Continuous drainage for the treatment of gastric cancer with pericardial metastasis and cardiac tamponade: A case report.

Key Clinical Message: Signet-ring cell gastric carcinomas presenting as pericardial effusion early in diagnosis are rare and associated with high mortality and a poor prognosis. There are two interesting aspects of this case: primary gastric carcinoma presenting as cardiac tamponade and the metastatic behavior of gastric signet-ring cell carcinoma. Abstract: This report describes an 83-year-old man diagnosed to have cardiac tamponade due to massive pericardial effusion. A cytological analysis of the pericardial effusion disclosed adenocarcinoma. The patient was treated with continuous pericardial drainage and the amount of pericardial effusion decreased.

Selexipag for the treatment of chronic thromboembolic pulmonary hypertension.

BACKGROUND: Treatment options for inoperable chronic thromboembolic pulmonary hypertension (CTEPH) remain limited. Selexipag, an oral selective IP prostacyclin receptor agonist approved for pulmonary arterial hypertension, is a potential treatment option for CTEPH. METHODS: In this multicentre, randomised, double-blind, placebo-controlled study, 78 Japanese patients with inoperable CTEPH or persistent/recurrent pulmonary hypertension after pulmonary endarterectomy and/or balloon pulmonary angioplasty were randomly assigned to receive placebo or selexipag. The primary end-point was the change in pulmonary vascular resistance (PVR) from baseline to week 20. Secondary end-points were changes in other haemodynamic parameters: 6-min walk distance (6MWD), Borg dyspnoea scale score, World Health Organization (WHO) functional class, EuroQol five-dimension five-level tool and N-terminal pro-brain natriuretic peptide. RESULTS: The change in PVR was -98.2±111.3 dyn·s·cm-5 and -4.6±163.6 dyn·s·cm-5 in the selexipag and placebo groups, respectively (mean difference -93.5 dyn·s·cm-5; 95% CI -156.8 to -30.3; p=0.006). The changes in cardiac index (p<0.001) and Borg dyspnoea scale score (p=0.036) were also significantly improved over placebo. 6MWD and WHO functional class were not significantly improved. The common adverse events in the selexipag group corresponded to those generally observed following administration of a prostacyclin analogue. CONCLUSION: Selexipag significantly improved PVR and other haemodynamic variables in patients with CTEPH, although exercise capacity remained unchanged. Further large-scale investigation is necessary to prove the role of selexipag in CTEPH.

Optimal lesion size index to prevent conduction gap during pulmonary vein isolation.

INTRODUCTION: A novel real-time lesion size index (LSI) that incorporates contact force (CF), time, and power has been developed for safe and effective catheter ablation. The optimal LSI was evaluated to eliminate gap formation during pulmonary vein isolation (PVI). METHODS AND RESULTS: Consecutive patients were enrolled, who underwent their first PVI using a fiber-optic CF-sensing catheter for atrial fibrillation between December 2016 and October 2017. The CF parameters, force-time integral (FTI), and LSI for 3095 ablation points in 34 patients were evaluated. The FTI and LSI in the lesions with gaps or dormant conduction (gaps/DC) were significantly lower than those in the lesion without gaps/DC (FTI: 140.5 ± 54.5 and 232.4 ± 121.4 g s, P < 0.0001; LSI: 4.0 ± 0.6 and 4.7 ± 0.9, P < 0.0001, respectively). On receiver operating characteristic curve analysis, the optimal LSI threshold was 4.05 (sensitivity, 63.4%; specificity, 76.3%). The LSI of <5.25 predicted a gap or DC with a high sensitivity (sensitivity, 97.6%; specificity, 25.7%). In the posterior wall, which was 37% thinner than the nonposterior wall, a lower LSI of <3.95 showed a relatively high sensitivity (92.3%) and specificity (65.6%). CONCLUSIONS: The LSI can be used to predict gaps/DC during the PVI procedure. An LSI of 5.2 may be a suitable target for effective lesion formation. An LSI of 4.0 may be acceptable in the posterior wall, especially in areas adjacent to the esophagus.

Occult constrictive pericardial disease emerging 40 years after chest radiation therapy: a case report.

BACKGROUND: The main etiology of constrictive pericarditis (CP) has changed from tuberculosis to therapeutic mediastinal radiation and cardiac surgery. Occult constrictive pericardial disease (OCPD) is a covert disease in which CP is manifested in a condition of volume overload. CASE PRESENTATION: A 60-year-old patient with a history of thoracic radiation therapy for non-Hodgkin's lymphoma (40 years earlier) was transferred to our hospital for treatment of repeated congestive heart failure. For a preoperative hemodynamic study, pre-hydration with intravenous normal saline (50 mL/hour) was used to manifest the pericardial disease and prevent contrast-induced nephropathy. The hemodynamic study showed a right ventricular dip-plateau pattern and discordance of right and left ventricular systolic pressures during inspiration, which was not seen in the volume-controlled state. These responses were concordant with OCPD. A pericardiectomy, aortic valve replacement, and mitral and tricuspid valve repair were performed. Postoperatively, the heart failure was controlled with standard medication. CONCLUSIONS: This case revealed a volume-induced change in hemodynamics in OCPD with severe combined valvular heart disease, which suggests the importance of considering OCPD in patients who had undergone radiation therapy 40 years before.

Impact of left atrial size on isolation area in the acute phase of pulmonary vein isolation using 28 mm cryoballoon.

BACKGROUND: The impact of left atrial (LA) size on isolation area (ISA) using a 28-mm second-generation cryoballoon (CB) in the acute phase after pulmonary vein isolation (PVI) and the differences of CB from contact force-guided radiofrequency (RF) ablation have not been fully investigated. METHODS: We examined 85 consecutive patients (CB group, 35; RF group, 50) with drug-refractory paroxysmal atrial fibrillation who underwent their first PVI procedure at two institutions. We evaluated ISA after PVI using 3D-Merge computed tomography images (GE Healthcare, Little Chalfont, UK) and high-resolution electroanatomical mapping. RESULTS: Total ISA was significantly smaller in the CB group (20.6 ± 6.0 cm2 ) than in the RF group (29.0 ± 7.1 cm2 ; P < 0.0001). In the CB group, ISA of the left pulmonary vein (LPV), right pulmonary vein (RPV), and total ISA were not correlated with the left atrial surface area (LASA). The ratios of ISA to LASA (%ISA) of LPV and total ISA negatively correlated with LASA in the CB group (LPV: r = -0.4001, P = 0.0173; total ISA: r = -0.4733, P = 0.0041). In contrast, in the RF group, ISA of LPV, RPV, and total ISA positively correlated with LASA; (LPV: r = 0.5155, P = 0.001; RPV: r = 0.6398, P < 0.0001; total ISA: r = 0.7299, P < 0.0001). CONCLUSION: ISA created using CB was significantly smaller than that using RF and did not change regardless of LASA increment. Differences in ISA between the two groups became more prominent in the large atrium.

General anesthesia improves contact force and reduces gap formation in pulmonary vein isolation: a comparison with conscious sedation.

Compared to conscious sedation (CS), the use of general anesthesia (GA) in pulmonary vein isolation (PVI) is associated with a lower recurrence rate of atrial fibrillation (AF). GA may improve catheter stability and mapping system accuracy compared to CS, but its influence on contact force (CF) parameters during ipsilateral PVI has not previously been investigated. The study population comprised 176 consecutive patients (107 in GA group and 69 in CS group) with AF who underwent their first PVI procedure. We retrospectively assessed CF parameters, force-time integral (FTI), FTI/wall thickness during anatomical ipsilateral PVI and long-term outcome after ablation. Complete PVI with single continuous circular lesions around the ipsilateral PVs was achieved in 54 patients (50.5%) in the GA group but only 24 patients (34.8%) in the CS group (P = 0.04). The distribution of gaps did not differ between the groups. All CF parameters were significantly higher in the GA group than in the CS group (average CF: 19.4 ± 8.7 vs. 16.7 ± 7.7 g, P < 0.0001; FTI: 399.0 ± 262.5 vs. 293.9 ± 193.4 gs, P < 0.0001; FTI/wall thickness: 155.5 ± 106.1 vs. 115.7 ± 85.5 gs, P < 0.0001). GA was associated with lower AF recurrence rate in patients with paroxysmal AF but not with persistent AF. Compared with CS, GA improves CF parameters, FTI and FTI/wall thickness, and reduced gap formation after ipsilateral PVI.

Optimal Force-Time Integral for Pulmonary Vein Isolation According to Anatomical Wall Thickness Under the Ablation Line.

BACKGROUND: Low contact force and force-time integral (FTI) during catheter ablation are associated with ineffective lesion formation, whereas excessively high contact force and FTI may increase the risk of complications. We sought to evaluate the optimal FTI for pulmonary vein (PV) isolation based on atrial wall thickness under the ablation line. METHODS AND RESULTS: Contact force parameters and FTI during anatomical ipsilateral PV isolation for atrial fibrillation and atrial wall thickness were assessed retrospectively in 59 consecutive patients for their first PV isolation procedure. The PV antrum was divided into 8 segments, and the wall thickness of each segment under the ablation line was determined using multidetector computed tomography. The FTI for each ablation point was divided by the wall thickness of the PV antrum segment where each point was located to obtain FTI/wall thickness. In total, 5335 radiofrequency applications were delivered, and 85 gaps in PV isolation ablation lines and 15 dormant conductions induced by adenosine were detected. The gaps or dormant conductions were significantly associated with low contact force, radiofrequency duration, FTI, and FTI/wall thickness. Among them, FTI/wall thickness had the best prediction value for gaps or dormant conductions by receiver operating characteristic curve analysis. FTI/wall thickness of <76.4 gram-seconds per millimeter (gs/mm) predicted gaps or dormant conductions with sensitivity (88.0%) and specificity (83.6%), and FTI/wall thickness of <101.1 gs/mm was highly predictive (sensitivity 97.0%; specificity 69.6%). CONCLUSIONS: FTI/wall thickness is a strong predictor of gap and dormant conduction formation in PV isolation. An FTI/wall thickness ≈100 gs/mm could be a suitable target for effective ablation.

Chronic Ischemia Induced by Woven Coronary Artery Anomaly with Typical Atrial Flutter: Insights from Multiple Imaging Devices.

A 75-year-old man with a 120-bpm tachycardia and typical atrial flutter was admitted. Echocardiography showed a dilated left ventricle with anterior and apical wall akinesia. Tachycardia was terminated with cavotricuspid isthmus ablation. Multiple imaging findings revealed a woven coronary artery anomaly (WCAA) in the left anterior descending artery. Stress myocardial perfusion imaging was performed after ablation in the sinus rhythm and revealed stress-induced ischemia and a fixed low uptake in the WCAA territory. WCAA is generally regarded as a benign condition; however, compromised blood flow within the anomaly, caused by tachycardia-related diastolic shortening, may induce ischemia.

Acute myocardial infarction following food-dependent exercise-induced anaphylaxis.

A 70-year-old man with a history of food-dependent exercise-induced anaphylaxis (FDEIA) since age 50 was admitted to the emergency department with chest pain and urticaria caused by FDEIA. Coronary angiography revealed total occlusion of the proximal left anterior descending coronary artery. After thrombus aspiration, a bare metal stent was placed into the culprit lesion, resulting in no residual stenosis. Urticaria disappeared on the second hospital day. This is the first reported case, to our knowledge, in which acute myocardial infarction followed FDEIA. Physicians should be aware of acute myocardial infarction as a rare but potential complication of FDEIA.

Relation between hemodynamic changes after endoscopic transthoracic sympathicotomy and the number of sympathetic segments operated.

We examined the relation between hemodynamic changes after endoscopic transthoracic sympathicotomy (ETS) and the number of sympathetic segment operated. Cardiac functional indices using echocardiography and plasma noradrenaline concentration (NOR) were measured before and after ETS in 25 patients with palmar hyperhidrosis. Patients were divided into 2 groups. Group Th2-3 consisted of 16 patients (mean age 28 +/- 8 years),who underwent Th2-3 ETS. Group Th2-4 consisted of 6 patients (mean age 29 +/- 9 years), who underwent Th2-4 ETS. Before ETS, all hemodynamic parameters and NOR were similar between the 2 groups. After ETS, heart rate, systolic, diastolic, and mean blood pressures, rate-pressure product, and NOR decreased,whereas left ventricular end-systolic volume index, cardiac index, and ejection fraction did not change in the 2 groups. Systemic vascular resistance decreased in group Th2-4, whereas it did not change in group Th2-3. Left ventricular end-diastolic volume index and stroke index increased in group Th2-3, whereas it did not change in group Th2-4. After ETS, rate-pressure product, systolic, diastolic, and mean blood pressures in group Th2-4 were smaller than those in group Th2-3, whereas other parameters were similar between the 2 groups. Among percent changes in all hemodynamic parameters and NOR occurring after ETS, only the percent decrease in systolic blood pressure in group Th2-4 was larger than that in group Th2-3 (-15 +/- 12 % vs.-4+/-8%, respectively, p < 0.05). These findings suggest that only the change in blood pressure is related to the difference in the number of sympathetic segment operated.