Pericardiocentesis: History, Current Practice, and Future Directions.

PURPOSE OF REVIEW: To discuss the evolution in the approach to pericardial effusions and drainage from a historical perspective, the present state, and pathways for future innovative therapies. RECENT FINDINGS: Incorporation of advanced imaging tools has dramatically improved the safety profile of pericardial interventions. Outcome data allow for refined approaches to management of pericardial disease in special populations, such as pulmonary arterial hypertension. Consideration of intrapericardial interventions and pharmacotherapy represent novel and promising approaches to management of pericardial effusions moving forward. Although the impact of excess or rapidly accumulating pericardial fluid on hemodynamics has been recognized for centuries, the therapeutic approaches have only recently become more refined with the routine incorporation of such tools as echocardiography and fluoroscopy. The most utilized approaches for pericardiocentesis include the apical, subxiphoid, and parasternal, and the most favorable approach is that in which the pericardial fluid is closest to the body surface, where intervening vital structures are least likely to be damaged. With the notable exception of patients with pre-existing pulmonary hypertension, complete decompression of pericardial fluid with careful drain management reduces likelihood of pericardial effusion recurrence. In addition, percutaneous balloon pericardiotomies have been demonstrated to reduce recurrence in nonmalignant effusions.

Physiologic lead placement with electroanatomic mapping: A case series.

INTRODUCTION: His bundle pacing (HBP) and left bundle branch area pacing (LBBAP) have emerged as attractive alternatives to traditional biventricular pacing to achieve cardiac resynchronization therapy. Early reported results have been inconsistent, particularly amongst patients in whom initial placement with traditional approaches has been unsuccessful or those with complex anatomy or congenital abnormalities. In this report, we describe the use of three-dimensional electroanatomic mapping (EAM) in five selected cases. METHODS: Five patients from multiple clinical sites underwent EAM-guided HBP or LBBAP by highly trained electrophysiologists with significant experience with conduction system pacing. Each patient in this series underwent EAM-guided conduction system pacing due to complex anatomy and/or prior failed lead implantation. RESULTS: EAM-guided lead implantation was successful in all five cases. Capture thresholds were relatively low and patients continued to have evidence of successful lead implantation with minimum 1-month follow-up. The fluoroscopy time varied, likely owing to the variable complexity of the cases. CONCLUSIONS: The use of EAM, in combination with traditional intracardiac electrograms with or without fluoroscopy, allows more targeted and precise placement of leads for HBP and LBBAP pacing. Further investigation is needed to determine this strategy's long-term performance and to optimize patient selection.

Polytetrafluoroethylene Is a Safe and Effective Interposition Conduit for Caval Reconstruction After Resection of Primary Leiomyosarcoma of the Inferior Vena Cava.

BACKGROUND: Primary leiomyosarcoma of the inferior vena cava (IVC) is a rare soft tissue sarcoma. Techniques for caval reconstruction after tumor resection vary widely. Our single-center experience serves as one of the largest reviews of caval reconstruction using polytetrafluoroethylene (PTFE) interposition grafts published in the past 10 years. METHODS: We conducted a single-center retrospective review of all patients who had undergone surgical resection of IVC leiomyosarcomas since January 1, 2007. Information regarding the procedure and patient-specific data was obtained from the institution's electronic medical record. RESULTS: We identified 4 patients (3 women and 1 man) who had undergone surgical resection for IVC leiomyosarcoma with PTFE graft reconstruction. Adjunct procedures (i.e., arteriovenous fistulas) were not used to maintain graft patency. There was no perioperative mortality within our patient population. One patient returned within 30 days with an acute kidney injury associated with a partially occlusive thrombus in the proximal part of the PTFE conduit. Another patient was found to have infolding of the PTFE graft due to inappropriate graft oversizing at the time of the index operation. Two patients developed distant metastases within a year of surgery, despite having tumor-free margins at the time of the initial operation. All the PTFE interposition grafts remained patent throughout the follow-up without the need for an additional intervention. CONCLUSIONS: PTFE interposition graft may be a safe and effective conduit for caval reconstruction after resection of a primary leiomyosarcoma of the IVC, but further research is necessary to establish appropriate management guidelines.

Surgical resection and graft replacement for primary inferior vena cava leiomyosarcoma: A multicenter experience.

OBJECTIVE: Primary leiomyosarcoma of the inferior vena cava (IVC) is best managed with surgical resection when technically feasible. However, consensus is lacking regarding the best choice of conduit and reconstruction technique. The aim of the present multicenter study was to perform a comprehensive assessment through the VLFDC (Vascular Low Frequency Disease Consortium) to determine the most effective method for caval reconstruction after resection of primary leiomyosarcoma of the IVC. METHODS: A multicenter, standardized database review of patients who had undergone surgical resection and reconstruction of the IVC for primary leiomyosarcoma from 2007 to 2017 was performed. The demographics, periprocedural details, and postoperative outcomes were analyzed. RESULTS: A total of 92 patients (60 women and 32 men), with a mean age of 60.1 years (range, 30-88 years) were treated. Metastatic disease was present in 22%. The tumor location was below the renal veins in 49 (53%), between the renal and hepatic veins in 52 (57%), and above the hepatic veins in 13 patients (14%). The conduits used for reconstruction included ringed polytetrafluoroethylene (PTFE; n = 80), nonringed PTFE (n = 1), Dacron (n = 1), autogenous vein (n = 1), bovine pericardium (n = 4), and cryopreserved tissue (n = 5). Complete R0 resection was accomplished in 73 patients (79%). In-hospital mortality was 2%, with a median length of stay of 8 days. The primary patency of PTFE reconstructed IVCs was 97% and 92% at 1 and 5 years, respectively, compared with 73% at 1 and 5 years for the non-PTFE reconstructed IVCs. The overall 1-, 3-, and 5-year survival for the entire cohort were 94%, 86%, and 65%, respectively CONCLUSIONS: The findings from our multi-institutional study have demonstrated that complete en bloc resection of IVC leiomyosarcoma with vascular surgical reconstruction in selected patients results in low perioperative mortality and is associated with excellent long-term patency. A ringed PTFE graft was the most commonly used conduit for caval reconstruction, yielding excellent long-term primary patency.

Retrospective review of 290 small carotid cave aneurysms over 17 years.

OBJECTIVE: The carotid cave is a unique intradural region located along the medial aspect of the internal carotid artery. Small carotid cave aneurysms confined within this space are bound by the carotid sulcus of the sphenoid bone and are thought to have a low risk of rupture or growth. However, there is a lack of data on the natural history of this subset of aneurysms. METHODS: The authors present a retrospective case series of 290 small (≤ 4 mm) carotid cave aneurysms evaluated and managed at their institution between January 2000 and June 2017. RESULTS: No patient presented with a subarachnoid hemorrhage attributable to a carotid cave aneurysm, and there were no instances of aneurysm rupture or growth during 911.0 aneurysm-years of clinical follow-up or 726.3 aneurysm-years of imaging follow-up, respectively. CONCLUSIONS: This series demonstrates the benign nature of small carotid cave aneurysms.