channel opener. Treatments were tested against receptor and non-receptor-mediated contraction in the human radial artery. METHOD: Isometric tension was measured in response to angiotensin II, KCl and vasopressin in 108 radial artery rings (taken from 31 patients undergoing coronary artery bypass grafting). Control responses were compared with rings pretreated with fluphenazine or minoxidil sulphate. Vasopressin responses were also compared in the presence of glyceryl trinitrate or the reversible Rho kinase inhibitor Y27632. RESULTS: Fluphenazine pretreatment significantly suppressed vasoconstriction to all agonists tested. Maximal responses to angiotensin II, vasopressin and KCl were reduced by 42+/-19%, 35+/-8% and 48+/-15% respectively, without any measurable effect on the EC(50). Minoxidil sulphate showed no discernable effect. Vasopressin-induced contraction was also reduced by high levels of glyceryl trinitrate (220 microM; 50 microg/ml) or 10 microM Y27632. CONCLUSIONS: The irreversible calmodulin antagonist fluphenazine has potential to be developed as an inhibitor of contraction in arterial graft vessels. The involvement of Rho kinase indicates that other vasoconstrictors and surgical stress can sensitize radial artery to vasopressin-induced contraction. Strategies targeting this pathway also have future potential.

Spontaneous right atrial thrombus in a patient with Crohn's disease: an unusual right atrial mass.

Crohn's disease is associated with systemic manifestations including increased risk of thromboembolism. We report a young female patient with active Crohn's disease who presented with spontaneous right atrial thrombus.

A quadricuspid aortic valve in a patient with neurofibromatosis type 1.

Quadricuspid aortic valve is a rare cardiovascular abnormality. Herein is described the case of a male patient with neurofibromatosis type 1 (NF1) who was found to have a quadricuspid aortic valve causing severe aortic regurgitation. Although congenital cardiac malformations have been described in patients with NF1, to the best of the present authors' knowledge this is the first time that a quadricuspid valve in a patient with neurofibromatosis has been described.

An aberrant donor pulmonary vein during lung transplant: a surgical challenge.

Aberrant pulmonary veins are uncommon. Anastomosis of such a vein during a lung transplant operation may provide a surgical challenge. We report the first case of an aberrant pulmonary vein anastomosed to the left atrial appendage during the implantation of the left lung.