Roles of venovenous anastomosis and umbilical cord insertion abnormalities in birthweight discordance in monochorionic-diamniotic twin pregnancies without twin-twin transfusion syndrome.

AIM: We evaluated risk factors for birthweight discordance in monochorionic diamniotic (MCDA) twin pregnancies without twin-twin transfusion syndrome (TTTS). METHODS: We investigated all MCDA twin placentas injected with colored dye at our institution between 2007 and 2015. We excluded pairs of twins with TTTS, fetal demise, or severe fetal malformation. All pairs of twins were assigned to the discordant group (birthweight discordance ≥ 25%) or the concordant group (birthweight discordance < 25%). In each pair of twins, we described vascular anastomoses as either arterioarterial, venovenous (VV), or arterial-venous, and abnormal umbilical cord insertion as either marginal or velamentous. We also recorded placental sharing discordance. RESULTS: A total of 150 placentas were analyzed. The incidence of VV anastomosis in the discordant group (40%) was significantly higher than that in the concordant group (12%, P = 0.005). Unilateral abnormal umbilical cord insertion was significantly more common in the discordant group (85%) than in the concordant group (38%, P < 0.001). Placental sharing discordance was seen more frequently in the discordant group than in the concordant group. Multiple logistic analysis revealed that VV anastomosis (odds ratio: 4.7; 95% confidence interval: 1.2-18.6, P < 0.01) and unilateral abnormal umbilical cord insertion of the smaller twin (odds ratio: 5.7; 95% confidence interval: 1.4-22.9, P < 0.01) were independent risk factors for birthweight discordance. CONCLUSION: VV anastomoses and unilateral abnormal umbilical cord insertion of the smaller twin are independent risk factors for birthweight discordance in MCDA twin pregnancies without TTTS.

Histopathology of Giant Coronary Artery Aneurysm Associated with Coronary Artery Fistula.

Giant coronary artery aneurysms related to coronary fistula are rare, and the precise mechanisms by which they occur are unknown. We present a case of giant coronary artery aneurysm of the left coronary artery to the pulmonary artery fistula with a lack of internal and (or) external elastic lamina and medial degeneration.

A Fatal Case of Coin Battery Ingestion in an 18-Month-Old Child: Case Report and Literature Review.

The ingestion of extraneous substances is quite common in clinical practice; it usually befalls in the pediatric age, mostly between 6 months and 6 years. In most cases, complications do not emerge, and the prognosis is considered favorable. However, when a case of battery ingestion occurs, serious adverse events may develop. The ingestion of these components is a potential life-threatening event for children.In this article, we report the case of an 18-month-old child who died from hemorrhagic shock due to an aortoesophageal fistula caused by a 20 mm lithium button battery lodged in the esophagus.The child presented vomiting blood, and laboratory results revealed a severe anemization, which later led to death.The autopsy showed a coin battery located in the middle third of the esophagus as well as a transmural erosion of the esophageal wall with fistulization into the aortic wall. The histological examination revealed a severe necrosis of the esophageal and aortic walls in line with the junction between the aortic arch and the descending part.

Volume overload induces autophagic degradation of procollagen in cardiac fibroblasts.

In a pure volume overloaded (VO) heart, interstitial collagen loss is degraded by matrix metalloproteinases (MMPs) that leads to left ventricular (LV) dilatation and heart failure. Cardiac fibroblasts are the primary source of extracellular matrix proteins that connect cardiomyocytes. The goal of this study was to determine how VO affects intracellular procollagen in cardiac fibroblasts. Using the aortocaval fistula (ACF) model in Sprague-Dawley rats, we demonstrate that cardiac fibroblasts isolated from 4 and 12 wk ACF animals have decreased intracellular procollagen I compared to the fibroblasts from age-matched shams. The reduction of procollagen I is associated with increased autophagy as demonstrated by increased autophagic vacuoles and LC3-II expression. To test the relationship between autophagy and procollagen degradation, we treated adult cardiac fibroblasts with either an autophagy inducer, rapamycin, or an inhibitor, wortmannin, and found that procollagen I protein levels were decreased in fibroblasts treated with rapamycin and elevated in wortmannin-treated cells. In addition, we demonstrated that VO induces oxidative stresses in cardiac fibroblasts from 4 and 12 wk ACF rats. Treatment of cultured cardiac fibroblasts with an oxidative stress-inducing agent (DMNQ) induces autophagy and intracellular procollagen I and fibronectin degradation, which is reversed by wortmannin but not by the global MMP inhibitor (PD166793). Mechanical stretch of cardiac fibroblasts also induces oxidative stress and autophagic degradation of procollagen I and fibronectin. Our results suggest that in addition to the well-known effects of MMPs on extracellular collagen degradation in VO, there is a concurrent degradation of intracellular procollagen and fibronectin mediated by oxidative stress-induced autophagy in cardiac fibroblasts.

Circumflex coronary artery to left atrium fistula caused by mitral isthmus ablation.

Mitral isthmus ablation is an important component of catheter ablation for persistent atrial fibrillation and mitral isthmus dependent flutters. We describe a case where mitral isthmus ablation caused a fistula between the left circumflex artery and the left atrium and symptomatic ischaemia. The fistula was successfully closed with a covered stent.

Management options for aorto-oesophageal fistula: case histories and review of the literature.

OBJECTIVE: An aorto-oesophageal fistula is a rare clinical entity, leading to life-threatening gastrointestinal bleeding. Thoracic aortic aneurysms are the most common cause of aorto-oesophageal fistulae; further causes involve foreign body ingestion, trauma (in most cases iatrogenic), carcinoma or, very rarely, aortitis tuberculotica. METHODS: Due to its rarity, there are no large multicentre studies present to evaluate the efficacy of different therapeutic management options. Since it is associated with significant morbidity and mortality, we give a short summary of various treatment approaches performed in our clinical practice in the past three years. The most straightforward therapeutic option may be an endovascular aortic repair and subtotal oesophageal resection followed by gastro-oesophageal reconstruction, but other alternative treatment possibilities are also present, although with probable higher morbidity. CONCLUSIONS: Eliminating the source of bleeding as an emergency, resecting the oesophagus urgently to prevent sepsis and reconstructing the gastrointestinal continuity as an elective case after having the inflammatory processes settled seems to justify the endovascular aortic repair and subtotal oesophageal resection, followed by a gastro-oesophageal reconstruction, as an effective surgical approach.

Death due to traumatic tracheo-brachiocephalic artery fistula: an autopsy case.

Tracheo-brachiocephalic artery fistulas were rarely reported lesions often described in cases with tracheostomy procedures. Reported case was 26 year-old male drainage worker, trapped under the stony soil while excavating drainage canal. Rescue operation was performed, but he was reached dead. Provincial prosecutor mandated autopsy after crime scene investigation. Autopsy examination revealed traumatically formed tracheo-brachiocephalic fistula. We aimed to report an intersting case of traumatic tracheo-brachiocephalic artery fistula identified in forensic autopsy.

Multimodality imaging of the mitral paravalvular abscess cavity with left ventriculo-atrial fistula.

Paravalvular complications may occur in patients with infective endocarditis. Paravalvular abscess formation rarely occurs and if so it generally involves the aortic valve. Herein we present a case of left ventriculo-atrial fistula formation through mitral paravalvular abscess cavity shown by multimodality imaging including two- and real-time three-dimensional transoesophageal echocardiography (RT 3-D TEE), cardiac magnetic resonance imaging (CMRI), multislice computed tomography (MSCT) and ventriculography in a patient with a mechanical prosthetic mitral valve. This is the first case in the literature of a mechanical prosthetic mitral valve complicated by a left ventriculo-atrial fistula formation in a healed abscess cavity that is demonstrated with RT-3D TEE, cardiac MRI and MSCT.

Aortocaval fistula in rat: a unique model of volume-overload congestive heart failure and cardiac hypertrophy.

Despite continuous progress in our understanding of the pathogenesis of congestive heart failure (CHF) and its management, mortality remains high. Therefore, development of reliable experimental models of CHF and cardiac hypertrophy is essential to better understand disease progression and allow new therapy development. The aortocaval fistula (ACF) model, first described in dogs almost a century ago, has been adopted in rodents by several groups including ours. Although considered to be a model of high-output heart failure, its long-term renal and cardiac manifestations are similar to those seen in patients with low-output CHF. These include Na+-retention, cardiac hypertrophy and increased activity of both vasoconstrictor/antinatriureticneurohormonal systems and compensatory vasodilating/natriuretic systems. Previous data from our group and others suggest that progression of cardiorenal pathophysiology in this model is largely determined by balance between opposing hormonal forces, as reflected in states of CHF decompensation that are characterized by overactivation of vasoconstrictive/Na+-retaining systems. Thus, ACF serves as a simple, cheap, and reproducible platform to investigate the pathogenesis of CHF and to examine efficacy of new therapeutic approaches. Hereby, we will focus on the neurohormonal, renal, and cardiac manifestations of the ACF model in rats, with special emphasis on our own experience.

Left ventricular noncompaction and coronary artery fistula in an infant with deletion 22q11.2.

This report describes an infant presenting with deletion 22q11.2 in combination with left ventricular noncompaction and a coronary artery fistula. These two cardiac findings have rarely been reported in association with each other and have never been reported together in combination with deletion 22q11.2. The reported case demonstrates the expanding cardiac phenotype of individuals with deletion 22q11.2, suggesting that it may be appropriate to offer studies for the detection of deletion 22q11.2 to individuals with a wide range of structural cardiac defects.

An unusual cause of death in poisoning: a case report.

Arterioesophageal fistula is a rare cause of upper gastrointestinal tract bleeding. Arterioesophageal fistula and haematemesis are rare in poisoning, especially in noncorrosive poisoning. An arterioesophageal fistula can occur in patients with retroesophageal subclavian artery. This is usually associated with prolonged presence of nasogastric tube.

Fatal hemorrhage from a periumbilical wound: Stabbing or hemorrhage from a caput medusae?

Varices are the main clinical manifestation of portal hypertension, and their bleeding is the predominant cause of mortality from this condition. Periumbilical varices are known as "caput medusae." Reports of their bleeding are rare, with only three fatal cases described in the literature. The antemortem diagnosis is relatively simple, while the postmortem diagnosis is more complex. This paper is the first report of fatal hemorrhage from a caput medusae for which the diagnosis was made postmortem, thanks to a complete diagnostic process including scene and circumstances, medical history, and autopsy with detailed histology. The circumstantial analysis showed the presence of a large amount of blood at the scene, blood which originated from a small abdominal wound; an analysis of the subject's clinical data reported that he was affected by portal hypertension. The autopsy revealed some dilated and convoluted veins in the subcutaneous tissue of the umbilical region; a fistula between these veins and the abdominal wound was detected. The histological study confirmed the presence of periumbilical varices, one of them ruptured and connected with the overlying skin. The cause of death was attributed to a massive hemorrhage generated by a periumbilical varix in a patient affected by portal hypertension.

Multiple coronary fistulas originating from all major coronary arteries.

Coronary fistulas to one of the cardiac chambers are infrequent anomalies and usually are found unexpectedly. Fistulas communicating between coronary artery and left heart chambers are extremely rare, especially those emptying into the left ventricle. We report a case in which all three major coronary arteries emptied into the left ventricle through multiple microfistulas.

Aorto-left atrial fistula post-percutaneous device ASD closure.

Use of percutaneous devices for closure of atrial septal defects (ASD) continues to increase owing to relative safety and ease of implementation compared with traditional surgical repair. Complications such as perforation and displacement requiring surgical intervention have been reported. We describe a case of perforation with intracardiac fistula formation, with an underlying mechanism likely to be similar to the few cases previously described, occurring during medium term follow up after ASD device closure. Appropriate case selection can reduce the incidence of this complication with caution taken in ASD cases with deficient aortic and superior rims.

An unusual presentation of thoracic aortic aneurysm rupturing into the esophagus: an autopsy case report.

Ruptured aortic aneurysms often present with sudden death, and have varied signs and symptoms depending on the site of rupture and hemorrhage. We report a case of an aortic aneurysm with an aorto-esophageal fistula, which showed slow gastrointestinal bleeding for days before death. A 79-year-old male was brought to a hospital emergency unit, with a history of melena for about 3 days, and recent hematemesis. He collapsed immediately after endoscopy and died. A forensic autopsy which was performed due to possible medical malpractice demonstrated a large saccular aneurysm of the descending thoracic aorta with a fistula into the esophagus. A significant finding was a lid or valve shaped thrombus covering the aortic orifice of the fistula, which may have partly contributed to slow bleeding, and which may have been dislodged by endoscopy. This case suggests that very careful management of aorto-esophageal fistula is needed in patients with clinical signs of possible thoracic aortic aneurysm with slow hemorrhage.