Impact of fluorescent thoracic duct lymphography via intranodal approach in minimal access esophageal cancer surgery.

PURPOSE: Chyle leak resulting from thoracic duct (TD) injury poses significant morbidity and mortality challenges. We assessed the feasibility of using near-infrared (NIR) indocyanine green (ICG) imaging for intraoperative fluorescence TD lymphography during minimal access esophagectomy (MAE) in a semiprone position with inguinal nodal injection of ICG dye. METHODS: Ninety-nine patients with esophageal or gastroesophageal junctional cancer undergoing MAE received inguinal node injections of 2.5 mg ICG dye (total 5 mg) under sonographic guidance during anesthesia induction. Stryker's 1688 AIM HD system was used in 76 cases, Karl Storz OPAL 1 S in 20, and in three cases the Karl Storz Rubina. RESULTS: In 93 patients (94%), the TD was clearly delineated along its entire length; it was not visualized in 6 patients (6%). Fluorescence guidance facilitated TD ligation in 16 cases, while 3 cases required clipping of duct tributaries for oncological considerations. Twenty-eight patients exhibited minor duct variations. Fluorescence was sustained throughout surgery (median observation time 60 min post-injection; range 30-330). No patient experienced any chyle leak within 30 days post-surgery and no adverse reactions to ICG was evident. CONCLUSIONS: Intraoperative fluorescence TD lymphography using ICG during MAE in a semiprone position with inguinal nodal injection proved safe, feasible, and effective, allowing clear visualization of the TD in almost all cases. This approach aids safe ligation and reduces chyle leak risk. It offers real-time imaging of TD anatomy and variations, providing valuable feedback to surgeons for managing TD injuries during MAE procedures and represents an excellent educational tool.

Influence of neoadjuvant therapy on outcomes in patients with resectable carcinoma of esophagus and gastro-esophageal junction from a tertiary cancer care center in India.

BACKGROUND AND OBJECTIVES: The aim of this study is to compare the outcomes of neoadjuvant chemotherapy (nCT), neoadjuvant chemoradiotherapy (nCRT) followed by surgery to upfront surgery (surgery alone) in patients with resectable carcinoma of the esophagus (esophageal cancer [EC]), and gastro-esophageal junction (GEJ) in a limited resource setting. METHODS: A retrospective analysis of a prospectively maintained database was performed to identify patients (from January 2010 through December 2016) who underwent surgery for EC and GEJ cancers. RESULTS: A total of 454 patients were included and categorized into the following groups: nCT (n = 65), nCRT (n = 152) and upfront surgery (n = 237). Squamous cell carcinoma and adenocarcinoma accounted for two-thirds and one-third of the cases, respectively. nCRT group patients were also noted to have smaller tumors, lower margin positivity and a higher R0 resection rates. With a median follow up of 76 months (35-118 months) improved 5-year overall survival was noted in nCRT group in comparison to nCT and upfront surgery groups (56.5% vs. 34% and 35%, respectively, p = .021). CONCLUSIONS: The results of our study demonstrate the beneficial effect of nCRT for patients with EC and GEJ in a limited resource setting. Further studies are required to analyze and promote the benefits of nCRT in limited-resource settings.

Troponin Elevation in Sickle Cell Disease.

OBJECTIVE: Sickle cell disease is associated with cardiovascular abnormalities. Troponin is not typically measured in this population, and thus the significance of abnormal levels of troponin is unknown. We wanted to evaluate the use of troponin and factors that predispose troponin elevation in patients admitted with sickle cell pain crisis (SCPC). METHODS: We reviewed data of consecutive patients admitted to a tertiary care hospital between 2006 and 2011 with a diagnosis of SCPC. Subjects with elevated troponin (ET) (troponin I >0.04 ng/mL) were compared with those with normal troponin (NT) for demographics, risk factors, presence of echocardiography-derived tricuspid regurgitant jet velocity (TRV) ≥3 m/s suggesting pulmonary hypertension, and laboratory tests. The Mann-Whitney U test was used to compare groups. RESULTS: Two hundred eighty-three of 724 patients admitted with SCPC had chest pain. Troponin I was measured in 63 patients: 51 had NT and 12 had ET ranging from 0.06 to 3.42 ng/ml. ET was associated lower hemoglobin (p = 0.02), lower hematocrit (p = 0.02), lower platelet number (p < 0.001), higher LDH (p = 0.012), higher AST levels (p = 0.004), higher bilirubin levels (p = 0.006), and TRV ≥3 m/s (p = 0.028). CONCLUSIONS: Troponin was measured in <10% of patients with SCPC, and 1 out of 5 of them had ET. Troponin elevation was not associated with traditional cardiovascular risk factors but was associated with lower hematocrit, elevated LDH, bilirubin levels, and TRV ≥3 m/s.

Left atrial volume predicts atrial fibrillation recurrence after radiofrequency ablation: a meta-analysis.

Aims: Left atrial (LA) diameter is a predictor of atrial fibrillation (AF) recurrence following radiofrequency catheter ablation (RFA). However, LA volume (LAV) is more accurate in assessing LA size. Studies evaluating LAV as a predictor of AF recurrence are contradictory; therefore, we performed a meta-analysis to assess whether LAV is an independent predictor of AF recurrence following RFA. Methods and results: All studies reporting LAV/LAV index (LAVi) as a predictor of AF recurrence following RFA were included. For studies reporting mean LAV/ LAVi in patients with and without AF recurrence, standard difference in means (SDM) and standard errors were calculated, and combined using meta-analytical techniques. For studies reporting adjusted odds ratio (OR) for AF recurrence based on LAV/LAVi, log ORs were combined using generic inverse variance. Twenty one studies (3822 subjects) were included. Meta-analysis of 11 studies (1559 subjects) reporting LAV, showed that patients with AF recurrence had a higher mean LA volume compared to patients with no recurrence (SDM 0.801; CI 0.387-1.216). Data from 9 studies (1425 subjects) comparing LAVi showed that, patients with AF recurrence had a higher mean LAVi compared to patients with no recurrence (SDM-0.596; CI 0.305-0.888). Thirteen studies (2886 patients) reporting ORs for AF recurrence based on LAV/ LAVi, showed that LAV/LAVi was independently predictive of AF recurrence post-RFA (OR-1.032, CI- 1.012-1.052). Conclusions: Patients with AF recurrence following RFA have a higher mean LAV/LAVi compared to patients with no recurrence. Large LAV/LAVi increases the odds of AF recurrence post RFA.

Distinct kinetics of viral replication, T cell infiltration, and fibrosis in three phases of myocarditis following Theiler's virus infection.

We established a novel model of myocarditis induced with Theiler's murine encephalomyelitis virus (TMEV), which has been used as a viral model for multiple sclerosis and seizure/epilepsy. Following TMEV infection, C3H mice developed severe myocarditis with T cell infiltration, while C57BL/6 mice had mild lesions and SJL/J mice had no inflammation in the heart. In C3H mice, myocarditis was divided into three phases: acute viral, subacute immune, and chronic fibrotic phases. Using toll-like receptor (TLR) 4-deficient C3H mice, we found that interleukin (IL)-6, IL-17, TLR4, and anti-viral immune responses were associated with myocarditis susceptibility.

Treatment of methadone-induced torsades de pointes with lidocaine.

Methadone maintenance treatment (MMT) is commonly used for chronic pain control and for substitution in heroin addicts undergoing rehabilitation. Methadone is known to prolong QT interval and sometimes cause torsade de pointes (TdP) and ventricular fibrillation (VF). Treatment of TdP by antiarrhythmic drugs that prolong QT interval may worsen TdP. To our knowledge, worsening of methadone-induced TdP by amiodarone has not been reported before. We describe here a case of methadone-induced TdP that deteriorated into ventricular fibrillation upon treatment with intravenous (IV) amiodarone and resolved after discontinuation of amiodarone and treatment with IV magnesium, potassium, and lidocaine.

Thoracic Duct Lymphography by Near-Infrared Indocyanine Green Fluorescence imaging in Thoracic Surgery. A Review.

Near-infrared (NIR) fluorescence imaging with indocyanine green dye (ICG) is an emerging technology in detecting the anatomy of the thoracic duct; hence, it can be useful for the identification of the thoracic duct in real time and prevention of its injury during thoracic surgery. It helps to localize thoracic duct injury, identifying chyle leaks in difficult, recurrent, and refractory cases. This review paper provides insights regarding the current applications, advantages, and potential developments of NIR fluorescence imaging with ICG in recognizing thoracic duct during thoracic surgery.

Cardiac troponin I levels are a marker of myocardial dysfunction in subarachnoid hemorrhage and predicts poor neurologic outcome.

We evaluated the prognostic significance of myocardial dysfunction and associated cardiac troponin I elevation in patients with subarachnoid hemorrhage (SAH). Forty-one patients with no prior cardiac history and who presented with spontaneous SAH were prospectively studied. The LV ejection fraction (LVEF) and regional wall motion by echocardiogram were studied upon admission (Day 0), Day 1 and Day 3 following SAH. Serial troponin I levels, admission Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS) were compared in patients with and without LV wall motion abnormality (WMA). Eight patients (20%) had evidence of WMA, of which five (63%) had global hypokinesis and the rest had regional WMA. Patients with WMA had significantly lower LVEF (30% vs 62%, p<0.001) at Day 0, significantly higher troponin I (0.938 vs 0.077, p<0.001) and significantly lower admission GCS (8.2 vs 14.1, p<0.001) compared to those without WMA. LV systolic function improved in 25% of patients by Day 3. Neurologic outcome (GOS) was adversely related to increase in troponin I levels (p=0.04), whereas WMA predicted poor neurologic status (GCS) (P<0.01) and increased hospital stay (P<0.01). Cardiac troponin I levels appear to be a sensitive marker of myocardial dysfunction, which occurred in 20% of patients with SAH, and helps predict poor neurologic outcome.

Pneumomediastinum: A Rare Complication of Epidural Analgesia.

Pneumomediastinum is a rare complication following epidural block using the loss of resistance (LOR) technique with air. It is speculated to result from the opening of potential space connecting the epidural space and the posterior mediastinum via intervertebral foramina through fascial planes. To date, only two cases of pneumomediastinum after epidural block have been reported. An incidental finding of pneumomediastinum two days after the procedure has not been reported before. Epidural block as a cause should be considered among multiple causes while interpreting the imaging of this life-threatening complication in the postoperative period.

Myocardial dysfunction in subarachnoid hemorrhage: prognostication by echo cardiography and cardiac enzymes. A prospective study.

BACKGROUND: The myocardial dysfunction in nontraumatic sub-arachnoid hemorrhage (SAH) is not well understood. Borderline elevations of cardiac biomarkers, electrocardiographic repolarization abnormalities and systolic dysfunction have been reported but the clinical significance of these abnormalities is uncertain. METHODS: Patients without history of cardiac disease were prospectively evaluated for cardiac dysfunction. Myocardial regional wall motion and left ventricular ejection fraction (LVEF) were serially studied by transthoracic echocardiogram along with cardiac enzymes. RESULTS: The mean age of the study population was 53 years. Majority of the patients had aneurysms (N = 38). The mean LVEF was 55 +/- 15%. Eight patients had evidence of WMA, mostly global hypokinesia (63%). The mean LVEF of patients with WMA was significantly lower compared to those without WMA (p < 0.001) at day 0. Systolic function recovered in 25% of these patients. The mean value of troponin was significantly higher in those with WMA (p < 0.001) and mean GCS upon admission was significantly lower (p < 0.001). On multivariate analysis, WMA were associated with poor GCS (p < 0.01) and increased hospitalization (P < 0.01). CONCLUSIONS: WMA with systolic dysfunction occurred in 20% of patients and recovered within 3 days in 25%. Patients with evidence of WMA had a significant myocardial dysfunction, higher troponin levels and poor GCS.

Poor outcome of indigent patients with peripartum cardiomyopathy in the United States.

OBJECTIVE: Peripartum cardiomyopathy (PPCM) patients from Haiti and South Africa have poor survival and poor left ventricular (LV) function recovery compared with patients from the United States. There are no reported studies of PPCM among the African American population in the United States. We evaluated the prognosis of PPCM in a mostly African American population. STUDY DESIGN: We analyzed the clinical and echocardiographic data of 44 (39 African American) patients with PPCM over an 11 year period (1992-2003). RESULTS: Thirty-nine patients were indigent and 5 had health insurance. During a mean follow-up of 24.0 (range, 0.1-264) months, 7 (15.9%) patients died and LV function returned to normal in 14 (35%). CONCLUSION: LV function recovery and survival rates of PPCM patients observed in our study are similar to those reported from Haiti and South Africa and different from what is generally accepted in the United States.

Diagnosis of a very rare variant of cor triatriatum dexter by contrast echocardiography: a case report.

Cor triatriatum dexter is a rare congenital abnormality in which the right atrium is divided into two chambers by a membrane. A rare variant of cor triatriatum dexter where the membrane is attached to the left of the superior vena cava at one end and to the right of inferior vena cava and coronary sinus at the other end has been described only once before. We describe here a case of this very rare variant of cor triatriatum dexter that was diagnosed using contrast echocardiography.

Platypnea-orthodeoxia syndrome: a diagnostic challenge.

Platypnea-orthodeoxia (P-O) syndrome is an underdiagnosed condition characterized by dyspnea and deoxygenation accompanying a change from a recumbent to an upright position. It is caused by increased right-to-left shunting of blood on assuming an upright position. The diagnosis of this shunt is often challenging. A case where a diagnosis was missed despite performing a tilt transesophageal echocardiogram with bubble study and a technetium labeled macroaggregated albumin scan is presented. However, a large patent foramen ovale (PFO) was found on autopsy. A brief overview of the diagnostic workup and management of this condition along with methods to increase the sensitivity of diagnostic tests is discussed.

Outcomes of cardiac resynchronisation therapy in patients with heart failure with atrial fibrillation: a systematic review and meta-analysis of observational studies.

Background: Cardiac resynchronisation therapy (CRT) is beneficial in selected patients with heart failure (HF) in normal sinus rhythm (NSR). We sought to evaluate the impact of CRT with or without atrioventricular junction (AVJ) ablation in patients with HF with concomitant atrial fibrillation (AF). Methods and results: Literature was searched (inception through 30 August 2017) for observational studies that reported outcomes in patients with HF with CRT and AF that reported all-cause and cardiovascular mortality. Thirty-one studies with 83, 571 patients were included. CRT did not decrease mortality compared with internal cardioverter defibrillator or medical therapy alone in patients with HF and AF with indications for CRT (OR: 0.851, 95% CI 0.616 to 1.176, p=0.328, I2=86.954). CRT-AF patients had significantly higher all-cause and cardiovascular mortality than CRT-NSR patients ([OR: 1.472, 95% CI 1.301 to 1.664, p=0.000] and [OR: 1.857, 95% CI 1.350 to 2.554, p=0.000] respectively). Change in left ventricular ejection fraction was not different between CRT patients with and without AF (p=0.705). AVJ ablation, however, improved all-cause mortality in CRT-AF patients when compared with CRT-AF patients without AVJ ablation (OR: 0.485, 95% CI 0.247 to 0.952, p=0.035). With AVJ ablation, there was no difference in all-cause mortality in CRT-AF patients compared with CRT-NSR patients (OR: 1.245, 95% CI 0.914 to 1.696, p=0.165). Conclusion: The results of our meta-analysis suggest that AF was associated with decreased CRT benefits in patients with HF. CRT, however, benefits patients with AF with AVJ ablation.

Therapies to increase high-density lipoprotein cholesterol and their effect on cardiovascular outcomes and regression of atherosclerosis.

Epidemiological studies have shown that decreased level of high-density lipoprotein (HDL) cholesterol (C) is an independent inverse predictor of coronary artery disease (CAD) even in patients with normal levels of low-density lipoprotein (LDL)-C. There is an abundance of evidence in favor of statins and aggressive LDL-C lowering therapy for both primary and secondary prevention of CAD. In contrast, the evidence for reduction of CAD risk with HDL-C raising therapy is relatively thin, partly due to the paucity of effective and safe drugs for increasing HDL-C level. However, there are emerging new therapies for raising HDL-C level and growing evidence in favor of pharmacologic therapies to raise HDL-C level. We present in this article a review of pharmacologic therapies that are currently available to increase HDL-C level, their safety and efficacy in relation to cardiovascular endpoints.

Arrhythmogenic right ventricular dysplasia/cardiomyopathy: clinical profile of four patients and review.

Four patients with arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) are described. Two patients presented with sustained ventricular tachycardia and two with cardiac arrest from which they were successfully resuscitated. All four patients had typical electrocardiographic and echocardiographic features and fulfilled the task force criteria for diagnosis of ARVD/C. All four patients had T wave inversion in chest leads V1 to V4, and two had epsilon waves, and all four had premature ventricular complexes of left bundle branch block and left axis deviation pattern. All patients showed a markedly enlarged, thin and hypokinetic right ventricle. Three patients had implantable cardioverter defibrillator (ICD) implanted and are doing well. One patient who refused an ICD died suddenly 6 months after his initial presentation. Three surviving patients are on sotalol for suppression of ventricular tachycardia episodes triggering ICD shocks. A review of the existing literature on diagnosis of ARVD/C, its clinical presentation and natural history, its genetic basis, risk stratification, treatment, and prognosis is presented.

Control of cardiovascular risk factors and use of aspirin in diabetic patients remain elusive.

OBJECTIVES: Type 2 diabetics are at higher risk for cardiovascular disease. To reduce this risk, the American Diabetes Association recommends traditional cardiovascular disease risk factor modification, reducing hemoglobin A1c (HbA1c), and the use of aspirin for patients over 30 years of age. The goal of this study was to analyze how well these goals were achieved in type 2 diabetics. METHODS: Patients with type 2 diabetes from July 2004 to June 2005 were included. Data were collected on demographics, preexisting coronary artery disease (CAD), blood pressure control, HbA1c, low-density lipoprotein cholesterol level, and microalbuminuria. RESULTS: One hundred thirty-nine patients were included (18% had CAD). Blood pressure was controlled in 46.04% of patients; 41.72% reached target HbA1c; 47.48% reached target low-density lipoprotein cholesterol; and 43.88% had microalbuminuria. No significant difference was noted between diabetics with or without CAD. Aspirin was used in 64% of patients with CAD and in 28.15% patients without CAD. CONCLUSIONS: Optimal cardiovascular risk modification was achieved in less than 50% of type 2 diabetics. Aspirin remains underused for primary prevention. These results highlight the continued difficulties in achieving control of diabetes to the extent recommended by American Diabetes Association guidelines.

Electrocardiographic abnormalities in patients with acute burn injuries.

OBJECTIVE: To determine the incidence and types of electrocardiographic (ECG) abnormalities in patients admitted with acute burn injuries and correlate them with the degree and the extent of burn injuries. METHODS: Retrospective analysis of 192 patients admitted to the burn unit was performed. Thirty-four patients met the inclusion criteria of having a 12-lead ECG performed on admission and at least one more time during their stay. RESULTS: There were 26 men and 8 women. The average age of patients was 53.4 +/- 17.5 years. The average degree of burn was 2.4 +/- 0.6 and the average body surface area (BSA) involved was 12.8 +/- 11.8%. There were 18 patients (53%) with ECG abnormalities. Five patients had sinus tachycardia, including two with premature atrial complexes (PACs) and one with ST-T abnormality. Three patients had premature ventricular complexes (PVCs), including one with a paced atrial rhythm and one with a prolonged QT interval. Right bundle branch block was present in two patients, and low voltage QRS was present in one. Atrial fibrillation was present in two patients, including one with ST-T abnormality due to digitalis effect. Four patients had a prolonged QT interval as the sole abnormality. One patient had left ventricular hypertrophy, an old inferior myocardial infarct, PACs, and non-specific ST-T wave abnormality. CONCLUSIONS: In patients with acute burn injuries sinus tachycardia and a prolonged QT interval were the most common ECG abnormalities. There was no correlation between the extent of burn injuries and observed ECG abnormalities. No patient had a life threatening arrhythmia, and all patients had a good outcome.

Non-vitamin K antagonists oral anticoagulants are as safe and effective as warfarin for cardioversion of atrial fibrillation: A systematic review and meta-analysis.

BACKGROUND: Current guidelines recommend anticoagulation using warfarin with bridging parenteral anticoagulation or one of the non-vitamin K antagonist oral anticoagulants (NOACs) to prevent thromboembolic events in patients undergoing cardioversion for atrial fibrillation (AF). We aimed to compare by meta-analytical techniques, the safety and efficacy of NOACs versus warfarin in patients undergoing cardioversion. METHODS: PUBMED, EMBASE, Cochrane CENTRAL and CINAHL were searched electronically in addition to manual search for randomized controlled trials (RCTs) comparing NOACs and warfarin in patients undergoing cardioversion for AF. Mortality, major bleeding and ischemic and hemorrhagic stroke were compared between the two agents. RESULTS: A total of 7 trials with 7588 total patients were included in the meta-analysis. NOACs, as compared to warfarin, resulted in similar risk of ischemic stroke [odds ratio (OR): 0.49 (95% confidence interval (CI): 0.20-1.19; P = 0.12], major bleeding [0.71 (0.37-1.38), P = 0.32], mortality [0.73 (0.32-1.67); P = 0.45], and hemorrhagic stroke [0.96 (0.11-8.70); P = 0.97]. The results were consistent across subgroup analyses. CONCLUSIONS: Based on the current meta-analysis, NOACs and warfarin have comparable efficacy and safety in patients with atrial fibrillation undergoing cardioversion.

Aldosterone Antagonist Therapy and Mortality in Patients With ST-Segment Elevation Myocardial Infarction Without Heart Failure: A Systematic Review and Meta-analysis.

Importance: Treatment with aldosterone antagonists is recommended and has been shown to have beneficial effects in patients with ST-segment elevation myocardial infarction (STEMI) and left ventricular ejection fraction (LVEF) less than 40%. However, the role of aldosterone antagonists in patients with ejection fraction greater than 40% or without congestive heart failure is not well known. Objectives: To perform a systematic review and meta-analysis using standard techniques to determine the role of therapy with aldosterone antagonists in this patient population. Data Sources: PubMed, Embase, CINAHL, and Cochrane Central databases were searched and a manual search for relevant references from the selected articles and published reviews was performed from database inception through June 2017. Study Selection: Randomized clinical trials that evaluated treatment with aldosterone antagonists in patients with STEMI without clinical heart failure or LVEF greater than 40% were included. Data Extraction and Synthesis: Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to conduct and report the meta-analysis, which used a random-effects model. Two investigators independently performed the database search and agreed on the final study selection. A manual search was performed for relevant references from the selected articles and published reviews. Main Outcomes and Measures: The outcomes analyzed were mortality, new congestive heart failure, recurrent myocardial infarction, ventricular arrhythmia, and changes in LVEF, serum potassium level, and creatinine level at follow-up. Results: In all, 10 randomized clinical trials with a total of 4147 unique patients were included in the meta-analysis. In patients who presented with STEMI without heart failure, treatment with aldosterone antagonists compared with control was associated with lower risk of mortality (2.4% vs 3.9%; odds ratio [OR], 0.62; 95% CI, 0.42-0.91; P = .01) and similar risks of myocardial infarction (1.6% vs 1.5%; OR, 1.03; 95% CI, 0.57-1.86; P = .91), new congestive heart failure (4.3% vs 5.4%; OR, 0.82; 95% CI, 0.56-1.20; P = .31), and ventricular arrhythmia (4.1% vs 5.1%; OR, 0.76; 95% CI, 0.45-1.31; P = .33). Similarly, treatment with aldosterone antagonists compared with control was associated with a small yet significant increase in LVEF (mean difference, 1.58%; 95% CI, 0.18%-2.97%; P = .03), a small increase in serum potassium level (mean difference, 0.07 mEq/L; 95% CI, 0.01-0.13 mEq/L; P = .02), and no change in serum creatinine level (standardized mean difference, 1.4; 95% CI, -0.43 to 3.24; P = .13). Conclusions and Relevance: Treatment with aldosterone antagonists is associated with a mortality benefit in patients with STEMI with LVEF greater than 40% or without heart failure.