Adjunctive low-voltage area ablation for patients with atrial fibrillation: An updated meta-analysis of randomized controlled trials.

BACKGROUND: The efficacy and safety of adjunctive low-voltage area (LVA) ablation on outcomes of catheter ablation (CA) for atrial fibrillation (AF) remains uncertain. METHODS: PubMed, Embase, Cochrane Library, and ClinicalTrials.gov were searched for randomized controlled trials (RCTs) comparing CA with versus without LVA ablation for patients with AF. Risk ratios (RR) with 95% confidence intervals (CI) were pooled with a random-effects model. Our primary endpoint was recurrence of atrial tachyarrhythmia (ATA), including AF, atrial flutter, or atrial tachycardia. We used R version 4.3.1 for all statistical analyses. RESULTS: Our meta-analysis included 10 RCTs encompassing 1780 patients, of whom 890 (50%) were randomized to LVA ablation. Adjunctive LVA ablation significantly reduced recurrence of ATA (RR 0.76; 95% CI 0.67-0.88; p < .01) and reduced the number of redo ablation procedures (RR 0.54; 95% CI 0.35-0.85; p < .01), as compared with conventional ablation. Among 691 (43%) patients with documented LVAs on baseline substrate mapping, adjunctive LVA ablation substantially reduced ATA recurrences (RR 0.57; 95% CI 0.38-0.86; p < .01). There was no significant difference between groups in terms of periprocedural adverse events (RR 0.78; 95% CI 0.39-1.56; p = .49). CONCLUSIONS: Adjunctive LVA ablation is an effective and safe strategy for reducing recurrences of ATA among patients who undergo CA for AF.

Navigating the penetrance and phenotypic spectrum of inherited cardiomyopathies.

Inherited cardiomyopathies are genetic diseases that can lead to heart failure and sudden cardiac death. These conditions tend to run in families, following an autosomal dominant pattern where first-degree relatives have a 50% chance of carrying the pathogenic variant. Despite significant advancements and increased accessibility of genetic testing, accurately predicting the phenotypic expression of these conditions remains challenging due to the inherent variability in their clinical manifestations and the incomplete penetrance observed. This poses challenges in providing patient care and effectively communicating the potential risk of future disease to patients and their families. To address these challenges, this review aims to synthesize the available evidence on penetrance, expressivity, and factors influencing disease expression to improve communication and risk assessment for patients with inherited cardiomyopathies and their family members.

The Effectiveness and Safety of Leadless Pacemakers: An Updated Meta-Analysis.

BACKGROUND: Leadless pacemakers (LPs) are promising alternatives to traditional transvenous pacemakers (TVPs), but their comparative effectiveness and safety in clinical outcomes remain uncertain. METHODS: We systematically searched PubMed, Embase, Scopus, Cochrane, and ClinicalTrials.gov for studies comparing LPs and TVPs. A restricted maximum likelihood random-effects model was used for all outcomes. Heterogeneity was assessed using I2 statistics. We performed a subgroup analysis with studies with multivariate-adjusted data. RESULTS: We included 21 studies involving 47,229 patients, of whom 12,199 (25.8%) underwent LP implantation. Compared with TVPs, LPs were associated with a significantly lower risk of overall complications (OR 0.61; 95% CI 0.45-0.81; p < 0.01), dislodgement (OR 0.34; 95% CI 0.20-0.56; p < 0.01), and pneumothorax (OR 0.27; 95% CI 0.16-0.46; p < 0.01). No significant difference in all-cause mortality was observed in the overall analysis (OR 1.43; 95% CI 0.65-3.15; p = 0.35) and in studies with multivariate-adjusted data (OR 1.34; 95% CI 0.65-2.78; p = 0.43). However, LPs were associated with a higher risk of pericardial effusion (OR 2.47; 95% CI 1.39-4.38; p < 0.01) and cardiac tamponade (OR 3.75; 95% CI 2.41-5.83; p < 0.01). LPs also demonstrated a lower pacing capture threshold (MD -0.19 V; 95% CI [-0.23 V]-[-0.16 V]; p < 0.01), but no significant difference in impedance (MD 32.63 ohms; 95% CI [-22.50 ohms]-[87.76 ohms]; p = 0.25). CONCLUSIONS: These findings suggest that LPs were associated with lower overall complication rates and similar effectiveness to TVPs. However, randomized controlled trials are warranted to validate these results.

Primary hepatic pleomorphic liposarcoma: Case report and literature review.

Primary hepatic liposarcoma is an extremely rare malignant tumour derived from adipocytes and is part of the group of mesenchymal tumours. We present the case of a 43-year-old Hispanic male patient with a pleomorphic hepatic liposarcoma and absence of MDM2 gene amplification. Two years and six months after surgery, the patient is asymptomatic. The present case is the first report of this entity with positive immunohistochemical testing for p16, p53, S100, vimentin and absence of MDM2 gene amplification.

Intracardiac vs transesophageal echocardiography for left atrial appendage occlusion: An updated systematic review and meta-analysis.

BACKGROUND: Multiple studies continue to evaluate the use of intracardiac echocardiography (ICE) and transesophageal echocardiography (TEE) for guiding left atrial appendage occlusion (LAAO). OBJECTIVE: The purpose of this study was to conduct an updated meta-analysis comparing the effectiveness and safety outcomes of both imaging modalities. METHODS: PubMed, Cochrane, and Embase were searched for studies comparing ICE vs TEE to guide LAAO. Odds ratios (ORs) with 95% confidence intervals (CIs) were pooled using a random-effects model. The primary effectiveness endpoint was procedural success. The primary safety endpoint included the overall complications rate. Additional safety outcomes were assessed as secondary endpoints. Subgroup analysis of primary endpoints was conducted according to device type (Amulet, LAmbre, Watchman, Watchman FLX) and study region (American, Asia, Europe). R Version 4.3.1 was used for all statistical analyses. RESULTS: Our meta-analysis included 19 observational studies encompassing 42,474 patients, of whom 4415 (10.4%) underwent ICE-guided LAAO. Compared with TEE, ICE was associated with a marginally higher procedural success (OR 1.33; 95% CI 1.01-1.76; P = .04; I2 = 0%). There was no significant difference in the overall complications rate (OR 1.02; 95% CI 0.77-1.36; P = .89; I2 = 5%). However, ICE showed higher rates of pericardial effusion (OR 2.11; 95% CI 1.47-3.03; P <.001; I2 = 0%) and residual iatrogenic atrial septal defect (iASD) (OR 1.52; 95% CI 1.15-2.03; P <.004; I2 = 0%). Subgroup analysis revealed variations in procedural success within the ICE group across study regions (P = .02). CONCLUSION: In this updated meta-analysis, the increasing adoption of ICE-guided LAAO demonstrated higher procedural success rates compared to TEE, although with limited statistical significance. Overall complication rates were similar; however, ICE showed higher rates of pericardial effusion and residual iASD.

Young females affected with hydatidosis, case report.

Hydatidosis is a zoonosis, caused by a cestode (Echinococcus). Management will depend on the organs affected by the infection and the response to medical treatment. Therapy may be clinical in early stages, but in case of poor response to drug therapy, surgery is the preferred choice. We present two cases in young females, the first case is with Hydatid cysts in both lungs and liver, she received initial medical treatment with lack of response, and surgery was indicated to resect the pulmonary and hepatic lesions. The second case is of a female with Hydatid cysts in the right lung. She was misdiagnosed at the beginning thinking of pneumonia and pulmonary abscess but after further investigation, hydatid cysts were the diagnosis, due to symptoms consistent with thoracic pain and persistent cough and the size of the cyst, surgery was indicated.

Tumor hepático de presentación atípica en imágenes / Liver tumor of atypical presentation in images

RESUMEN El presente manuscrito desea recalcar la importancia de los diferentes métodos de diagnóstico. En este caso el paciente presentó clíni-ca de dolor abdominal y el estudio de ecografía indicó la presencia de una masa; sin embargo, se puede apreciar la disyuntiva que se presenta entre los resultados histopatológicos de la biopsia core, los marcadores serológicos, los estudios de imagen y el diagnóstico definitivo posterior a la resección quirúrgica total de la lesión. El hepatocarcinoma tiene un aspecto tomográfico diferente y presenta elevación de marcadores oncológicos en pacientes con antecedentes previos de hepatopatía, por lo que la presentación de esta forma resulta atípica. Palabras claves: Hepatocarcinoma, cirrosis, metástasis

ABSTRACT This manuscript highlights the importance of the different diagnostic methods. In this case, the patient presented clinical symptoms of abdominal pain and the ultrasound showed the presence of a mass in the liver; however, the diagnosis was not easily achieved because there was a disjunctive between the histopathological result of the core biopsy, the serological markers, and the imaging studies. Definitive diagnosis was only possible after total surgical resection of the lesion. Hepatocellular carcinoma has a different tomographic appearance and presents elevated oncological markers in patients with a previous history of liver disease, so the presentation of this form is atypical.Keywords: Hepatocarcinoma, cirrhosis, metastasis.Correspondencia: Elizabeth ZamoraTeléfonos: 0982546676 e-mail: ezamora@hmetro.med.ecElizabeth Zamora: https://orcid.org/0000-0003-1807-625XFrans Serpa:https://orcid.org/0000-0001-6437-1140Fernanda Avalos:https://orcid.org/0000-0003-1917-3780IDs Orcid

Resultados de la resección hepática laparoscópica en el Hospital Metropolitano / Results of laparoscopic liver resection in the Metropolitan Hospital

Objetivo: evaluar los resultados perioperatorios de las resecciones hepáticas por abordaje laparoscópico, su seguridad y eficacia. Materiales y métodos: estudio epidemiológico descriptivo retrospectivo de serie de casos en el Hospital Metropolitano, en el cual se incluyó a todos los pacientes a quienes se realizó resecciones hepáticas laparoscópicas, durante un período de 10 años. Las variables recogidas se agruparon de la siguiente manera: I. Variables de los datos generales (edad, sexo, comorbilidades), II. Variables de diagnóstico prequirúrgico y cirugía, III. Variables de resultados intraoperatorios y posquirúrgico (pérdida de sangre, complicaciones, tiempo quirúrgico, etcétera). Resultados: de 10 pacientes identificados, 8 fueron de sexo femenino y 2 de sexo masculino, edad promedio: 46,8 años, 60% no presentó comorbilidades, estancia hospitalaria promedio: 5,3 días, tiempo quirúrgico promedio: 211 minutos, diagnóstico prequirúrgico más frecuente: hemangioma; sin embargo, en el histopatológico predominó la hiperplasia nodular focal en un 30%, y la patología maligna se observó en el 50% de los casos, de los cuales no hubo márgenes comprometidos; se presentó aproximadamente 20% de complicaciones posquirúrgicas de las cuales las más frecuentes fueron el sangrado y las trasfusiones. Conclusiones: la hepatectomía laparoscópica es una técnica segura y efectiva con baja morbilidad, además de las ventajas de la cirugía laparoscópica.

Objective: To evaluate the perioperative results of liver resections by laparoscopic approach, their safety and efficacy. Methods: A retrospective descriptive epidemiological study of a series of cases at the Hospital Metropolitano, including all patients who undergo laparoscopic liver resections. The variables collected are grouped as follows: I. Variables of the general data (age, sex, comorbidities), II. Pre-surgical diagnosis and surgery variables, III. Variables of intraoperative and postoperative results (blood loss, complications, surgical time, etc). Results: Of 10 identified patients, 8 were women and 2 were male, with an average age of 46.8 years, 60% without comorbidities, hospital stay with an average of 5.3 days, average surgical time of 211 minutes, the most frequent presurgical diagnosis was hemangioma however, in the histopathology, focal nodular hyperplasia predominated in 30%, and malignant pathology was detected in 50% of cases, of which there were no compromised margins, and 20% of complications were found among them more frequent bleeding and transfusions. Conclusions: Laparoscopic hepatectomy is a safe and effective technique with low morbidity in addition to having the advantages of laparoscopic surgery.

Seguridad del procedimiento de Whipple: experiencia de 10 años en un centro de tercer nivel / Whipple procedure safety: 10 year experience in a third level center / Whipple procedure safety: 10 year experience in a third level center

Resumen Antecedentes: el procedimiento de Whipple, apesar de los avances en cirugía, continúa siendo el procedimiento más complejo en cirugía general. Su principal indicación es la patología neoplásica de páncreas, duodeno y vías biliares que persiste como un desafío terapéutico debido a su alta morbilidad y mortalidad que en nuestro país alcanza 40% a 60% y de 15% a 30%, respectivamente. Objetivo: determinar la seguridad del procedimiento de Whipple en una institución privada de tercer nivel. Materiales y métodos: se realizó un estudio observacional retrospectivo, desde 2007 hasta 2017 en el Hospital Metropolitano. Datos recolectados: indicación quirúrgica, complicaciones, estancia hospitalaria, entre otros, que se analizaron con JASP 0.9.2.0. Resultados: universo 30 pacientes, edad promedio: 60,1 años IC (95%: 39 a 79 años); mujeres: 56%, hombres: 44%. Estancia hospitalaria promedio: 15 días con un DS:15 días. Principales indicaciones: adenocarcinoma de páncreas 33,3%, adenocarcinoma de ámpula de Vatter 16,7% colangiocarcinoma 16,7%. Según la escala Clavien Dindo, el 76,7% presentó complicaciones; sin embargo, de éstas el 59,9% fueron leves. Mortalidad intrahospitalaria: 6,7%. Conclusiones: atribuimos los resultados, entre otros motivos, a la disponibilidad de facilidades técnicas y a la experiencia del equipo quirúrgico que enfatiza en la prevención de las complicaciones o, si se presentare, al diagnóstico oportuno y tratamiento adecuado con todo el arsenal terapéutico requerido.

Abstract: Background: The Whipple procedure, despite advances in surgery, remains the most complex procedure in general surgery, its main indication is the neoplastic pathology of pancreas, duodenum and bile ducts. This persists as a therapeutic challenge due to its high morbidity and mortality that in our country reaches from 40% to 60% and from 15% to 30%, respectively. Objective: Determine the safety of performing the Whipple procedure in a third level private institution. Materials and methods: A retrospective observational study was conducted from 2007 to 2017 at the Hospital Metropolitano, the data collected included: surgical indication, complications, hospital stay, among others; these were analyzed with JASP 0.9.2.0. Results: We included 30 patients, their mean age was 60.1 years, 95% CI: 39 -79 years; 56% were women and 44% men. The average hospital stay was 15 days with a SD:15 days. The main indications were: adenocarcinoma of the pancreas 33.3%, adenocarcinoma of the Vatter ampulla 16.7% and cholangiocarcinoma 16.7%. According to the Clavien Dindo scale, 76.7% presented complications, however, 59.9% of these were mild. In-hospital mortality reached 6.7%. Conclusions: We attribute the results shown, among others, to the availability of technical facilities, as well as to the experience of the surgical team, emphasizing the prevention of complications or in the case of occurrence, provide a timely diagnosis and adequate treatment with allthe required therapeutic methods.

Tratamiento quirúrgico de la enfermedad poliquística hepática autosómica dominante, serie de casos / Surgical treatment of autosomic polycistic liver disease, case series

Nowadays liver and biliary tract surgery are the most commonly performed procedures worldwide; refinement in surgical techniques, anesthetic care and liver transplantation have revolutionized the treatment of liver diseases that were previously incurable. The autosomal dominant polycystic liver disease is a rare condition that may be associated with polycystic kidney disease or can present alone; the symptoms of this condition occur in the advanced stages of the disease. Despite the multiple modalities of treatment available, surgery with hepatectomy and fenestration has shown better results in patients with early satiety and massive hepatomegaly. A literature review was carried out and a number of cases dealt with this disease at the Metropolitan Hospital in Quito, Ecuador, are presented.

Nowadays liver and biliary tract surgery are the most commonly performed procedures worldwide; refinement in surgical techniques, anesthetic care and liver transplantation have revolutionized the treatment of liver diseases that were previously incurable. The autosomal dominant polycystic liver disease is a rare condition that may be associated with polycystic kidney disease or can present alone; the symptoms of this condition occur in the advanced stages of the disease. Despite the multiple modalities of treatment available, surgery with hepatectomy and fenestration has shown better results in patients with early satiety and massive hepatomegaly.