Surgical management of adrenal tumours extending into the right atrium.

This paper discusses the surgical approach for the treatment of adrenal tumours extending into the right atrium (RA), using a cardio-pulmonary bypass (CPB) associated with deep hypothermic circulatory arrest (DHCA). Pre-operative planning and surgical steps are described in details. The association of CPB with hypothermic circulatory arrest (HCA) provides a bloodless operating field, direct intra-vascular vision, reduces the risk of embolization and allows extensive inferior vena cava (IVC) or RA repair in cases of infiltration of the vascular wall. Establishing a dedicated multidisciplinary team with experience in managing these challenging cases is fundamental to offer treatment to patients with advanced disease, who would otherwise risk being turned down for surgery. A close collaboration between general and cardiac surgeons and a deep understanding of the surgical procedure steps are fundamental to safely performing these procedures. We advocate centralising adrenal surgery in a small number of units with adequate multidisciplinary support.

Acyclovir-induced thrombocytopaenia in a patient with SLE.

Acyclovir has been used in the treatment of herpes simplex and varicella zoster viral infections for over 30 years. The side effects of oral treatment at standard doses are rare and include headache, diarrhoea, dizziness and malaise. We report a patient with a new diagnosis of systemic lupus erythematosus (SLE) who developed thrombocytopaenia within days on a therapeutic dose with acyclovir. Prompt discontinuation of acyclovir and treatment with intravenous immunoglobulin resulted in reversal of the above potentially serious complication. Therefore a high index of suspicion should be exercised in patients with SLE who require treatment with acyclovir for herpes viral infections. In these patients regular platelet count measurement should be considered while on treatment with the above antiviral agent.

Non-valvular atrial fibrillation: impact of apixaban on patient outcomes.

Atrial fibrillation is the most common arrhythmia worldwide, and carries a significantly increased risk of thromboembolic stroke. Initially, vitamin K antagonists were used as stroke prophylaxis; but more recently, a group of drugs known as novel oral anticoagulants have been developed. Apixaban belongs to this group of drugs, and is a factor Xa inhibitor that has emerged as a popular pharmacological agent worldwide. In this review, we will provide an overview of the pivotal trials in the development of apixaban, while also critically evaluating the new emerging real-world data, and discussing the effectiveness, safety, economic viability and future prospects of apixaban and how it impacts on patient outcomes in those with non-valvular atrial fibrillation.

Ventricular Fibrillation following Varicella Zoster Myocarditis.

Varicella-zoster virus (VZV) infection can rarely lead to serious cardiac complications and life-threatening arrhythmias. We present a case of a 46-year-old male patient who developed VZV myocarditis and presented with recurrent syncopal episodes followed by a cardiac arrest. He had a further collapse eight years later, and cardiac magnetic resonance imaging (MRI) demonstrated mild mid-wall basal and inferolateral wall fibrosis. He was treated with an implantable cardioverter defibrillator (ICD) and represented two years later with ICD shocks, and interrogation of the device revealed ventricular fibrillation episodes. This case demonstrates the life-threatening long-term sequelae of VZV myocarditis in adults. We suggest that VZV myocarditis should be considered in all patients who present with a syncopal event after VZV infection. In these patients, ICD implantation is a potentially life-saving procedure.