Proactive esophageal cooling during laser cardiac ablation: A computer modeling study.

BACKGROUND AND OBJECTIVES: Laser ablation is increasingly used to treat atrial fibrillation (AF). However, atrioesophageal injury remains a potentially serious complication. While proactive esophageal cooling (PEC) reduces esophageal injury during radiofrequency ablation, the effects of PEC during laser ablation have not previously been determined. We aimed to evaluate the protective effects of PEC during laser ablation of AF by means of a theoretical study based on computer modeling. METHODS: Three-dimensional mathematical models were built for 20 different cases including a fragment of atrial wall (myocardium), epicardial fat (adipose tissue), connective tissue, and esophageal wall. The esophagus was considered with and without PEC. Laser-tissue interaction was modeled using Beer-Lambert's law, Pennes' Bioheat equation was used to compute the resultant heating, and the Arrhenius equation was used to estimate the fraction of tissue damage (FOD), assuming a threshold of 63% to assess induced necrosis. We modeled laser irradiation power of 8.5 W over 20 s. Thermal simulations extended up to 250 s to account for thermal latency. RESULTS: PEC significantly altered the temperature distribution around the cooling device, resulting in lower temperatures (around 22°C less in the esophagus and 9°C in the atrial wall) compared to the case without PEC. This thermal reduction translated into the absence of transmural lesions in the esophagus. The esophagus was thermally damaged only in the cases without PEC and with a distance equal to or shorter than 3.5 mm between the esophagus and endocardium (inner boundary of the atrial wall). Furthermore, PEC demonstrated minimal impact on the lesion created across the atrial wall, either in terms of maximum temperature or FOD. CONCLUSIONS: PEC reduces the potential for esophageal injury without degrading the intended cardiac lesions for a variety of different tissue thicknesses. Thermal latency may influence lesion formation during laser ablation and may play a part in any collateral damage.

Interatrial Septum Stenting for Hypoplastic Left Heart Syndrome in Ex Utero Intrapartum Therapy.

Patients with hypoplastic left heart syndrome (HLHS) with intact atrial septum have an increased mortality rate. This presentation occurs in 6% to 10% of cases. We present a patient with fetal diagnosis of HLHS with restrictive atrial septum. We performed a cesarean section at 37 weeks of gestation, and under ex utero intrapartum treatment proceeded with a median sternotomy and transatrial stenting for left atrial decompression due to findings of intact atrial septum on the fetal echocardiogram performed during the procedure. Subsequently, the patient underwent hybrid stage I palliation followed by a comprehensive stage II procedure at five months of age, but unfortunately died from postoperative complications.

Congenital giant right atrial aneurysm.

Right atrial aneurysm is a rare congenital heart condition defined as a dilation of the right atrium in the absence of an underlying cause [1]. The clinical presentation varies; most patients are asymptomatic, while others may experience arrhythmias or intracavitary thrombi [1, 2]. We report a case.

Intravascular leiomyomatosis with cardiac extension, a case report.

BACKGROUND: Intravascular leiomyomatosis (IVL) is a histologically benign smooth muscle tumor arising from the uterus that can spread through the pelvic veins and, on rare occasions, extend as far as the heart via the inferior vena cava. Despite its benign characteristics, it can behave like a malignant tumor leading to significant morbidity and even mortality if left untreated. CASE PRESENTATION: The patient is a 42-year-old woman with a past medical history of uterine leiomyomas. She presented with heavy bleeding and frequent spotting; therefore, she went to her gynecologist. After further evaluation, a mass within the uterus that expanded into the pelvic veins, inferior vena cava, and right atrium was discovered. After the complete removal of the mass, the patient underwent full recovery. IVL with cardiac extension was the final diagnosis. CONCLUSION: Although IVL is rare, it must be considered in women who underwent previous hysterectomies or myomectomies and present with symptoms of right heart failure. The ideal therapy will need the aid of a multidisciplinary team and will depend on the patient's symptoms, previous operative history, the tumor's extension, and resectability.

Clinical Effects of Surgical Left Atrial Reduction and Concomitant Mitral Valve Replacement in Patients with Giant Left Atrium.

INTRODUCTION: A giant left atrium may cause respiratory dysfunction and hemodynamic disturbance postoperatively. This retrospective study aimed to evaluate clinical effects of surgical left atrial reduction in concomitant cardiac valves operations. METHODS: One hundred and thirty-five patients with heart valve diseases and giant left atriums from January 2004 to July 2021 were enrolled into this research. They were divided into the folded group (n=63) and the unfolded group (n=72). Patients in the folded group had undergone cardiac valve operations concomitantly with left atrial reductions. The perioperative characteristics were compared between both groups, and subgroup analysis was performed. RESULTS: There were five deaths in the folded group and 25 deaths in the unfolded group (P<0.001). Complications including pneumonia, sepsis, multiple organs dysfunction syndrome, low cardiac output syndrome, and the use of continuous renal replacement therapy were significantly fewer in the folded group. The receiver operating characteristic curve of left atrial max. diameter predicting mortality was significant (area under the curve=0.878, P=0.005), and the cutoff point was 96.5 mm. The stratified analysis for sex showed that more female patients died in the unfolded group. Logistic regression for mortality showed that the left atrium unfolded, left atrial max. diameter, cardiopulmonary bypass time, and mechanical ventilation time increased the risk of death. CONCLUSION: Surgical left atrial reduction concomitantly with valves replacement could decrease mortality and was safe and effective in giant left atrium patients.

Anterior vs. posterior position of dispersive patch during radiofrequency catheter ablation: insights from in silico modelling.

AIMS: To test the hypothesis that the dispersive patch (DP) location does not significantly affect the current distribution around the catheter tip during radiofrequency catheter ablation (RFCA) but may affect lesions size through differences in impedance due to factors far from the catheter tip. METHODS: An in silico model of RFCA in the posterior left atrium and anterior right ventricle was created using anatomic measurements from patient thoracic computed tomography scans and tested the effect of anterior vs. posterior DP locations on baseline impedance, myocardial power delivery, radiofrequency current path, and predicted lesion size. RESULTS: For posterior left atrium ablation, the baseline impedance, total current delivered, current distribution, and proportion of power delivered to the myocardium were all similar with both anterior and posterior DP locations, resulting in similar RFCA lesion sizes (< 0.2 mm difference). For anterior right ventricular (RV) ablation, an anterior DP location resulted in slightly higher proportion of power delivered to the myocardium and lower baseline impedance leading to slightly larger RFCA lesions (0.6 mm deeper and 0.8 mm wider). CONCLUSIONS: An anterior vs. posterior DP location will not meaningfully affect RFCA for posterior left atrial ablation, and the slightly larger lesions predicted with anterior DP location for anterior RV ablation are of unclear clinical significance.

Recurrent multi-cameral cardiac myxomas in a child with Carney complex.

Cardiac myxoma is a relatively rare tumour, usually solitary, that occurs primarily in the left atrium of adults, but comprises only 30% of cardiac tumours in children. We recently treated a 12-year-old girl with multiple recurrent myxomas in three cardiac chambers(following surgical resection 3 years earlier). Genomic analysis showed the PKAR1A mutation typical for Carney complex.

The Technology of Homogeneous Scar Tissue Creating as a Result of Ablation of the Atrial Wall with a Radiofrequency Bipolar Clamp: an Experimental and Clinical Study.

INTRODUCTION: The objective of this study was to develop a radiofrequency ablation technique to create a homogeneous scar tissue in the atrial myocardium. METHODS: In the double-blinded morphological stage of the study, the left atrial appendage was used as an anatomical model to investigate the efficacy of one experimental and two conventional techniques to create ablation lines. Then, these lines were studied by morphologists. The clinical stage involved investigation of the outcomes of the developed technique for creation of ablation lines. During thoracoscopic radiofrequency fragmentation of the left atrium, all ablation lines were created using the experimental radiofrequency technique. RESULTS: In all histological sections of ablation lines created using the criterion of "steady decrease in the time to transmurality", there were no intact (viable) cells, in contrast to the other two conventional methods, i.e., a homogeneous scar of the atrial wall. Investigation of clinical efficacy of this developed technique revealed recurrent atrial fibrillation only in six of 137 patients (4.4%) at median follow-up time of 36 (10; 58) months. None of the patients developed specific complications (wall perforation or bleeding). According to intracardiac mapping performed after the end of the blind period, the sources of atrial fibrillation in these six patients were outside the radiofrequency ablation zone (perimitral or in the right atrium). CONCLUSION: A steady decrease in the time to transmurality should be considered as the priority intraoperative criterion for the formation of a homogeneous scar during radiofrequency ablation of the left atrium wall using a bipolar ablation clamp.

Wilms tumor in children: A multivariate analysis of prognostic factors, with emphasis on inferior vena cava/right atrium extension. Results from a single-center study.

BACKGROUND: To identify prognostic factors for overall survival through the analysis of 132 patients with Wilms tumor followed at a single center, with emphasis on the inferior vena cava/right atrium extension. METHODS: Retrospective analysis of overall survival using logistic regression models and including age, sex, clinical features, associated syndromes, comorbidities, tumor size before chemotherapy, stage, presence of metastatic disease and its site, invasion of adjacent structures, inferior vena cava/right atrium extension, laterality, tumor histology, chemotherapy protocol, and radiotherapy as potential risk factors. RESULTS: From January 2000 through November 2021, 132 patients met the inclusion criteria, 64 females and 68 males; 15 (11.4%) patients presented with tumoral extension to inferior vena cava/right atrium and 44 had metastatic disease (33.3%). Based on logistic regression, the factors correlating to a fatal outcome were male sex (p = 0.046), high risk histology (p = 0.036), and the presence of metastatic disease (p = 0.003). None of the patients presenting inferior vena cava/right atrium extension died (p = 0.992). In a specific analysis of metastatic sites, hepatic metastasis alone showed correlation with a fatal outcome (p = 0.001). CONCLUSION: These results underline the importance of identifying and treating metastatic disease and high-risk tumors. The female gender as a potential driver for a less aggressive disease is a new finding that deserves further investigation. The accurate identification of inferior vena cava/right atrium extension, subsequent preoperative chemotherapy, and resection with a skilled team promoted survival rates of all patients. LEVEL OF EVIDENCE: II.

A Simple Modified Technique of Pleuropericardial Window: Towards 0% Recurrence.

Recurrent pericardial effusion is commonly encountered in neoplastic and infective disorders. Intervention is compulsory in patients with unstable hemodynamics and tamponading effusion. Surgical options include: pericardiocentesis, subxiphoid pericardiostomy, and pericardial window. The latter has proved to have lower incidence of recurrence; however, the technique has been continuously refined to improve the recurrence-free survival and decrease postoperative morbidity. We herein present a novel simple modification to minimize recurrence by anchoring the free edges of pericardial fenestration overlying the superior vena cava and right atrium to the chest wall. Follow-up showed no recurrence compared to 3.5% in the conventional procedure.

Direct Anastomosis of Persistent Left Superior Vena Cava to Right Superior Vena Cava in a Pediatric Patient with Tetralogy of Fallot: an Alternative Technique.

The presence of persistent left superior vena cava to the left atrium connection without an innominate vein may give rise to technical challenges during intracardiac repair. In this report, the end-to-side anastomosis technique of the persistent left superior vena cava to the right superior vena cava is discussed in a patient with tetralogy of Fallot associated with persistent left superior vena cava draining directly into the left atrium. A successful end-to-side anastomosis between the persistent left superior vena cava and the right superior vena cava was performed and short-term anastomosis patency was documented via angiography.

Atuação do anestesiologista na correção cirúrgica tardia de forame oval patente: relato de caso / Role of the anesthesiologist in late surgical correction of foramen ovale patent: case report

Introdução: O forame oval (FO) é uma abertura embrionária localizada no septo interatrial, que permite a passagem de sangue oxigenado do átrio direito para o átrio esquerdo, essencial para a circulação fetal. O FO persiste em cerca de 15-35% da população adulta, sendo denominado forame oval patente (FOP). O FOP possui importância clínica pois pode estimular a formação de trombos, ou mesmo servir como um canal para embolia paradoxal. Objetivo: Descrever a atuação do anestesiologista na correção tardia de FOP. Metodologia: Trata-se do relato de um caso único atendido no Hospital do Servidor Público Municipal de São Paulo (HSPM), localizado na cidade de São Paulo - SP. Relato do Caso: Tratou-se de uma paciente do sexo feminino, 68 anos de idade, com múltiplas comorbidades, histórico de 12 acidentes vasculares cerebrais prévios e três episódios de acidente isquêmico transitório. Durante o procedimento cirúrgico de correção da FOP, a paciente foi monitorada por cardioscopia, oximetria de pulso, capnografia expiratória e pressão arterial invasiva. A anestesia foi realizada com lidocaína, propofol, sufentanil e rocurônio, e a manutenção anestésica foi feita com remifentanil e sevoflurano. A paciente recebeu efedrina, metaraminol e nitroglicerina durante a cirurgia, e as gasometrias realizadas antes e após o procedimento foram normais. Após a extubação, foi encaminhada à Unidade de Terapia Intensiva com cateter nasal de oxigênio, mantendo os parâmetros ventilatórios adequados e recebendo analgesia com dipirona e tramadol. Conclusão: O anestesista desempenha um papel crucial na correção do FOP, com a anestesia adequada proporcionando conforto e segurança ao paciente durante o procedimento cirúrgico. A anestesia geral é frequentemente utilizada, fornecendo inconsciência, supressão da dor e estabilidade fisiológica ao paciente. Técnicas complementares, como anestesia local ou regional, podem ser utilizadas de acordo com o caso. A escolha da anestesia adequada depende de diversos fatores, como a saúde geral do paciente, a extensão da cirurgia, a presença de comorbidades e as preferências individuais. Palavras-chave: Cirurgia Cardíaca. Anestesiologia. Forame Oval Patente. Relato de caso.

Atrial approaches in mitral valve surgery: a propensity analysis of differences in the incidence of clinically relevant adverse effects.

BACKGROUND: The lack of evidence on complications using mitral valve approaches leaves the choice of risk exposure to the surgeon's preference, based on individual experience, speed, ease, and quality of exposure. METHODS: The present study analysed patients undergoing mitral valve surgery using a superior transseptal approach or a left-atrial approach between 2006 and 2018. We included first-time elective mitral valve procedures, isolated, or combined, without a history of rhythm disturbances. We used propensity score matching based on 26 perioperative variables. The primary endpoint was the association between the superior transeptal approach and clinically significant adverse outcomes, including arrhythmias, need for a permanent pacemaker, cerebrovascular events, and mortality. RESULTS: A total of 652 patients met the inclusion criteria; 391 received the left atrial approach, and 261 received the superior transseptal approach. After matching, 96 patients were compared with 69 patients, respectively. The distribution of the preoperative and perioperative variables was similar. There was no difference in the incidence of supraventricular tachyarrhythmias or the need for treatment. The incidence of nodal rhythm (p = 0.008) and length of stay in intensive care (p = 0.04) were higher in the superior transseptal group, but the need for permanent pacemaker implantation was the same. Likewise, there was no difference in the need for anticoagulation due to arrhythmia, the incidence of cerebrovascular events or mortality in the postoperative period or in the long-term follow-up. CONCLUSION: We did not find an association with permanent heart rhythm disorders or any other significant adverse clinical outcome. Therefore, the superior transeptal approach is useful and safe for mitral valve exposure.

Proactive esophageal cooling protects against thermal insults during high-power short-duration radiofrequency cardiac ablation.

BACKGROUND: Proactive cooling with a novel cooling device has been shown to reduce endoscopically identified thermal injury during radiofrequency (RF) ablation for the treatment of atrial fibrillation using medium power settings. We aimed to evaluate the effects of proactive cooling during high-power short-duration (HPSD) ablation. METHODS: A computer model accounting for the left atrium (1.5 mm thickness) and esophagus including the active cooling device was created. We used the Arrhenius equation to estimate the esophageal thermal damage during 50 W/ 10 s and 90 W/ 4 s RF ablations. RESULTS: With proactive esophageal cooling in place, temperatures in the esophageal tissue were significantly reduced from control conditions without cooling, and the resulting percentage of damage to the esophageal wall was reduced around 50%, restricting damage to the epi-esophageal region and consequently sparing the remainder of the esophageal tissue, including the mucosal surface. Lesions in the atrial wall remained transmural despite cooling, and maximum width barely changed (<0.8 mm). CONCLUSIONS: Proactive esophageal cooling significantly reduces temperatures and the resulting fraction of damage in the esophagus during HPSD ablation. These findings offer a mechanistic rationale explaining the high degree of safety encountered to date using proactive esophageal cooling, and further underscore the fact that temperature monitoring is inadequate to avoid thermal damage to the esophagus.

A Malignant Lymphoma Growing Inside a Cardiac Mixoma: A Case Report.

INTRODUCTION: Lymphomas arising from cardiac myxomas represent a particularly rare pathology, with only few cases reported in the literature.Case presentation: We report a complete excision of a malignant lymphoma arising from a cardiac myxoma in a 44-year-old female patient. The myxoma presented like a floating mass within the left atrium with a maximum diameter of 3.5 cm. The clinical post-operative period was uneventful and the patient was dismissed on the 6th post-operative day. CONCLUSION: This case reinforces the concept of radical excision of cardiac neoplasms.

Gerbode defect or left ventricular to right atrial shunt. Case report and literature review / Defecto tipo Gerbode o comunicación entre el ventrículo izquierdo y la aurícula derecha. Reporte de un caso y revisión de la literatura

Gerbode defect is a communication from the left ventricle to right atrium and it could be categorized in congenital or acquired. It is a rare condition that can represent as much as 0.08% of all septal defects. Those acquired defects can be associated to endocarditis and after valvular surgery. The objective is to report a case of Gerbode atria-ventricular septal defect in Instituto Nacional de Cardiología Ignacio Chavez. The present case is about a 36 years old male patient with a typical presentation of mitral regurgitation, the echocardiogram reports a perforation in the anterior mitral leaflet and a Gerbode ventricular septal defect, that represents the heterogeneity of the clinical presentation of this pathology, also we show the findings in imaging studies that contributed to diagnosis and its surgical resolution. Gerbode defect is an uncommon pathology, many times associated to other cardiovascular entity, difficulting diagnose. It requires image studies and a complete presurgical evaluation in order to achieve opportune diagnosis.

El defecto tipo Gerbode es una comunicación del ventrículo izquierdo a la aurícula derecha, que puede clasificarse como congénita o adquirida. Es una condición rara que puede representar hasta el 0.08% de los defectos septales congénitos. Los defectos adquiridos pueden asociarse a endocarditis y presentarse también posterior a cambios valvulares. El objetivo es reportar un caso de comunicación interventricular de Gerbode en el Instituto Nacional de Cardiología. Paciente varón, de 36 años, con presentación clínica típica de insuficiencia mitral, ecocardiografía con hallazgo de rotura de la valva anterior de la válvula mitral y comunicación interventricular tipo Gerbode. Se ponen de manifiesto la heterogeneidad clínica con la que se presenta esta patología y los hallazgos de imagen que contribuyen al diagnóstico y su resolución quirúrgica. La comunicación interventricular tipo Gerbode es una patología infrecuente, muchas veces asociada a otra afección cardiovascular, lo que la hace de difícil diagnóstico. Se requieren estudios de imagen y una evaluación preoperatoria completa para su detección oportuna.

Transatrial management of inadvertent puncture of the posterior wall during transseptal access for atrial fibrillation ablation: technical report.

Transseptal puncture for atrial fibrillation ablation is a safe and common procedure. However, complications, such as cardiac tamponade, may be fatal if not recognized and treated. Our goal is to report a bailout strategy, by which management of an inadvertent puncture of the posterior wall of the left atrium was possible. It was followed by successful pulmonary vein isolation, without the need for subsequent subxiphoid puncture.