Transvenous management of cardiac implantable electronic device late lead perforation.

INTRODUCTION: Late lead perforation (LLP), defined as perforation ≥30 days from cardiac implantable electronic device implant, is a rare diagnosis and little data exist regarding management practices and outcomes. The purpose of this study was to evaluate the occurrence, safety, and efficacy of transvenous management of clinically significant LLP. METHODS: The electronic medical records of a single-center tertiary hospital were reviewed for all patients who were referred for LLP or its sequelae. RESULTS: Eleven consecutive patients were identified from October 2011 to December 2018 with clinically significant LLP. Patients most often presented with pericardial symptoms with the exception of one asymptomatic patient. The median time from lead implant to intervention for LLP was 246 days. Nine patients were managed with an initial transvenous approach, with one requiring sternotomy (lead 6.3 years old). Two patients had a surgical approach, one performed at an outside hospital with subsequent death and another had a mini-thoracotomy, but the lead was removed percutaneously with no surgical repair. In this small cohort, there was no association between the lead extending beyond the parietal pericardium and surgical repair (P = .99). CONCLUSION: Our single-center experience suggests that LLP can be initially managed with a cautious transvenous approach in most patients, but intraprocedural ultrasound for pericardial monitoring and a rescue plan with immediate surgical back up is mandatory.

Radiation-Associated Pericardial Disease.

PURPOSE OF REVIEW: This review highlights the literature related to pericardial injury following radiation for oncologic diseases. RECENT FINDINGS: Radiation-associated pericardial disease can have devastating consequences. Unfortunately, there is considerably less evidence regarding pericardial syndromes following thoracic radiation as compared to other cardiovascular outcomes. Pericardial complications of radiation may arise acutely or have an insidious onset several decades after treatment. Transthoracic echocardiography is the screening imaging modality of choice, while cardiac magnetic resonance imaging further characterizes the pericardium and guides treatment decision-making. Cardiac CT can be useful for assessing pericardial calcification. Ongoing efforts to lessen inadvertent cardiac injury are directed towards the revision of radiation techniques and protocols. As survival of mediastinal and thoracic malignancies continues to improve, radiation-associated pericardial disease is increasingly relevant. Though advances in radiation oncology demonstrate promise in curtailing cardiotoxicity, the long-term effects pertaining to pericardial complications remain to be seen.

Ventricular tachycardia and chest pain due to foreign body in the pericardium caused by self-injurious behaviour.

A 14-year-old girl suddenly developed ventricular tachycardia and severe chest pain during hospitalisation for trauma surgery. CT revealed a needle in the pericardium. Careful interview elicited that she had inserted the needle by herself, and Munchausen syndrome was diagnosed. This is the first report of ventricular tachycardia caused by a foreign body in a patient with Munchausen syndrome.

A word of caution: never use tacks for mesh fixation to the diaphragm!

BACKGROUND: The mesh fixation technique used in repair of hiatal hernias and subxiphoid ventral and incisional hernias must meet strenuous requirements. In the literature, there are reports of life-threatening complications with cardiac tamponade and a high mortality rate on using tacks. The continuing practice of tack deployment for mesh fixation to the diaphragm and esophageal hiatus should be critically reviewed. METHODS: In a systematic search of the available literature in May 2017, 23 cases of severe penetrating cardiac complications were identified. The authors became aware of two other cases in which they acted as medical experts. Furthermore, the instructions for use issued by the manufacturers of the tacks were reviewed with regard to their deployment in the diaphragm. RESULTS: Twenty-three of 25 cases (92%) with severe cardiac injuries and subsequent cardiac tamponade were triggered by the use of tacks in the diaphragm. In six cases (24%), these related to ventral and incisional hernias with extension to the subxiphoid area, and in 19 cases (76%) to mesh-augmented hiatoplasty. Twelve of 25 (48%) patients died as a result of pericardial and/or heart muscle injury with cardiac tamponade despite heart surgery intervention. In the tack manufacturers' instructions for use, their deployment in the diaphragm, in particular in the vicinity of the heart, is contraindicated. Likewise, the existing guidelines urgently advise against the use of tacks in the diaphragm, recommending instead alternative fixation techniques. CONCLUSIONS: Tacks should not be used for mesh fixation in the diaphragm above the costal arch.

Delayed Presentation of Traumatic Pericardial Rupture: Diagnostic and Surgical Considerations for Treatment.

Traumatic pericardial rupture is a rare event with high mortality. We present the case of a 15-year-old boy who sustained thoracic and abdominal trauma secondary to motor vehicle collision, with a delayed diagnosis of traumatic pericardial rupture with cardiac herniation. Out of concern for torsion and hemodynamic collapse, surgical repair was advised. We have developed a novel surgical approach to this rare condition, utilizing a combination of thoracoscopic and open surgical techniques. The guiding principles of our repair include the utilization of fenestrated pieces of bovine pericardium to create a tension free repair, minimizing the likelihood of pericardial effusion, and returning the cardiac mass to normal anatomic position.

Thoracic trauma in fatal falls from height - Traumatic pneumopericardium correlates with height of fall and severe injury.

Pneumopericardium (PPC) describes the collection of gas in the pericardial sac. In tension Pneumopericardium (tPPC), this collection of gas may lead to cardiac tamponade. PPC following blunt trauma is considered a rare finding, as reflected by the low number of case reports on the topic. We analyzed the prevalence and pathophysiology of PPC and the associated trauma in 44 cases of falls from height. We retrospectively analyzed postmortem CT data and autopsy reports of fatal falls in the period March 2014-2017. A valid estimation of the height of the fall and a documented impact on an even and hard surface were inclusion criteria. A total of 44 cases were included in the study. We identified PPC in 18 of the 44 cases, and it was associated with an increased height of the fall, alongside aortic, pericardial, and myocardial ruptures. All cases with PPC also presented with bilateral pneumothorax. Five cases presented with a "ballooning" pericardium, indicating tPPC. PPC is a common finding in cases of falls from great heights. Due to a significant correlation with height and thus impact severity, PPC may be used as a reconstructive element in medico-legal investigations. Association with trauma makes PPC a sign of severe thoracic injury in postmortem and clinical radiology.

[Rabbit Model for Evaluation of Anti-adhesive Materials after Open Heart Surgery].

Surgical trauma to the pericardial mesothelium during open heart procedures has formation of fibrovascular adhesions. Surgeons are confronted with cardiac adhesions, leading to an increased surgical risk such as intractable bleeding and possible catastrophic hemorrhage. In order to solve the problem, the anti-adhesion membrane has been developed and used. However, their performances are far from perfect, so it has been expected to develop a novel anti-adhesive material. For preparing an anti-adhesive material, there is 1 serious problem, a lack of golden standard of animal model for evaluation of anti-adhesivity. In this study, we tried to establish a standard system for evaluation of the performance of anti-adhesive materials for the chest-area surgery using rabbit. Setting the condition of the damage to heart, the objective evaluation system was established. And we performed experimental study to evaluate prevention of adhesions with pericardial substitutes and our product under development based on this model.

A Diaphragmatic Hernia and Pericardial Rupture Caused by Blunt Injury of the Chest: A Case Review.

Blunt traumatic diaphragmatic hernias are most commonly seen in combination with other injuries. Right diaphragmatic ruptures with serious pericardium ruptures are relatively rare. The diagnosis of diaphragmatic hernias is not difficult; however, prior to surgery, it is difficult to judge whether pericardium damage has occurred, particularly on the right side. This injury may occur in a critical pathological state in which cardiac tissue is outside the pericardium due to the pericardial defect. Severe hemodynamic disorders or even death may occur if the patient's condition is not diagnosed and treated in a timely manner. The transportation of patients with severe trauma must be performed with extreme caution. It is necessary to weigh a wide range of differential diagnoses in a serious and thorough initial investigation.

Mortality due to a retained circle hook in a longfin mako shark Isurus paucus (Guitart-Manday).

A female longfin mako shark Isurus paucus (Guitart-Manday, 1966) was found moribund on the Atlantic Ocean beach near Canaveral National Seashore, Florida; the shark died shortly after stranding. Macroscopic lesions included a partially healed bite mark on the left pectoral fin, a clefted snout, pericardial effusion and a pericardial mass surrounding a 12/0 circle fishing hook. The heart, pericardial mass, gills, ovary, oviduct, shell gland, epigonal organ, liver, kidney and intrarenal and interrenal glands were processed for histopathology and examined by brightfield microscopy. Microscopic examination revealed chronic proliferative and pyogranulomatous pericarditis and myocarditis with rhabdomyolysis, fibrosis and thrombosis; scant bacteria and multifocal granular deposits of iron were found intralesionally. In addition, acute, multifocal infarcts within the epigonal organ and gill filaments were found in association with emboli formed by necrocellular material. The ovary had high numbers of atretic follicles, and the liver had diffuse, severe hepatocellular degeneration, multifocal spongiosis and moderate numbers of melanomacrophage cells. This report provides evidence of direct mortality due to systemic lesions associated with retained fishing gear in a prohibited shark species. Due to the large numbers of sharks released from both recreational and commercial fisheries worldwide, impact of delayed post-release mortality on shark populations is an important consideration.

Cardiovascular perforation during placement of an Avalon Elite® Bicaval dual lumen ECMO cannula in a newborn.

Proper functioning of the Avalon Elite® bicaval dual lumen ECMO cannula (Maquet Cardiovascular, Wayne, NJ, USA) requires precise placement of the distal draining port within the lumen of the inferior vena cava (IVC). In order to advance the cannula to the correct position, a 0.038" guidewire is placed into the IVC under echocardiographic or fluoroscopic guidance. We report a case of perforation of the intrapericardiac section of the IVC by the guidewire in a neonate, not detected at the time of placement, resulting in cardiac tamponade and death. We recommend routine echocardiographic surveillance after placement of Avalon Elite® cannulas to rule out hemopericardium.

Fatal lawn mower related projectile injury.

Fatal lawn mower related injuries are a relatively rare occurrence. In a forensic setting, the primary aim is to reconstruct the injury mechanism and establish the cause of death. A relatively rare, but characteristic type of injury is a so-called projectile or missile injury. This occurs when the operator or a bystander is impacted by an object mobilized from the grass by the rotating mower blades. This type of injury often leaves only modest external trauma, which increases the risk of overlooking an entry wound. In this paper we present a case of a fatal lawn mower related projectile injury which was initially overlooked, later interpreted as a possible gunshot homicide, and finally identified as a lawn mower related projectile injury when autopsy revealed a piece of metal thread in the main bronchus to the right middle lobe, hemopericardium, and right-sided hemothorax. To our knowledge, this injury mechanism has not previously been reported as a cause of death. This case illustrates the importance of postmortem radiological imaging and interdisciplinary cooperation when establishing manner and cause of death in unusual cases.

Traumatic pericardial rupture with secondary cardiac herniation in a dog.

OBJECTIVE: To describe the unique finding and treatment of a dog with cardiac herniation due to traumatic pericardial rupture. CASE SUMMARY: A 6.5-year-old entire male Yorkshire Terrier was presented for further management after being hit by a car. Despite suspected significant intrathoracic trauma at that time, the patient regained hemodynamic stability and had orthopedic surgery to correct a right iliac fracture. The patient was readmitted to the hospital 12 days following the initial visit due to considerable respiratory difficulty after accidentally being dropped several feet. Thoracic radiographs revealed an unusual severe mediastinal shift to the left with an atypical position of the cardiac silhouette against the left lateral thoracic wall. Due to the severe respiratory compromise of the patient and newly developed pneumothorax, an exploratory thoracotomy was recommended, where a complete rupture of the pericardium was identified, with secondary left-sided prolapse of the heart. Other more common intrathoracic injuries (ie, lung perforation, rib fractures) were also identified and partially repaired. The patient recovered successfully and was discharged 4 days postoperatively. NEW OR UNIQUE INFORMATION PROVIDED: This is the first case report in the veterinary literature of traumatic pericardial rupture and cardiac herniation. According to human case descriptions, this is a rare and often fatal occurrence, which can be significantly challenging to diagnose preoperatively or antemortem. Emergency veterinary clinicians should be aware of this rare but important complication of blunt thoracic trauma. Surgical intervention may be necessary in cases with suspected or confirmed entrapment of great vessels or cardiac chambers, although these abnormalities were not present in this case.

Pericardial tamponade with a normal cardiopericardial silhouette due to a penetrating metallic projectile propelled by a lawnmower.

This report describes a case of pericardial tamponade in a 6-year-old boy due to a penetrating projectile coat hunger wire propelled by a lawnmower. A dismissible dermal injury at the entry point and a normal initial cardiopericardial silhouette are reported. The report issues a new warning to be added to the warnings already listed in lawnmower manuals.

Left hemothorax: an unusual complication of delayed right ventricular perforation by a permanent pacemaker lead.

Cardiac ventricle perforation by a pacemaker (PM) lead is an uncommon complication of PM implantation. We report a patient with a delayed right ventricular perforation from a permanent PM lead which presented as a left hemothorax.

Dying transfixing his own heart: a rare case of suicide by stabbing.

A 22-year-old man was found dead in his room, lying on his bed, with a kitchen knife embedded in his thorax. The external examination revealed only 1 deep incised horizontal wound in the third left intercostal space beside the sternum. There were no hesitation marks or defense injuries. On both flexor sides of the wrists, the forearms, and the arms and on the right and the left side of the neck, there were several old transversal cut scars. At the autopsy, once the single-edged knife was removed, and after a median sternotomy, the penetration depth of the stab wound revealed an incision of the left pleura, the pericardium, and the transfixed heart, from the anterior to the posterior side, ending on the seventh thoracic vertebra. Toxicological screening resulted as negative. Death occurred as a result of hemorrhagic shock after deep myocardial injuries. A psychiatric history of paranoid schizophrenia; the old scars, which were marks of previous attempted suicides; and the position of the weapon suggested that it was a suicide caused by a single strong stab wound in the cardiac region. This unusual manner of self-stabbing with a single stab to the heart without hesitation wounds was important to exclude other causes of death.

Intramyocardial hematoma with epicardial rupture following percutaneous coronary intervention.

Intramyocardial (or subepicardial) hematomas are uncommon conditions that occur mostly after myocardial infarction, percutaneous coronary intervention (PCI), coronary artery bypass surgery, cardiac surgery, or chest trauma. Coronary perforation is a rare complication of PCI and the subset of patients developing an intramyocardial hematoma, usually considered a catastrophic event, is even rarer. We describe here the case of 63-year-old man in whom an intramyocardial hematoma with epicardial rupture occurred after PCI. The patient was treated conservatively with a successful outcome.

Fatal cardiac tamponade by Bodkin.

Cardiac tamponade is life-threatening, slow or rapid compression of the heart due to the pericardial accumulation of fluid, pus, blood, clots or gas, as a result of effusion, trauma or rupture of the heart. Penetrating injuries of the chest are most commonly the result of stab wounds and are often associated with a range of potentially life-threatening injuries. It must be treated by pericardial drainage as soon as possible. Sometimes the injury resulting in life-threatening conditions may be so small that it could be missed in the first instance. We present a case report in which the deceased was stabbed by Bodkin at road side. As the wound was so minute, it was not appreciated and time was lost in getting treatment, resulting in loss of a precious life.