Ultrasound monitoring to detect embolic phenomena in the inferior vena cava during hip arthroplasty.

INTRODUCTION AND OBJECTIVES: Embolic phenomena frequently occur during hip joint replacement surgery, and may lead to haemodynamic instability in frail patients. Transoesophageal ultrasound monitoring is rarely available in non-cardiac operating theatres, and cannot be performed in awake patients under spinal anaesthesia. The main objectives of this prospective exploratory study were to determine the feasibility of using an alternative ultrasound approach to monitor the inferior vena cava during hip replacement surgery, and to determine the intra and interobserver reliability of the ultrasound findings. METHOD: We conducted a prospective exploratory study in 20 patients undergoing cemented hip arthroplasty in the supine position under spinal anaesthesia and sedation. The inferior vena cava was assessed through a subcostal window at 10 intraoperative time points, and the findings were rated on a qualitative embolism severity scale. The ultrasound images were evaluated by 2 independent observers. RESULTS: An adequate subcostal window was obtained in 90% of cases. Intra- and inter-observer reliability was high (kappa index >0.80, p < 0.001). Nearly all (95%) patients presented some degree of embolism, which was severe in 50% of cases. CONCLUSIONS: Our study suggests that ultrasound assessment of embolic phenomena in the inferior vena cava through a subcostal window is feasible in 90% of cases. The qualitative embolic severity rating scale is highly reproducible and has high intra- and inter-observer reliability.

Treatment of gastric varices with cyanoacrylate complicated by systemic embolization.

Acute gastric variceal bleeding is a life-threatening condition that could be effectively treated with endoscopic cyanoacrylate injection diluted with lipiodol. The mixture acts as a tissue adhesive that polymerizes when in contact with blood in a gastric varix. This work reports a patient that presented to the emergency department with upper gastrointestinal bleeding due to acute variceal bleeding, who developed systemic embolization following cyanoacrylate injection therapy. This complication culminated in cerebral, splenic and renal infarctions with a fatal outcome. Systemic embolization is a very rare, but the most severe complication associated with endoscopic cyanoacrylate injection and should be considered in patients undergoing this treatment.

Median Lobe Urethral Embolus After Focal Ablation of Gleason 7 Prostate Cancer.

This is the case of a man, aged 56 years, who presented with urinary intermittency, frequency, urgency, and dysuria 5 months after undergoing focal laser ablation (FLA) of Gleason 3+4=7 prostate cancer (PC). Cystoscopy revealed a foreign body obstruction of the bladder and the patient experienced immediate relief after its removal. Final pathology confirmed the diagnosis of the foreign body as a piece of necrotic prostatic tissue originating from the median lobe. To our knowledge, this is the first case of intermittent urethral obstruction by a sloughed median prostatic lobe following FLA. FLA is an emerging therapy for low- or intermediate-grade PCs, and this case highlights the need for continued evaluation of long-term outcomes of this procedure.

Fenómenos embólicos y ecocardiografía transtorácica (ETT) durante cirugía de artroplastía de cadera (AC) / Embolic phenomena in hip Arthroplasty with intraoperative transthoracic echocardiography (TTE)

Embolic event's exist during hip arthroplasty surgery and specially those who had been caused by hip fracture. Complications depends mainly on the preoperative clinical conditions, and may even be subclinical if the patient was previously healthy. Thus, thanks to the technology progress, especially transesophageal echocardiography (TEE), it has been possible to identify these embolic phenomena at an early stage, allowing to be anticipated and treated an eventual cardiorespiratory compromise. A report was made of 2 patients with hip fracture, who underwent hip arthroplasty surgery (HA), in which through transthoracic echocardiography (TTE), it was possible to visualize embolic events, mainly during the acetabular reaming and the press-fit impact of the Cup. One patient presented hemodynamic impact that was early treated. This emphasizes how critical that period of the surgery is, and that when the anesthesiologist must be especially vigilant. There could be different causes: the energy made by the surgeons to make the acetabular reaming or to insert the cup; or even the destruction of the surrounding tissue during the fracture moment. So, in that way blood thrombus, air, fat or bone can get into the blood vessels and produce eventual complications. Therefore, special attention is required to the hemodynamic changes that may occur in these stages of surgery. Particularly, in these cases, in whom the patient's receive regional anesthesia and were positioned on lateral decubitus, it has to monitored by TTE and not by TEE, which gave more limitations at the moment to get the different echocardiograph Windows, thus it was chosen to use the subxiphoid window to see the inferior vena cava. In both cases, it was visualized embolic's events. But as it's said before, only one presented hemodynamic compromised. Also stands out, the relevance that there is more access to TTE in most of the operating centers of the country, unlike the TEE, which the transducer use for it, is more difficult for the anesthesiologist to get access to it and also requires more training.

Durante las cirugías de prótesis de cadera y especialmente aquellas por fractura de cadera pueden presentar eventos embólicos. Las complicaciones dependen principalmente de la condición clínica preoperatoria, pudiendo incluso ser subclínico si el paciente es sano. Así, gracias al progreso de la tecnología, particularmente la ecocardiografía transesofágica (ETE) y transtoraxica (ETT), se ha logrado identificar precozmente dichos fenómenos embólicos, permitiendo anticipar y tratar oportunamente una eventual descompensación cardiorrespiratoria. Se realizó un reporte de 2 pacientes con fractura de cadera, que se sometieron a una cirugía de artroplastía de cadera (AC), en los cuales mediante la vigilancia de ETT, se logró visualizar estos eventos, principalmente durante la fenestración e impactación del cotilo en el acetábulo, presentando uno de estos pacientes un impacto hemodinámico que se trató precozmente. Las causas de las embolías pueden ser variadas, como la presión ejercida por el cirujano para fenestrar e introducir la prótesis o la destrucción del tejido circundante a la lesión durante el momento de la fractura, entre otros. Así, se pueden producir embolias de trombos, grasa, hueso o incluso aire que pueda entrar al torrente sanguíneo y producir eventualmente complicaciones. Con estos hallazgos, ecográficos y en algunas oportunidades clínicos, se podría demostrar lo crítico que es aquel período de la cirugía, en donde se requiere especial atención a los cambios hemodinámicos que se puedan producir, y en el que el anestesiólogo debe estar especialmente vigilante. Particularmente, en estos casos, en que las pacientes recibieron anestesia regional y se intervino en posición de decúbito lateral, se tuvo que realizar monitoreo mediante ETT y no ETE, lo cual entrego más limitantes a la hora de conseguir buena calidad de ventanas cardiacas y por lo tanto, después de visualizar las distintas ventanas se optó por utilizar la ventana subxifoidea para visualizar la vena Cava inferior y así observar los distintos eventos embólicos circulantes. En ambas pacientes se pudieron apreciar eventos embólicos, pero en sólo una paciente tuvo compromiso cardiorrespiratorio con hipotensión, aumento de la frecuencia cardiaca y desaturación. Junto con la demostración de la posibilidad de visualización de embolías con ETT, se destaca la relevancia de que existe mayor acceso a este tipo de ecografía en gran parte de los pabellones de nuestro país, a diferencia de la ETE, en la que la sonda utilizada es de más difícil acceso por parte de los anestesistas y requiere un mayor entrenamiento.

Vulvar Paget disease secondary to high-grade urothelial carcinoma with underlying massive vascular embolization and cervical involvement: case report of unusual presentation.

BACKGROUND: Vulvar extramammary Paget disease is a rare chronic condition, that presents with non-specific symptoms such as pruritus and eczematous lesions. Because most of these lesions are noninvasive, the distinction between primary and secondary Paget disease is crucial to management. CASE PRESENTATION: We report an unusual case of vulvar Paget disease associated with massive dermal vascular embolization, cervicovaginal involvement and metastasis to inguinal and retroperitoneal lymph nodes. The intraepithelial vulvar lesion had a classical appearance and was accompanied by extensive component of dermal lymphovascular tumor emboli, similar to those observed in inflammatory breast carcinoma. Immunohistochemical analysis revealed that the lesion was secondary to high-grade urothelial cell carcinoma. The patient had a history of superficial low-grade papillary urothelial carcinoma of the bladder, which had appeared 2 years before the onset of vulvar symptoms. CONCLUSIONS: Eczematoid vulvar lesions merit careful clinical examination and biopsy, including vulva mapping and immunohistochemistry. The information obtained may help to define and classify a particular presentation of Paget disease. Noninvasive primary lesions do not require the same aggressive approaches required for the treatment of invasive and secondary disease.

Endocarditis marántica con embolia sistémica como manifestación de adenocarcinoma papilar de pulmón / Nonbacterial thrombotic endocarditis with systemic embolism as a manifestation of papillary lung adenocarcinoma

Resumen: Se presenta el caso de un hombre de 61 años, portador de un cáncer pulmonar en quien lesiones de aspecto embólico llevan al diagnóstico de Endocarditis marántica (no infecciosa). Se describen las características clínicas del paciente, los métodos diagnósticos incluyendo imágenes ecocardiográficas y la confirmación necrópsica.

Abstracts: A 61-year-old male with skin lesions suggesting embolic phenomena, was thoroughly investigated and a final diagnosis of marantic (non-infectious) endocarditis was established. Clinical characteristics and diagnostic investigation through laboratory test and images sustained the diagnosis. The use of transesophageal echocardiography is emphasized. This was finally confirmed by findings at necropsy.

Embolismo arterial agudo como forma de presentación clínica inicial de una hidatidosis diseminada: reporte de un caso / Acute arterial embolism as the clinical presentation of a disseminated hydatidosis: case report

La hidatidosis es una zoonosis producida por el parásito Echinococcus granulosus. En el ciclo zoonótico del parásito, el hombre es un huésped intermediario y sufre la enfermedad tras la ingesta de alimentos y agua contaminados por la materia fecal de animales infectados. En Argentina, la enfermedad constituye un problema importante de salud pública. Suele manifestarse con compromiso hepático y pulmonar. La afectación de otros órganos, que incluyen el corazón, es infrecuente.

Hydatidosis is a parasitic infection caused by the Echinococcus granulosus larvae, transmitted by the ingestion of infected food, characterized by the formation of cysts in vital organs. In Argentina, the disease is spread throughout the territory, constituting an important public health issue. The disease usually affects the liver and lungs. The affection of other organs is rare, and even more uncommon the affection of the heart. We present the case of a disseminated hydatidosis in a pediatric patient, whose initial clinical manifestation was an acute arterial embolism of the right limb caused by the rupture of a hydatidic cardiac cyst.

Acute arterial embolism as the clinical presentation of a disseminated hydatidosis: case report. / Embolismo arterial agudo como forma de presentación clínica inicial de una hidatidosis diseminada: reporte de un caso.

Hydatidosis is a parasitic infection caused by the Echinococcus granulosus larvae, transmitted by the ingestion of infected food, characterized by the formation of cysts in vital organs. In Argentina, the disease is spread throughout the territory, constituting an important public health issue. The disease usually affects the liver and lungs. The affection of other organs is rare, and even more uncommon the affection of the heart. We present the case of a disseminated hydatidosis in a pediatric patient, whose initial clinical manifestation was an acute arterial embolism of the right limb caused by the rupture of a hydatidic cardiac cyst.

La hidatidosis es una zoonosis producida por el parásito Echinococcus granulosus. En el ciclo zoonótico del parásito, el hombre es un huésped intermediario y sufre la enfermedad tras la ingesta de alimentos y agua contaminados por la materia fecal de animales infectados. En Argentina, la enfermedad constituye un problema importante de salud pública. Suele manifestarse con compromiso hepático y pulmonar. La afectación de otros órganos, que incluyen el corazón, es infrecuente. Se presenta un caso de embolia arterial aguda como manifestación clínica inicial de una hidatidosis diseminada en un paciente pediátrico, a partir de la ruptura de un quiste hidatídico cardíaco.

Embolization by Bullet Dislodged from the Heart.

Embolization by a dislodged projectile is a rare complication that may occur in cases of gunshot cardiac injuries. We report a case of a firearm projectile cardiac injury that evolved, with dislocation of the projectile during cardiac surgery, into embolization of the right external carotid artery.

Embolization by Bullet Dislodged from the Heart

Abstract Embolization by a dislodged projectile is a rare complication that may occur in cases of gunshot cardiac injuries. We report a case of a firearm projectile cardiac injury that evolved, with dislocation of the projectile during cardiac surgery, into embolization of the right external carotid artery.

Orejuela izquierda en la enfermedad reumática mitral: principal fuente embolígena en la fibrilación auricular / Left atrial appendage in rheumatic mitral valve disease: The main source of embolism in atrial fibrillation

Resumen: Objetivo: Demostrar que la resección quirúrgica de la orejuela izquierda en los pacientes con enfermedad reumática mitral y fibrilación auricular persistente de larga evolución disminuye la posibilidad de embolia cerebral. Asimismo, esto también elimina la necesidad de anticoagulación oral a largo plazo. Método: Se estudiaron en forma observacional y prospectiva 27 pacientes adultos con enfermedad reumática mitral y fibrilación auricular persistente de larga evolución, sometidos a cirugía valvular mitral y resección quirúrgica de la orejuela izquierda. La anticoagulación oral con warfarina fue suspendida después del tercer mes postoperatorio, recibiendo solamente aspirina a largo plazo. El punto final fue la ausencia de embolia cerebral. Secundariamente, se evaluó la formación de trombos en la aurícula izquierda por ecocardiografía transtorácica postoperatoria. Resultados: Después del tercer mes, ningún paciente presentó embolia cerebral. Un paciente exhibió isquemia cerebral transitoria dentro de los primeros 3 meses en tratamiento con warfarina. Secundariamente, en la cirugía se encontró trombo en aurícula izquierda en 11 casos (40.7%). De estos 11, 6 (54.5%) habían tenido embolia cerebral previamente, sin encontrar significación estadística (p = 0.703). Conclusiones: Este estudio muestra que pudiera haber indicios de que la orejuela izquierda pueda ser la principal fuente embolígena en la enfermedad reumática mitral, y que su resección pueda eliminar el riesgo de embolia cerebral en pacientes con enfermedad reumática mitral y fibrilación auricular persistente de larga evolución.

Abstract: Objective: To demonstrate that surgical removal of the left atrial appendage in patients with rheumatic mitral valve disease and long standing persistent atrial fibrillation decreases the possibility of stroke. This also removes the need for long-term oral anticoagulation after surgery. Method: A descriptive, prospective, observational study was conducted on 27 adult patients with rheumatic mitral valve disease and long standing persistent atrial fibrillation, who had undergone mitral valve surgery and surgical removal of the left atrial appendage. Oral anti-coagulation was stopped in the third month after surgery. The end-point was the absence of embolic stroke. An assessment was also made of postoperative embolism formation in the left atrium using transthoracic echocardiography. Results: None of the patients showed embolic stroke after the third post-operative month. Only one patient exhibited transient ischaemic attack on warfarin therapy within the three postoperative months. Left atrial thrombi were also found in 11 (40.7%) cases during surgery. Of these, 6 (54.5%) had had embolic stroke, with no statistical significance (P = .703). Conclusions: This study suggests there might be signs that the left atrial appendage may be the main source of emboli in rheumatic mitral valve disease, and its resection could eliminate the risk of stroke in patients with rheumatic mitral valve disease and long-standing persistent atrial fibrillation.

Embolic Stroke of Undetermined Source in Latin America: A Review.

BACKGROUND: Stroke is a major health concern throughout Latin America. As elsewhere, no precise cause can be determined for a substantial portion of strokes. In 6 studies since 2010 in the region, 16% to 43% of ischemic strokes were identified as cryptogenic. The term embolic stroke of undetermined source (ESUS) has been proposed as more clinically useful and positively defined than the vague term cryptogenic. The epidemiology of ESUS in Latin America is largely unknown. REVIEW SUMMARY: This article aims to provide a description of the epidemiology of ESUS in Latin America and practical information regarding available diagnostic procedures and current guidelines. Atrial fibrillation (AF) is a significant risk factor for stroke, observed in approximately 10% of Mexican and Brazilian stroke patients. Previously unknown AF has been detected through extended monitoring in numerous studies of stroke patients, including 8% of patients in an Argentinian study, and is a possible contributing cause of ESUS. External or implantable outpatient cardiac monitoring has shown increased diagnostic yield for the detection of intermittent AF versus standard cardiac monitoring, but is infrequently used in Latin America. CONCLUSIONS: Undiagnosed AF is likely to contribute significantly to cryptogenic stroke and ESUS. Research is needed to continue evaluation of the optimum means of identifying clinically relevant occult AF. In view of the thromboembolic mechanism of ESUS, anticoagulant therapy may prove useful in prevention of recurrence. Ongoing trials are evaluating use of dabigatran, rivaroxaban, or apixaban versus aspirin for reducing the risk of recurrent stroke in patients with previous ESUS.

Assessment of aortic wall thrombus predicts outcomes of endovascular repair of complex aortic aneurysms using fenestrated and branched endografts.

OBJECTIVE: The goal of this study was to investigate the correlation between atherothrombotic aortic wall thrombus (AWT) and clinical outcomes in patients treated by fenestrated-branched endovascular aortic repair (F-BEVAR) and present a new classification system for assessment of AWT burden. METHODS: The clinical data of 301 patients treated for pararenal and thoracoabdominal aortic aneurysms (TAAAs) by F-BEVAR was reviewed. The study excluded 89 patients with extent I to III TAAA because of extensive laminated thrombus within the aneurysm sac. Computed tomography angiograms were analyzed in all patients to determine the location, extent, and severity of atherothrombotic AWT. The aorta was divided into three segments: ascending and arch (A), thoracic (B) and renal-mesenteric (C). Volumetric measurements (cm3) of AWT were performed using TeraRecon software (TeraRecon Inc, Foster City, Calif). These volumes were used to create an AWT index by dividing the AWT volume from the total aortic volume. A classification system was proposed using objective assessment of the number of affected segments, thrombus type, thickness, area, and circumference. Clinical outcomes included 30-day mortality, neurologic and gastrointestinal complications, renal events (Risk, Injury, Failure, Loss of kidney function, End-stage renal disease [RIFLE]), and solid organ infarction. RESULTS: The study included 212 patients, 169 men (80%) and 43 women (20%), with a mean age of 76 ± 7 years. A total of 700 renal-mesenteric arteries were incorporated (3.1 ± 1 vessels/patient). AWT was classified as mild in 98 patients (46%) and was considered moderate or severe in 114 (54%). There was one death (0.5%) at 30 days. Solid organ infarction was present in 50 patients (24%), and acute kidney injury occurred in 45 patients (21%) by RIFLE criteria. An association with higher AWT indices was found for time to resume enteral diet (P = .0004) and decline in renal function (P = .0003). Patients with acute kidney injury 2 by RIFLE criterion had significantly higher (P = .002) AWT index scores in segment B. Spinal cord injury occurred in three patients (1.4%) and stroke in four (1.9%), but were not associated with the AWT index. Severity of AWT using the new proposed classification system correlated with the AWT index in all three segments (P < .001). Any of the end points occurred in 35% of the patients with mild and in 53% of those with moderate or severe AWT (P = .016). CONCLUSIONS: AWT predicts solid organ infarction, renal function deterioration, and longer time to resume enteral diet after F-BEVAR of pararenal and type IV TAAAs. Evaluation of AWT should be part of preoperative planning and decision making for selection of the ideal method of treatment in these patients.

Asymptomatic and symptomatic embolic events in infective endocarditis: associated factors and clinical impact

ABSTRACT Background: Embolic complications of infective endocarditis are common. The impact of asymptomatic embolism is uncertain. Objectives: To determine the frequency of emboli due to IE and to identify events associated with embolism. Methods: Retrospective analysis of an endocarditis database, prospectively implemented, with a post hoc study driven by analysis of data on embolic events. Data was obtained from the International Collaboration Endocarditis case report forms and additional information on embolic events and imaging reports were obtained from the medical records. Variables associated with embolism were analyzed by the statistical software R version 3.1.0. Results: In the study period, 2006-2011, 136 episodes of definite infective endocarditis were included. The most common complication was heart failure (55.1%), followed by embolism (50%). Among the 100 medical records analyzed for emboli in left-sided infective endocarditis, 36 (36%) were found to have had asymptomatic events, 11 (11%) to the central nervous system and 28 (28%) to the spleen. Cardiac surgery was performed in 98/136 (72%). In the multivariate analysis, splenomegaly was the only associated factor for embolism to any site (p < 0.01, OR 4.7, 95% CI 2.04-11). Factors associated with embolism to the spleen were positive blood cultures (p = 0.05, OR 8.9, 95% CI 1.45-177) and splenomegaly (p < 0.01, OR 9.28, 95% CI 3.32-29); those associated to the central nervous system were infective endocarditis of the mitral valve (p < 0.05, OR 3.5, 95% CI 1.23-10) and male gender (p < 0.05, OR 3.2, 95% CI 1.04-10). Splenectomy and cardiac surgery did not impact on in-hospital mortality. Conclusions: Asymptomatic embolism to the central nervous system and to the spleen were frequent. Splenomegaly was consistently associated with embolic events.

Asymptomatic and symptomatic embolic events in infective endocarditis: associated factors and clinical impact.

BACKGROUND: Embolic complications of infective endocarditis are common. The impact of asymptomatic embolism is uncertain. OBJECTIVES: To determine the frequency of emboli due to IE and to identify events associated with embolism. METHODS: Retrospective analysis of an endocarditis database, prospectively implemented, with a post hoc study driven by analysis of data on embolic events. Data was obtained from the International Collaboration Endocarditis case report forms and additional information on embolic events and imaging reports were obtained from the medical records. Variables associated with embolism were analyzed by the statistical software R version 3.1.0. RESULTS: In the study period, 2006-2011, 136 episodes of definite infective endocarditis were included. The most common complication was heart failure (55.1%), followed by embolism (50%). Among the 100 medical records analyzed for emboli in left-sided infective endocarditis, 36 (36%) were found to have had asymptomatic events, 11 (11%) to the central nervous system and 28 (28%) to the spleen. Cardiac surgery was performed in 98/136 (72%). In the multivariate analysis, splenomegaly was the only associated factor for embolism to any site (p<0.01, OR 4.7, 95% CI 2.04-11). Factors associated with embolism to the spleen were positive blood cultures (p=0.05, OR 8.9, 95% CI 1.45-177) and splenomegaly (p<0.01, OR 9.28, 95% CI 3.32-29); those associated to the central nervous system were infective endocarditis of the mitral valve (p<0.05, OR 3.5, 95% CI 1.23-10) and male gender (p<0.05, OR 3.2, 95% CI 1.04-10). Splenectomy and cardiac surgery did not impact on in-hospital mortality. CONCLUSIONS: Asymptomatic embolism to the central nervous system and to the spleen were frequent. Splenomegaly was consistently associated with embolic events.

Clinicopathological Spectrum of Mitral Valve Myxoma.

Cardiac myxomas are the most common primary tumors of the heart. Although these tumors have been reported in all cardiac chambers, myxomas arising from heart valves are extremely rare. Here, the details are described of a patient with mitral valve myxoma, and a review is provided of 99 cases reported in the literature. Mitral valve myxomas most often occur in middle-aged patients, with a slight female predominance. Most of the tumors arise in an isolated fashion on the atrial side of the anterior mitral valve leaflet. Embolic events were the most frequent manifestation, followed by obstructive symptoms. Unlike atrial wall myxomas, these tumors have a lower incidence of constitutional manifestations. Tumor resection with valve preservation is the usual method of surgical treatment in isolated tumors, while most patients with multiple valve myxomas underwent valve replacement. Mitral valve myxomas should be considered in the differential diagnosis of mitral valve tumors, with an awareness of a relatively high risk of embolic events. This location should not raise suspicion for a heritable myxoma syndrome. Prompt surgical resection is warranted to reduce complications.

[Left atrial appendage in rheumatic mitral valve disease: The main source of embolism in atrial fibrillation]. / Orejuela izquierda en la enfermedad reumática mitral: principal fuente embolígena en la fibrilación auricular.

OBJECTIVE: To demonstrate that surgical removal of the left atrial appendage in patients with rheumatic mitral valve disease and long standing persistent atrial fibrillation decreases the possibility of stroke. This also removes the need for long-term oral anticoagulation after surgery. METHOD: A descriptive, prospective, observational study was conducted on 27 adult patients with rheumatic mitral valve disease and long standing persistent atrial fibrillation, who had undergone mitral valve surgery and surgical removal of the left atrial appendage. Oral anticoagulation was stopped in the third month after surgery. The end-point was the absence of embolic stroke. An assessment was also made of postoperative embolism formation in the left atrium using transthoracic echocardiography. RESULTS: None of the patients showed embolic stroke after the third post-operative month. Only one patient exhibited transient ischaemic attack on warfarin therapy within the three postoperative months. Left atrial thrombi were also found in 11 (40.7%) cases during surgery. Of these, 6 (54.5%) had had embolic stroke, with no statistical significance (P=.703). CONCLUSIONS: This study suggests there might be signs that the left atrial appendage may be the main source of emboli in rheumatic mitral valve disease, and its resection could eliminate the risk of stroke in patients with rheumatic mitral valve disease and long-standing persistent atrial fibrillation.

IATROGENIC MICROCHIP ARTERIAL EMBOLISM IN A CHILEAN FLAMINGO (PHOENICOPTERUS CHILENSIS).

Aberrant microchip migration has been reported in domestic animal species, but in most cases, this migration is atraumatic to the patient. Reports of microchip-associated trauma and sarcoma development also have been reported in a variety of mammal species. This report describes accidental arterial microchip insertion causing obstruction of the iliac artery in a Chilean flamingo (Phoenicopterus chilensis). Diagnostic imaging included digital radiography and pre- and post-contrast computed tomography to determine the location of the microchip. Surgical removal of the microchip was attempted; however, the flamingo died intraoperatively. Postmortem evaluation found trauma to the epicardium, without penetration of the ventricle. The descending aorta was found traumatized and identified as the most likely insertion point leading to the embolism.