A rare case of a pulmonary valve papillary fibroelastoma.

CASE: A 67-year-old female presented with an exceedingly rare cardiac neoplasm - papillary fibroelastoma. This is made rarer still as it occurred on the pulmonary valve. The patient complained of a prolonged history of chest discomfort. Magnetic resonance imaging and echocardiography revealed a pulmonary valve papillary fibroelastoma. Surgical excision proved curative and the patient remains asymptomatic to date. DISCUSSION: The literature surrounding papillary fibroelastomas is discussed. Primary cardiac tumours are uncommon. Papillary fibroelastomas occurring the right side of the heart comprise less than 0.05% of these. They have a characteristic macroscopic appearance which allow them to be easily identified with echocardiography and at surgical excision. They can present in a variety of ways including classical cardiac symptoms, embolic complications or as an incidental finding. Surgical excision is the definitive treatment.

A Cautionary Note on Pembrolizumab use in Patients with Ascending Aortic Aneurysms.

Case description: We describe a case of a patient treated with pembrolizumab (an immune checkpoint inhibitor) for metastatic scalp melanoma. He had a previous history of colorectal cancer, prostatic cancer and chronic polymyalgia rheumatica. The patient was known to have a stable ascending aortic aneurysm of 4.5 cm. However, he developed a rapid expansion of the ascending aortic aneurysm with the size crossing the threshold for surgery. The patient was referred to the cardiothoracic surgery service for intervention and he subsequently underwent surgery. The patient was electively admitted one week later for resection of aortic aneurysm, aortoplasty and external graft fixation. Pathologically, gross evidence of dissection was not identified; however, the histological analysis of the media showed laminar medial necrosis, multifocal in nature, with occasional clusters of histiocytic cells appreciated at their edge reminiscent of that seen in an inflammatory aortitis (granulomatous/giant cell type). Discussion: Immune checkpoint inhibitor-induced aortitis is becoming increasingly evident, and its presentation can vary. It has been discovered incidentally on surveillance imaging with the use of nivolumab. In other cases, patients have been symptomatic to severely symptomatic. Atezolizumab with carboplatin and etoposide has been reported to cause abdominal aortitis which was responsive to corticosteroids and subsequent discontinuation of atezolizumab. Pembrolizumab has been linked to a case of transverse aortic arch aortitis. In our case, the inflammatory aortitis due to pembrolizumab was the cause of the rapid expansion of the ascending aortic aneurysm. Conclusion: Patients with known aortic aneurysms should undergo careful surveillance when commencing immune-checkpoint inhibitor therapy. LEARNING POINTS: Immune checkpoint inhibitors are being increasingly used in the treatment of metastatic malignancy. However, they are a relatively new group of medications, and the side effect profile of each is yet to be fully recognised. Aortitis has occurred with several different immune checkpoint inhibitors.Patients with known aortic aneurysms should undergo careful surveillance when commencing immune checkpoint inhibitors.All interventional therapeutic options should be considered early in these patients on the development of aneurysmal expansion.

A clinico-pathological conference on constrictive pericarditis secondary to rheumatoid arthritis: a case report with expert commentary and review of the literature.

Constrictive pericarditis is the commonest cardiac complication of rheumatoid arthritis (RA). Two percent of patients with RA develop significant clinical symptoms of pericarditis, which may not correlate with joint disease duration or severity. Symptoms are often vague and non-specific, which frequently delays the diagnosis and subsequent management. Surgical excision of the pericardium is the only definitive treatment option. We present the case of a 60 year-old lady with RA who presented with symptoms due to pericardial constriction and underwent radical pericardectomy.

Patient selection criteria for primary total hip Arthroplasty in displaced intracapsular hip fractures: Are they appropriate?

INTRODUCTION: This study aims to determine, by outcome analysis, the appropriateness of current criteria employed to select patients for total hip arthroplasty (THA) as the primary treatment for displaced intracapsular hip fracture (DICHF). This study is intended to inform prospective randomised controlled trials investigating the efficacy of THA as a primary treatment. MATERIALS AND METHODS: Contemporary THA eligibility criteria were derived from recent publications relating to pre-fracture residence, mobility and independence. Outcome data were analysed for 96 patients (19% of 506 consecutive patients with DICHF between March 2003 and February 2005) who fulfilled those criteria. The variables analysed included age, gender, co-existing injuries, co-morbidities, social circumstances, mobility, independence, delay to surgery, readmission and death. The 96 patients included in the study were followed for 3 years. The primary outcome was the combined achievement of home or warden-assisted accommodation at 3 months, no patient readmission within 6 weeks of discharge and survival to 1 year. Secondary outcome was survival to 3 years. RESULTS: At 3 months, 86 patients (90%) had returned home, three (3.1%) required nursing or residential home placement, four (4.2%) were still resident in a community hospital and three (3.1%) had died. A total of ten patients failed to return to their own home. Eight patients (8.3%) were readmitted within 6 weeks. At 1 year, eight patients (8.3%) had died; by 3 years, the mortality rate was 25%. Patients not achieving return to home were older (84.8 years vs. 79.7 years, p = 0.19), prior to fracture weremore likely to use a walking aid (odds ratio [OR] 2.35) or required home support (OR 1.74). The number of co-morbidities was not an association. Backward selection applied to the above data produced an OR of 1.12 (confidence interval [CI] 1.01-1.21) for age as a variable in patients successfully discharged home, so that for each increase in age by year, the odds of home not being the final destination increased by 12%. These factors were also reflected in the patients requiring readmission within 6 weeks from discharge. CONCLUSIONS: If maintaining a high level of activity and independence is the expectation in patients considered for THA for DICHFs, then current selection criteria appear to be appropriate in identifying those capable of returning home, remaining independent and surviving to 1 year compared to the whole DICHF population. With a 75% 3-year survival, the postulated benefit of THA will not be realised in many patients and this needs to be considered. Cost-effectiveness trials are required before broad practice change occurs.